C L I N I C I A N ’ S G U I D E TO

Assessing and Counseling

Older Drivers
4th Edition
Clinician’s Guide to Assessing
and Counseling Older Drivers
4th Edition

ACKNOWLEDGEMENTS

This 4th edition of the Clinician’s Guide to Assessing and Counseling Older Drivers is the product of a cooperative
agreement between the American Geriatrics Society (AGS) and the National Highway Traffic Safety Administration
(NHTSA), and is an update to the 3rd edition of the Clinician’s Guide to Assessing and Counseling Older Drivers.

EDITORIAL BOARD
Editorial Board Chair Irene Moore, MSSW, LISW-S Subject Expert Reviewers
Alice Pomidor, MD, MPH, AGSF Professor Emerita, Department of
Elizabeth Green, OTR/L, CDRS,
Professor, Department of Geriatrics Family & Community Medicine
University of Cincinnati Geriatric CAE
Florida State University College of
Medicine Program Executive Director
Medicine
Cincinnati, OH Association for Driver Rehabilitation
Tallahassee, FL
Specialists
Barbara Resnick, PhD, RN, CRNP,
Editorial Board Members Jennifer Nordine, OTR/L, CDRS
FAAN, FAANP
Driving to Independence
Anne E. Dickerson, PhD, OTR/L, Professor and Sonya Ziporkin
ADED President, 2015 and 2018
FAOTA Gershowitz Chair in Gerontology
Department of Occupational Therapy University of Maryland Marc Samuels, OT, CDRS
East Carolina University Baltimore, MD Driver Rehabilitation Program Manager
Greenville, NC Department of Veterans Affairs Palo
Elin Schold-Davis, OTR/L, CDRS
Alto
Shelly Gray, PharmD, MS Project Coordinator
2019 President, Association of Driving
Professor and Vice Chair for Curriculum American Occupational Therapy
Rehabilitation Specialists (ADED)
and Instruction, Department of Association (AOTA) Older Driver
Pharmacy Initiative
Bethesda, MD Legal Advisor
Director, Geriatric Program and Plein
Certificate Brian MacKenzie, Judge (Ret.)
School of Pharmacy University of Subject Expert Advisory Panel CFO Justice Speakers Institute LLC
Washington
Linda Hill, MD, MPH
Seattle, WA
Clinical Professor, Department of Family Medical Editor
Richard Marottoli, MD Medicine and Public Health Susan E. Aiello, DVM, ELS
Medical Director of the Dorothy Adler Director of Training, Research and WordsWorld Consulting
Geriatric Assessment Center Education for Driving Safety (TREDS)
Yale University University of California San Diego
New Haven, CT
Shelley Bhattacharya, DO, MPH
Associate Professor
Division of Geriatric Medicine and
Palliative Care
Department of Family Medicine at the
Landon Center on Aging
University of Kansas Medical Center
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Copyright Disclosure of Financial Interests

As an accredited provider of Continuing Medical
The Clinician’s Guide to Assessing and Counseling Older Drivers, 4th Edi-
Education, the American Geriatrics Society
tion is published by the American Geriatrics Society as a service to health
continuously strives to ensure that the education
care providers involved in the care of older adults.
activities planned and conducted by our faculty
Although the Clinician’s Guide to Assessing and Counseling Older Drivers, meet generally accepted ethical standards as
4th Edition, is distributed by various companies in the health care field, it is codified by the ACCME, the Food and Drug
independently prepared. All decisions regarding its content are solely the Administration, and the American Medical
responsibility of the authors. Their decisions are not subject to any form of Association’s Guide for Gifts to Physicians. To this
approval by other interests or organizations. end, we have implemented a process wherein
The information in this guide is provided to assist health care providers in everyone who is in a position to control the
evaluating the ability of their older patients to operate motor vehicles safe- content of an educational activity has disclosed
ly as part of their everyday, personal activities. Evaluating the ability of pa- to us all relevant financial relationships with any
tients to operate commercial vehicles or to function as professional drivers commercial interests within the past 12 months
involves more stringent criteria and is beyond the scope of this publication. as related to the content of their presentations
and under which we work to resolve any real or
This guide is not intended as a standard of medical care, nor should it be
apparent conflicts of interest. Conflicts of interest
used as a substitute for health care providers’ clinical judgment. Rather, this
in this particular CME activity have been resolved
guide reflects the scientific literature and views of experts as of November
by having the presentation content independently
2018, and is provided for informational and educational purposes only.
peer reviewed before publication by the Editorial
None of this guide’s materials should be construed as legal advice nor
Board and Question Review Committee.
used to resolve legal problems. If legal advice is required, we urge you to
The following contributors have returned
consult an attorney who is licensed to practice in your state. In addition,
disclosure forms indicating that they (and/or their
we encourage clinicians using the guide to be sure that contact with other
spouses/partners) have no affiliation with, or
health professionals proceeds in accordance with appropriate ethical and
financial interest in, any commercial interest that
HIPAA guidelines (see chapter 7 for more details).
may have direct interest in the subject matter of
Material from this guide may be reproduced. However, the authors of this their chapters/questions:
guide strongly discourage changes to the content, as it has undergone
Shelley Bhattacharya, DO, MPH
rigorous, comprehensive review by medical specialists and other experts in
the field of older driver safety. Anne E. Dickerson, PhD, OTR/L, FAOTA

No responsibility is assumed by the authors or the American Geriatrics Shelly Gray, PharmD, MS
Society for any injury or damage to persons or property, as a matter of Elizabeth Green, OTR/L, CDRS, CAE
product liability, negligence, warranty, or otherwise, arising out of the use Linda Hill, MD, MPH
or application of any methods, products, instructions, or ideas contained
Brian MacKenzie, Judge (Ret.)
herein. No guarantee, endorsement, or warranty of any kind, express or im-
plied (including specifically no warrant of merchantability or of fitness for a Richard Marottoli, MD
particular purpose) is given by the Society in connection with any informa- Irene Moore, MSSW, LISW-S, AGSF
tion contained herein. Independent verification of any diagnosis, treatment, Jennifer Nordine, OTR/L, CDRS
or drug use or dosage should be obtained. No test or procedure should be
Alice Pomidor, MD, MPH, AGSF
performed unless, in the judgment of an independent, qualified health care
provider, it is justified in the light of the risk involved. Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP
Marc Samuels, OT, CDRS
Citation: Pomidor A, ed. Clinician’s Guide to Assessing and Counseling
Elin Schold-Davis, OTR/L, CDRS
Older Drivers, 4th Edition. New York: The American Geriatrics Society;
The following contributors (and/or their spouses/
2019.
partners) have reported real or apparent conflicts
Copyright © 2019 by the American Geriatrics Society. of interest that have been resolved through a peer
review content validation process:
All rights reserved. Except where authorized, no part of this publication Susan E. Aiello, DVM, ELS
may be reproduced, stored in a retrieval system, or transmitted in any form
Dr. Aiello holds stock in Merck.
or by any means, electronic, mechanical, photocopying, recording, or oth-
erwise without prior written permission of the American Geriatrics Society,
40 Fulton Street, 18th Floor, New York, NY 10038.

ISBN: 978-1-886775-64-0

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

TABLE OF CONTENTS

4 INTRODUCTION

6 CHAPTER 1 The Older Adult Driver: An Overview

18 CHAPTER 2 Is the Older Adult at Increased Risk of Unsafe Driving?

28 Screening and Assessment of Functional

CHAPTER 3 
Abilities for Driving

48 Clinical Interventions
CHAPTER 4 

60 CHAPTER 5 Driver Rehabilitation

80 CHAPTER 6 Advising the Older Adult About Transitioning from Driving

94 CHAPTER 7 Ethical and Legal Issues

108 CHAPTER 8 State Licensing and Reporting Laws

115 Medical Conditions, Functional Deficits, and Medications

CHAPTER 9 
That May Affect Driving Safety

158 CHAPTER 10 Meeting Future Transportation Needs of Older Adults

172 APPENDICES CPT Codes®

176 APPENDICES Patient Caregiver Information

219 APPENDICES Clinical Team Resources

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

INTRODUCTION – 4TH EDITION

T
ranslating research findings and public health initiatives into practical everyday
applications for patient-centered care is a constant challenge for clinicians engaged
in the care of older adults. Nearly everyone, regardless of profession or specialty,
will be working with older adults as either patients or caregivers in the next 20 years
as the baby boomer generation enters their retirement years living longer and being more
active than any previous generation. As the most mobile generation to date, these older
adults are already putting in more miles behind the wheel and expect to remain mobile in
the community as they age, ideally with a driving “life expectancy” that keeps up with their
lifespan.

In order to support older adults’ access prevent motor vehicle crashes and injury to
to health care, social interaction, and older adults. Motor vehicle injuries persist
nutrition through independent mobility, as the leading cause of injury-related deaths
interprofessional clinical team members among 65- to 74-year-olds and are the
need office-based tools to screen for medical second leading cause (after falls) among 75-
and functional issues which may affect to 84-year-olds. While traffic safety programs
driving ability, assess the risk of driving have had partial success in reducing crash
impairment, intervene to optimize treatment rates for all drivers, the fatality rate for drivers
and functional ability, refer appropriately for over age 65 has consistently remained high.
specialized care and driving rehabilitation, Increased comorbidities and frailty associated
and provide counseling about planning for with aging make it far more difficult to survive
transitioning from driving if necessary. a crash, and the expected massive increase
in the number of older adults on the road
The American Geriatrics Society (AGS)
is certain to lead to increased injuries and
extended a cooperative agreement with the
deaths unless we can successfully intervene
U.S. Department of Transportation’s National
to prevent harm.
Highway Traffic Safety Administration
(NHTSA) to update and expand the Clinician’s Healthcare practitioners caring for older
Guide to Assessing and Counseling Older adults are in a leading position to address
Drivers, 3rd Edition to this current 4th edition. and correct this public health concern at
the individual patient and caregiver level.
The main goal of the Clinician’s Guide
By providing effective health care, clinicians
remains helping healthcare practitioners

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

can help their patients maintain a high level team encounter older adults. We hope that
of fitness, enabling them to preserve safe you will find the Clinician’s Guide useful and
driving skills later in life and protecting them welcome your feedback as we move forward
against serious injuries in the event of a crash. in engaging our older adults and caregivers
By adopting preventive practices—including in maintaining safe mobility for life.
the assessment and counseling strategies
This publication resulted from a cooperative
outlined in this guide—clinicians can better
agreement between the U.S. Department
identify older drivers at risk for crashes, help
of Transportation, National Highway Traffic
enhance their driving safety, and ease the
Safety Administration (NHTSA), and the
transition to driving retirement if and when it
American Geriatrics Society (AGS). The
becomes necessary.
opinions, findings, and conclusions expressed
We wish to thank our program officers at in this publication are those of the author(s)
NHTSA for their continued support of the and not necessarily those of the U.S.
Clinician’s Guide project over the years in Department of Transportation or NHTSA.
addressing the important area of older driver The United States Government assumes no
mobility, especially the pioneering work of liability for its contents or use thereof. If trade
Essie Wagner. names, manufacturers’ name, or specific
products are mentioned, it is because they
Our current interprofessional Editorial
are considered essential to the object of the
Board has taken great care to preserve the
publication and should not be construed
intent of providing the best evidence-based
as an endorsement. The United States
recommendations from the current literature,
Government does not endorse products or
while recognizing the different environments
manufacturers.
of care in which members of the clinical

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

C H A P T E R 1 THE OLDER ADULT DRIVER: AN OVERVIEW

KEY POINTS
n The number of older adult mental changes associated n Clinical team members can
drivers is growing rapidly, with aging, medications and/ help older adult drivers
and they are driving longer or disease. maintain safe driving skills
distances. n Many older adult drivers using the Plan for Older
n Motor vehicle crashes are far self-regulate their driving Driver Safety (PODS)
more harmful for older adults behavior. algorithm and may also
than for all other age groups. influence older adult drivers’
n Driving cessation is decisions to modify or stop
n The risk of crashes for older inevitable for many and driving if the older adult
drivers is in part related is often associated with develops functional disability
to physical, visual, and/or negative outcomes. that affects driving skills.

O
Mrs. Alvarez, a 72-year-old woman, mentions lder adult drivers like Mrs. Alvarez and
during a routine appointment that she would Mr. Phillips are encountered by clinical
like an earlier time slot so she can avoid heavy team members in every setting. In 2017,
traffic and driving in the dark. She denies previous some 50.9 million people --- over 16 percent of
crashes or injuries but seems anxious about
the total U.S. resident population --- were 65 and
her planned two-day road trip to attend her
older. 1 This population of older adults is expected
grandson’s graduation. She has arthritis, type
to nearly double by 2060.2 Approximately 84%
2 diabetes mellitus, hypertension, peripheral
neuropathy, and insomnia. Mrs. Alvarez admits of Americans 65 and older continue to drive,
to feeling less confident when driving and has with this cohort of 43.6 million older adult drivers
reduced her social and shopping activities comprising 19% of all licensed drivers in 20173. It
because of her worries. is expected that one of every four licensed drivers
How do you address these driving concerns? will be an older adult by 2050, in addition to
driving more miles than older drivers do today.4
Mr. Phillips, an 82-year-old man with a history
of hypertension, congestive heart failure, Common age-related changes that impact
atrial fibrillation, macular degeneration, and functional abilities in addition to medical
osteoarthritis, comes to your office for a follow-up conditions can make driving difficult, potentially
visit. You notice that Mr. Phillips has a great deal reducing the older adult’s independence, social
of trouble walking, uses a cane, and has difficulty contact, and access to nutrition, health care, and
reading his paperwork, even with his glasses. other services. There are three clinical levels of care
During your conversation, you ask him if he still
regarding driving ability in older adults (Table 1.1).
drives, and he states that he takes short trips
to run errands, get to appointments, and meet Assessing and managing potential driving disability
weekly with his bridge club. can be challenging and time consuming, because
What are your next steps in addressing his many clinicians often consider it a personal rather
fitness to drive? than a clinical issue. Legal and ethical questions
may also deter clinical team members from

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

addressing driving ability in older Level of Care Description

adults. Yet as medical conditions
arise and progress with advancing
Primary Assesses the older adult driver and intervenes to
prevention prevent the loss of driving ability
age, older adult drivers and their
caregivers will increasingly turn Secondary Addresses issues that have already caused the
to clinical team members for prevention loss of driving skills and attempts to restore
those skills through treatment and rehabilitation
guidance on safe driving. The
challenge is in balancing the Tertiary Identifies when irreversible loss of driving skills
safety of older adults against their prevention has occurred and includes recommending al-
transportation needs and the ternatives to avoid harm to the older adult and
others when driving is no longer an option
safety of society.
This guide is intended to help Table 1.1 - Clinical Levels of Care for Prevention of Driving Disability
answer the following questions
and, if necessary, help clinical team members health care settings for screening and perhaps
counsel patients about transportation planning, assessment or referral to another team member or
including driving cessation. specialist for further evaluation as needed. Although
n At what level of severity do medical conditions many health care professionals do not work directly
impair safe driving? with one another in the same setting, “virtual”
teams often come together during the course of
n What can be done to help older adults prolong
care for an individual older adult. Some of the skills
their driving life expectancy (time behind the
and roles of potential clinical team members are
wheel)?
described below to help identify opportunities for
n How can transportation planning ensure safe interprofessional collaboration and to maximize
mobility and continued participation in valued the available support for an older adult. The
activities (e.g., hair dresser, breakfast club, place professional roles defined below are not mutually
of worship)? exclusive; in practice, responsibilities may be shared
Note: The information in this guide is provided to across disciplines.
assist clinical team members in evaluating the ability
of older adults to safely operate motor vehicles as Physician/Nurse Practitioner/Physician Assistant
part of their everyday, personal activities. Evaluating The patient’s primary care provider, who may be a
the ability of older adults to operate commercial physician, nurse practitioner, or physician assistant,
motor vehicles (CMV) or to function as professional performs the medical evaluation to determine if the
drivers involves more stringent criteria and is older adult has any medical conditions that may
beyond the scope of this guide. affect his or her ability to drive safely. This medical
assessment helps to direct further supportive
CLINICAL TEAM MEMBERS AND interventions, referrals, and potential medical
THEIR ROLES treatment. Older adults are often more likely to
All clinical team members can help identify and consider changes in their driving practices if their
counsel older adults who may be at risk of driving primary care providers discuss the importance of
impairment. Clinical team members may have safety interventions.5
opportunities to interact with older adults in varied

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Nurse interventions for identified impairments to support

Nurses contribute to the medical assessment mobility in the environment, including driving, and
by monitoring basic vital signs and evaluating may recommend strategies, therapies, and assistive
functional abilities, disease risk factors, medication devices for rehabilitation. Occupational therapists
adherence and adverse effects, personal health often seek additional training to become driving
behaviors such as alcohol use, and health literacy. rehabilitation specialists, who can perform expert
This information can be used to facilitate changes special assessments and therapeutic interventions
in the care plan and follow-through by the older specifically regarding fitness to drive, including on-
adult and/or his or her caregivers. Home-health road testing.
nurses and direct care personal assistants often
Social Worker
have unique opportunities to closely observe,
counsel, and support older adults at home in their Social workers assess the older adult’s well-being
day-to-day activities. A nurse may also serve as a and transportation needs, evaluate the level of
case manager, health counselor, or a resource for caregiver support available, and help access
the older adult and caregivers, and liaison with affordable training and transportation options.
other clinical team members if older adults or Social workers may also counsel older adults and
their caregivers have health-related questions or their caregivers and help identify resources to
concerns. overcome barriers to changing driving patterns
or eventual driving retirement (such as financial
Pharmacist support or peer support groups).
Pharmacists can perform a thorough medication
Psychologist
history, including use of over-the-counter drugs;
assess adherence to medication regimens; assess Clinical psychologists often participate in advanced
the potential for medications, adverse effects, evaluation of the cognitive abilities needed for
or drug interactions to affect driving ability; and driving. In these assessments, clinical psychologists
counsel older adults on these issues. Pharmacists and neuropsychologists evaluate multiple cognitive
may also make recommendations to the clinical domains, including attention, memory, processing
team for optimal pharmacologic management of speed, executive skill, and judgement. They often
medical conditions that may impair driving, and also evaluate the relative contributions from mental
for dosage adjustment, timing, or therapeutic health conditions that could influence a patient’s
substitution of medications that may have driving- ability to drive (e.g., substance use, anxiety/
impairing effects. Some pharmacists also directly depression, and pain). Psychologists may provide
manage the treatment of various medical conditions interventions to both patients and their caregivers
that may contribute to driving impairment. that include adapting to changes in lifestyle and
transportation. Research psychologists study how
Occupational Therapist/Driving Rehabilitation the environment and vehicle and human factors
Specialist affect driving ability. A handbook from the American
Occupational therapists assess the older adult’s Bar Association and the American Psychological
functional abilities and the visual, cognitive, Association more thoroughly discusses a
perceptual, and physical capacities for those psychologist’s role in assessing the driving capacity
abilities. Occupational therapists provide of older adults with diminished capacity.6

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Tools Included in the Clinician’s Guide procedures (see Appendix A).

Many tools for evaluating older adult drivers, n Patient education materials for older adults
mobility counseling, and transportation planning and their caregivers that include a self-screening
have been developed in the United States and tool for driving safety, safe driving tips, driving
other countries. However, there are still relatively alternatives, and a resource sheet for concerned
few well-studied strategies that reliably predict caregivers (see Appendix B). Links for accessing
driving outcomes for each individual, in part recommended resources from reputable
because of the complexity of the issues involved organizations are also provided.
in driving and the heterogeneity of the older adult n Sample approaches in subsequent chapters
population. The new fourth edition of the Clinicians’ for conversations about driving assessment,
Guide to Assessing and Counseling Older Drivers rehabilitation, restriction, and cessation.
continues the collaboration between the American
n Online access to the guide through the
Geriatrics Society and the National Highway Traffic
American Geriatrics Society’s portal of resources
Safety Administration (NHTSA) to offer updated
(www.GeriatricsCareOnline.org) and via NHTSA’s
recommendations, tools, and resources for the
Older Drivers website (https://www.nhtsa.gov/
clinical team involved in the care of older adults for
road-safety/older-drivers).
use in multiple care settings as follows:
n A clinically based assessment of medical fitness KEY FACTS ABOUT OLDER ADULT DRIVERS
to drive, presented in the algorithm Plan for Older
Drivers’ Safety (PODS) (see below). The number of older adult drivers is growing
rapidly, and they are driving longer distances.
n A toolbox of practical, office-based functional
assessment tests for driving-related skills, the Life expectancy remains high7 and the older
Clinical Assessment of Driving Related Skills population is rapidly increasing. By the year 2060,
(CADReS) (see Chapter 3). The clinical team can the population of adults 65 and older will nearly
choose among these tests, depending on the double to approximately 95 million, making up
outcomes of screening tests and the individual at least 20% of the total U.S. population.8 In
older adult’s abilities (see Chapter 2). many states, including Florida and California, the
population of those older than 65 may reach 20%
n Information to help navigate the legal and
in this decade. The fastest growing segment of
ethical issues regarding patient driving safety,
the population is the 80-and-older group, which is
including information on patient reporting, with
anticipated to increase to 30 million over the next
a state-by-state list of licensing agency contact
30 years. Similar trends are occurring globally, with
information, and additional resources for locating
the expected worldwide population of people aged
license renewal criteria and reporting laws and
60 years or older expected to reach 21% by 2050,
procedures (see Chapters 7 and 8).
when the number of older adults is projected to
n A reference listing of medical conditions and exceed the number of children for the first time.9
medications that may affect driving, with specific Older adults are projected to outnumber children in
recommendations for each (see Chapter 9). the United States by the year 2035.2
n Recommended Current Procedural Terminology In addition, the United States has become a highly
(CPT) codes for assessment and counseling mobile society, and older adults drive for volunteer

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

activities and gainful employment, social and trauma from an airbag or steering wheel. Fragility
recreational needs, and cross-country travel. Recent begins to increase at ages 60-64 and increases
studies suggest that older adults are driving more steadily with advancing age.17
frequently, and transportation surveys reveal an n Ownership and use of older cars that are less
increasing number of miles driven per year for each crashworthy and lack some of the safety features
successive aging cohort.4 added to newer vehicles specifically designed
to enhance occupant protection and mitigate
Motor vehicle crashes are far more harmful for
the risks of frailty with a gradual decrease in
older adults than other age groups.
deaths per miles driven. Frontal air bags, required
In 2017, there were 6,784 people 65 and older who in all new passenger vehicles since the 1999
were killed in traffic-related crashes (up from 5,560 model year, help mitigate the severity of chest
in 2012).1 In 2017, 289,000 older adults were injured injuries; side air bags became added pieces of
in motor vehicle crashes.10 Most traffic fatalities in standard equipment by nearly all manufacturers,
crashes involving older drivers occurred during the but they are not mandated. Side air bags have
daytime (73%) on weekdays (69%), and involved been found to protect the head and reduce a
other vehicles (67%) at intersections.11 Unintentional driver’s risk of death in driver-side crashes by 37
injuries are the seventh leading cause of death percent and an SUV driver’s risk by 52 percent.18
among older adults, and motor vehicle crashes Vehicle protection (referred to by NHTSA as crash
are the second most common cause of injury after mitigation factors) for older adults may improve
falls.12,13 Beginning at age 75, older adult drivers as future cohorts of aging drivers purchase newer
have a higher fatality rate per mile driven than any vehicles with better design features.19
other age group except drivers younger than 29.14
n Overrepresentation of specific types of crashes
Older adult pedestrians are also more likely to be
such as left-hand turns that increase vulnerability
fatally injured at crosswalks than younger adults.12
to injury.
Although the fatality rates have slowly declined, the
continuing increase in the number of older adults However, enhancements in roadway design and
still results in a higher number of deaths in this age vehicle safety features that may be helping mitigate
group. the risks of frailty with a gradual decrease in deaths
per mile driven in the past decade. Proven safety
The rate of poor outcomes after a crash is
countermeasures engineered into roadway design
disproportionately higher in older adult drivers, due
can decrease crash impact for all road users,
in part to chest and head injuries.15 Relative to a
including older people.19 These countermeasures
driver 35-54 years old, older adults 70 and older are
include enhanced signals and signs, slower design
3.2 times more likely to die in a crash and about 1.5
speeds, minimized conflict points, and improved
times more likely to sustain a serious injury.16 There
walkways for pedestrians.
may be several reasons for this.
n Vehicle crash avoidance technology that is
n Increased fragility in some older adult drivers.
likely to improve older driver safety. For example,
For example, older adults have an increased
electronic stability control, which helps drivers
incidence of osteoporosis, which can lead to
maintain control of their vehicle on curves and
fractures, and/or atherosclerosis of the aorta,
slippery roads, became standard on all 2012
which can predispose to aortic rupture with chest

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

or later vehicles. NHTSA estimates installation believed that further improvements in traffic safety
of electronic stability control has reduced fatal using roadway countermeasures will likely result in
single-vehicle crashes by 38% and for SUVs (in improving driving performance or modifying driving
preventing roll overs) by 56%, without even behavior.26 The identification and management of
accounting for those in multicar crashes.20 For medical conditions, functional impairments, and
crash avoidance technologies, the reduction in potentially driving-impairing medications may
crashes was significant when comparing rates maintain or improve driving abilities and road safety.
of police-reported crashes for vehicles with and
without the technologies, for forward collision Many older adult drivers self-regulate their driv-
warning (27%), forward collision warning plus ing behavior.
autobrake (56%), lane departure warning (21%), As drivers age, they may begin to feel limited by
blind spot detection (23%), rear automatic braking slower reaction times, chronic health problems, and
(62%), rearview cameras (17%), and rear cross- effects of medications. Although transportation
traffic alert (22%).21 surveys over the years document that the current
cohort of older adult drivers is driving farther,
The risk of crashes for older drivers is in part re- in later life many reduce their mileage or stop
lated to physical, visual, and/or mental changes driving altogether. According to the 2017 National
associated with aging and/or disease.
Household Travel Survey, daily travel patterns for
Compared with crashes involving younger drivers, drivers 65 and older show more driving time and
which are due to inexperience or risky behaviors,23 more trips taken in 2017 than in 2009, with the
crashes among older adult drivers tend to be increase coming mostly among those ages 75 and
related to critical errors of inattention or slowed older.27 Older drivers are more likely to wear seat
speed of visual processing.24 Crashes involving belts and are less likely to drive at night, speed,
older adult drivers are often multiple-vehicle, tailgate, consume alcohol before driving, or engage
lower-speed events that occur at intersections and in other risky behaviors.28 Data also suggest that
involve left-hand turns.25 Causes include inadequate older women are more likely to self-regulate than
surveillance and difficulties judging the speed of men.29
other vehicles and the space available, such as an Despite all these self-regulating measures, motor
older driver’s failure to heed signs and grant the vehicle crash and fatality rates per mile driven
right-of-way.24 Lane departures off the road or into begin to increase significantly at age 70.14 On a
an adjacent lane are more frequently due to medical case-by-case level, the risk of a crash depends
events such as blackouts, drowsiness, or seizures.24 on whether each individual driver’s decreased
These driving behaviors indicate that visual, mileage and behavior modifications are sufficient
cognitive, and/or motor factors may affect driving to counterbalance any decline in driving ability. In
ability in older adults. Critical driver errors are some cases, decline may occur so insidiously (e.g.,
significantly more prevalent among older female peripheral vision loss) that the older driver is not
drivers than middle-aged female drivers but did not aware of it until a crash occurs. In fact, a recent
differ significantly by age for male drivers. However, study indicated that some older adults do not
critical errors due to medical events and illegal restrict their driving despite having significant visual
maneuvers occurred significantly more often among deficits.30 Reliance on driving as the only available
older male drivers than those in middle age.24 It is means of transportation can result in an unfortunate

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choice between poor options. In the case of the 2017 National Household Travel Survey, with
dementia, older adult drivers may lack the insight to older drivers travelling multiple times per week.27
realize they are unsafe to drive. These data also indicate that the probability of
In a series of focus groups conducted with older losing the ability to drive increases with advanced
adults who had stopped driving within the past 5 age. It is estimated that the average man will have
years, about 40% of the participants knew someone 6 years without the functional ability to drive a
older than 65 who had problems with driving but car, and the average woman will have 10 years.35
was still behind the wheel.31 Clearly, some older However, many older adults may overestimate
drivers require outside assessment and interventions their driving life expectancy, with more than half
when it comes to driving safety. This is well of drivers surveyed by the Centers for Disease
recognized by older adults themselves, with more Control and Prevention (CDC) reporting they would
than 7 in 10 of 1,700 adults 65 and older surveyed stop driving sometime in their 90s, and 1 in 10
supporting both mandating in-person license reporting they would never stop driving.36 Given
renewals and medical screenings for drivers older this outlook, it is likely that older adult drivers and
than 75.4 caregivers will be unprepared to address issues
related to driving cessation when that time comes.
Driving cessation is inevitable for many and Clinicians have an opportunity to shift the message
often associated with negative outcomes. from the negativity surrounding driving cessation
Driving is essential for performing necessary chores by facilitating a more proactive message through
and maintaining social connectedness, with the initiation of transportation planning early in the
latter having strong correlates with mental and process, when the discussion can include more
physical health.32 Many older adults continue to options so the individual has more control and
work past retirement age or engage in volunteer choice in the process. This may assist in avoiding
work or other organized activities. In most cases, decisions of cessation becoming an urgent matter
driving is the preferred means of transportation. or crisis. Clinicians can start the conversation about
In some rural or suburban areas, driving is the transportation planning early on to promote control
only available means of transportation. Just as the and choice by older adults and minimize urgent
driver’s license is a symbol of independence for crisis situations when driving cessation occurs.
adolescents, the ability to continue driving means Studies of driving cessation have noted increased
independent transportation and access to resources social isolation, decreased out-of-home activities,36
for day-to-day life for older adults and is highly and increased depressive symptoms.37,38 These
valued.33,34 outcomes have been well documented and
In a survey of 2,422 adults 50 and older, 86% of represent some of the negative consequences of
participants reported that driving was their usual driving cessation. It is important for the clinical
mode of transportation. Within this group, driving team to be supportive in the face of what may be
was the usual method of transportation for 85% of a devastating loss of independence, and to use
participants 75-79 years old, for 78% of participants available resources and professionals who can assist
80-84 years old, and for 60% of participants 85 and with transportation to allow older adults to maintain
older.26 This high utilization continued to be true in independence. These issues will be discussed in
subsequent chapters.

12
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Clinical team members can influence older adult driving-impairing medications. Driving abilities
drivers’ decisions to modify or stop driving, as share many attributes necessary for successful
well as help older adult drivers maintain safe ambulation, such as adequate visual, cognitive, and
driving skills. motor function. In fact, a history of falls has been
Although older adult drivers believe they should associated with a significantly increased risk of
be the ones to make the final decision about motor vehicle crash.42,43 Clinical team members can
driving,39 they also agree that their primary care reduce future risk of falls and fractures by advising
providers should advise them. In a series of focus on fall prevention and addressing certain extrinsic
groups conducted with older adults who had (environmental) and intrinsic factors.44 Tools such
stopped driving, all agreed that clinicians should as the CDC’s My Mobility Plan provides general
talk to older adults about driving, if a need exists. guidance for older adults seeking to maintain both
Although family advice had limited influence on the individual and community mobility.45
participants, most agreed if their physicians advised There is an assumption that clinical team members
them to stop driving and their family concurred, can and do make a difference by evaluating
they would certainly do so.31,40 This is consistent older adults for their fitness to drive. However,
with a focus group study with caregivers of drivers there is a crucial need for systematic study of this
with dementia, who stated that physicians should be hypothesis.46 Research and clinical reviews on the
involved in this important decision-making process.5 assessment of older adult drivers have focused on
Communication about driving is an emotionally screening methods to identify unsafe drivers and
charged and context-sensitive topic for older drivers restrict older drivers. Efforts to evaluate the efficacy
that best occurs with trusted providers, over time of driving rehabilitation strategies have been
and in a way that allows the older adult to maintain recently reviewed and updated by the occupational
agency.41 The clinical team together can provide therapy community,47 but other clinical interventions
the most complete information and advice for older have not been similarly studied in the United States.
adults and caregivers when arriving at decisions Clinical team members are in positions to identify
regarding driving. older adults at risk of unsafe driving or self-imposed
In addition to helping determine ability to drive driving cessation because of functional impairments,
safely, the members of the clinical team can assist and to help address and manage these issues so
at-risk older adult drivers to maintain safe mobility that older adults can continue to drive safely for as
in multiple ways, including recommending effective long as possible.
treatment and preventive health care measures, The final determination of an individual’s ability
playing a role in determining the ability of older to drive lies with the state licensing authority;
adults to drive safely, counseling older adults however, clinical team members can assist with
and caregivers, and helping access alternative this determination. Driver licensing regulations
transportation resources. and reporting laws vary greatly by state, and some
In many cases, clinical team members can help state laws are vague and open to interpretation.
older adult drivers to stay on the road longer by Therefore, it is important for clinical team members
identifying and managing medical conditions, to be aware of their state reporting laws and
such as cataracts and arthritis, or by discontinuing their responsibilities for reporting unsafe drivers

13
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

to the local driver licensing authority. For more - Refer older adult drivers with persistent deficits
information on state laws, see Chapter 8. For more despite optimal medical treatment, when
information on the role of the state licensing agency appropriate, to a driving rehabilitation specialist
in promoting safety of older drivers, see Chapter 10. for further driving evaluation and/or training in
Thus, clinical team members can play a more the use of adaptive equipment (see Chapter 5).
active role in preventing motor vehicle crashes n At all times, discuss the maintenance of
by assessing and counseling older adult drivers driving ability, safe driving behaviors, and driving
regarding their fitness to drive, recommending safe restrictions. When appropriate, counsel older
driving practices, referring older adults to driver adults and their caregivers on the importance
rehabilitation specialists, advising or recommending of transportation planning and potential driving
driving restrictions, and referring older adults cessation (see Chapter 6).
to state licensing authorities when appropriate. n Perform interval reevaluations and follow-up
To achieve these ends, clinical team members with older adults who should adjust their driving to
can follow the general principles below and determine if they have made changes, and monitor
recommendations in the algorithm Plan for Older those who stop driving for signs of depression and
Drivers’ Safety (PODS) (see below in this chapter): social isolation. Older drivers’ abilities are not static
n Screen for red flags such as medical conditions, and may improve or decline as their conditions
potentially driver-impairing medications, and recent change. For example, an older adult may benefit
adverse driving events or behaviors (see Chapter 2 from physical therapy after a stroke or surgery and
and the Appendix B handouts Testing Driver Safety, regain functional abilities permitting a return to
Drivers 65 Plus: Check Your Performance Self-Rating driving. Older adults may therefore reenter the
Tool, and How to Understand and Influence the PODS algorithm for reevaluation and/or treatment
Older Driver). at any step along the way.
n Assess driving-related functional skills in those Although primary care providers may have access
older adults at increased risk of unsafe driving. to the most resources to perform the PODS, other
For the toolbox of functional assessments, see clinicians also have a responsibility to discuss driving
the Clinical Assessment of Driving Related Skills with older adults. In addition, specialists in the fields
(CADReS) in Chapter 3. of cardiology, ophthalmology, neurology, psychiatry,
n Evaluate and treat at-risk older drivers for psychology, rehabilitation, orthopedics, emergency/
medical conditions and other causes that may be urgent care, trauma, and others all encounter older
impairing functional skills related to driving and adults with conditions that may have an impact on
intervene to: driving skills. When advising older adults, clinical
team members may wish to consult the reference
-O
 ptimize the treatment of underlying
list of medical conditions in Chapter 9.
medical and functional contributors to driving
impairment within the clinical team member’s
scope of practice or by referral to another
clinical team member or medical subspecialist
(see Chapter 4).

14
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Plan for Older Drivers’ Safety (PODS)

Plan for Older Drivers’ Safety (PODS)
Plan for Older Drivers’ Safety (PODS)

Step 1: Screening and Observation

Medical condition of concern?
Step 1: Screening
Symptoms and Observation
on review of systems?
Medical condition
Current/former driver?ofWants
concern?
to drive?
DrivingSymptoms onchanges
incidents or review of
in systems?
the past 5 years? Not At Risk: Minimal to No Positive Risk Factors Identified
Current/former driver? Wants
Older adult/caregiver to drive?
concerns? Discuss transportation plans and health maintenance
Driving incidents or changes in the past 5 years? Not At Risk: Minimal to No Positive Risk Factors Identified
Older adult/caregiver concerns? Discuss transportation plans and health maintenance
At Risk: Positive Risk Factors Identified
Step 2: Use Clinical Assessment of Driving Related Skills
(CADReS)Atto
Risk: Positive
Identify Risk Factors
Impairments andIdentified
Seek Remediation
Step
+ 2: Use Clinical Assessment +of Driving Related Skills + +
(CADReS) to Identify Impairments and Seek Remediation
+ + + +
Motor/Sensory:
General: Cognitive:
Vision: Range of Motion,
Driving History, IADLs MoCA, Trails B, Motor/Sensory:
Proprioception, Get Up
General: Fields, Acuity, Cognitive:
Questionnaire, Vision: Clock Drawing, and Go,of
Rapid Pace
Contrast Range Motion,
Medication
Driving Change
History, IADLs MoCA,Maze
Trails B, Walk Get Up
Fields, Acuity, Proprioception,
Questionnaire, Clock Drawing, and Go, Rapid Pace
Contrast
Medication Review Maze Walk

Step 3: Analysis of Screen and CADreS Not At Risk

Step 3: Analysis of Screen and CADreS Not At Risk

At Risk

At Risk
Clinical Specialist Evaluation and Driving Rehabilitation Specialist Evaluation
Intervention*
Clinical Specialist Evaluation and Driving Rehabilitation Evaluation
Intervention*
Rehab/ Vehicle
Medical Medical Intervention Adaptation/
Conditions Conditions Needed:
Rehab/ Training Needed:
Vehicle
Uncompensated
Medical Optimized
Medical Intervention
Refer to a Adaptation/
Refer to Available
orConditions
In Recovery Conditions Needed:
Specialist Training Needed:
Resources
Uncompensated
Phase Optimized Refer to a Refer to Available
or In Recovery Specialist Resources
Phase

Step 4: Driving Deficit Results

Step 4: Driving Deficit Results

No Significant Driving Deficit Identified: Fit To Drive

Driving Deficit Identified
Discuss transportation plans and health maintenance
No Significant Driving Deficit Identified: Fit To Drive
Driving Deficit Identified
Discuss transportation plans and health maintenance
Cessation of Driving:
Fit to Drive with No Driving Yet:
Restrictions: Counsel on
AlternativeofModes of Refer for Recovery
Perform Interval Cessation Driving: Plan
Fit to Drive with Transportation; Call NotoDriving
Revisit Yet:
Driving
Re-evaluations
Restrictions: Counsel on Repeat Step 3
for Family Meeting Refer for Recovery
Alternative Modes of
Perform Interval Plan to Revisit Driving
Transportation; Call
Re-evaluations Repeat Step 3
for Family Meeting

IADLs Instrumental Activities of Daily Living

MoCA Montreal Cognitive Assessment
IADLs Pathway stepActivities
Instrumental may be repeated if progressive assessment necessary
of Daily Living
*
MoCA Clinical specialists
Montreal Cognitivemay include medicine, nursing, rehabilitation, pharmacy
Assessment
and social
Pathway work,
step mayorbeothers, depending
repeated on the assessment
if progressive clinical setting
necessary
*---- Time Lapse
Clinical specialists may include medicine, nursing, pharmacy, social work,
occupational or physical therapy, psychology and others, depending on the
clinical setting
---- Time Lapse 15
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

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17
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

C H A P T E R 2 IS THE OLDER ADULT AT INCREASED RISK OF UNSAFE DRIVING?

KEY POINTS
n When taking the older n Do not make assumptions n Health care providers
adult’s history and reviewing about whether an older adult should take the approach of
the medical record, be alert is driving. Always be sure to optimizing safe driving rather
to “red flags,” which include ask about this key instrumental than simply stopping older
any medical conditions, activity of daily living. adults from driving.
health symptoms (e.g., pain, n Age alone is not a red flag
fatigue), visual, cognitive, or for driving safety. The media
motor changes, medications, often emphasizes age when an
functional decline, or older driver is involved in an
symptoms or signs that can injurious crash.
affect driving skills and safety.

T
Mr. Phillips, an 82-year-old man with a history his chapter discusses the first steps of the
of hypertension, congestive heart failure, Plan for Older Drivers’ Safety (PODS) and, in
atrial fibrillation, macular degeneration, and particular, provides a strategy for answering
osteoarthritis, comes to your office for a the question “Is the older adult at increased risk of
routine check-up. Mr. Phillips ambulates with a unsafe driving?” This part of the evaluation process
wide-based ataxic gait, uses a walker, and has includes clinical observation of the older adult,
impaired standing balance. He is unable to stand identifying red flags such as medical conditions,
from the exam chair without multiple attempts including cognitive and physical conditions,
and use of his arms, and he reports feeling symptoms associated with chronic illnesses, and
temporarily lightheaded on standing. He is no medications that may impair safe driving and
longer able to read newspaper print and tells you inquiring about new-onset driving behaviors that
he avoids driving at night and only goes short
may indicate declining traffic skills. The goal of the
distances to run errands, get to appointments,
assessment is to facilitate driving safety among
and meet weekly with his bridge club.
older adults and assure that those who can drive
Mrs. Bales, a 90-year-old woman, lives in a safely are helped to do so for as long as possible.
continuing care retirement community with her
92-year-old husband for whom she is the primary STEPS TO ANSWER THIS QUESTION
caregiver because of his Parkinson disease.
Observe the older adult throughout the
Her past medical history includes early macular
encounter.
degeneration, degenerative joint disease, and
hypertension. She has decreased range of Careful observation is often an important step in
motion in her neck and walks without an assistive diagnosis. During all patient encounters, clinicians
device but with a wide-based gait. She drinks should observe the older adult and be alert to:
a moderate amount of alcohol daily and was n  ensory impairment such as decreased vision,
S
recently started on oxycodone for chronic pain. hearing, or sensation in the extremities

18
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

n Inattention or loss of insight regarding personal are diagnosed, treated, and resolved. Significant
care (e.g., poor hygiene and grooming) pain and associated limitations in function seen with
n Impaired ambulation (e.g., difficulty walking or degenerative joint disease and use of opioids for
getting into and out of chairs)
Table 2.1 - Clinical Risk Factors for Impaired Driving
n  ifficulty with way finding (e.g., getting to or out
D
of the office) Risk Factor Signs and Symptoms

n Impaired attention, memory, language expression, Physical n Impaired balance

or comprehension capabilities n Vision and/or hearing impairment (not
hearing emergency sirens or horns honk-
n  ifficulties or lack of insight related to
D ing, not seeing street signs)
managing medical encounters, such as missed n Functional impairment, such as sensory or

appointments, repeated phone calls for the same range or motion (particularly ankle) with
regard to use of gas or brake pedals
issues, or appearing on the wrong day
n Decreased ability to turn the head to fully

In the example above, Mr. Phillips has difficulty with visualize an area
n Slow response to visual or auditory cues
balance and strength as revealed by his inability to
n Problems with reflexes (not reacting
get up from the chair without multiple tries and his quickly when there is a need to brake
wide-based gait. Moreover, he has visual changes suddenly)
such that he cannot read normal size print materials.
This raises a question as to whether he can operate Cognitive n Decreased short-term memory
ability n Decreased or impaired way finding
vehicle foot pedals properly or see well enough
n Easily distracted
to both drive and find his way safely. His physical
n Inability to learn new information quickly
limitations may not preclude driving, but they may n Inability to recognize unsafe situations
be indicators that more assessment is indicated. n Confusion over names and dates
n Difficulty with instrumental activities of
Be alert to conditions in the older adult’s med- daily living
ical history, examine the current list of medica-
tions, and perform a comprehensive review of Driving n Not using turn signals appropriately
systems. ability Difficulty turning the wheel and making
turns
During an interview of the older driver, clinicians n Difficulty staying in the correct driving

should be alert to “red flags,” i.e., any medical lane

n Difficulty judging the space between cars
condition, medication, or symptom that can affect
or upcoming exits
driving skills, due to acute changes or chronic n Hitting curbs when parking or backing up
functional deficits (see Chapter 9). Health symptoms n Stopping in traffic inappropriately
have been noted to be more strongly associated n Not following stop signs, yield signs,

with driving difficulties than health conditions.1 traffic lights, etc.

n Not noticing workmen or activity on the
For example, Mr. Phillips (introduced in previous
side of the road
chapter) presents with lightheadedness associated n Inappropriate speeds for the weather/
with atrial fibrillation. Symptoms of dizziness should driving conditions
be considered as a red flag, and Mr. Phillips should History of traffic violations, minor crashes,
or warnings
be counseled to cease driving until his symptoms

19
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

pain management, such as those noted with Mrs. or nausea, can impact the ability to concentrate
Bales, should also be considered “red flags.” Other and drive safely. Concern may be heightened in
conditions may impact safety and/or require training the face of already-present underlying concerns
to use compensatory techniques when driving, about visuospatial processing speed, cognition,
e.g., limited range of motion in the neck. Acute or or functional changes (e.g., the Trails B test [see
chronic pain can also be distracting and make it Chapters 3 and 4]), slow response time, and
unsafe for older adults to drive. Many factors can decreased attention.
put individuals at risk of unsafe driving and should The review of systems can reveal symptoms that
be explored during office visits (Table 2.1). may interfere with driving ability. For example, pain,
Most older adults have at least one chronic medical fatigue, episodes in which there has been a loss
condition and many have multiple conditions, the of consciousness, confusion, falling asleep while
most common including arthritis, hypertension, driving, feelings of faintness, memory loss, visual
hearing impairments, heart disease, cataracts, impairment, numbness or tingling in extremities,
dizziness, orthopedic impairments, and diabetes.2 history of falls, and muscle weakness (e.g., difficulty
The impact of multiple comorbidities is not well getting up from a chair) all have the potential to
known. Some of these conditions have been affect driving safety.
associated with driving impairment by virtue of both The clinical team should not make assumptions
their symptoms and their treatments (e.g., arthritis about whether an older adult is driving and should
and pain and fatigue; medication adverse effects) always be sure to ask about this important activity
that can influence driving safety. These conditions of daily living. Sometimes, older drivers themselves
will be discussed in more detail in subsequent or caregivers may raise concerns. If the older adult
chapters, including a reference list of medical or his or her caregiver asks your opinion about
conditions and medications that may affect driving whether the individual is safe to drive, any concerns
in Chapter 9, with some of the more common that have been noted should be explored. Has the
chronic conditions noted below in Table 2.3. older adult had any recent crashes, near-crashes,
Chronic illness and associated symptoms should or citations? Is he or she feeling uncomfortable or
be acknowledged and addressed so that driving, in unsafe driving? A list of specific driving behaviors
some situations, can be safely continued. that could indicate concerns for safety are found
Older adults generally take more medications in the Fitness to Drive Measure (freely available
than their younger counterparts and are more online).4 Clinicians should encourage caregivers to
susceptible to adverse effects. The American monitor and observe skills of the older adult driver
Geriatrics Society Beers Criteria® for potentially in real-world traffic situations, with full disclosure
inappropriate medication use in older adults is a and permission from the older driver. Concern
useful tool for screening medication lists.3 Whenever should be noted if caregivers will not drive with
medication is prescribed or the dosage of a current the individual or let others drive with him or her. If
medication is changed, it is important to inform the older adult is living in a retirement community
the older adult of potential effects or drug-drug (or continuing care retirement community, assisted
interactions that might affect driving safety. Adverse living, etc.), it may be helpful to obtain collateral
effects, such as drowsiness, confusion, dizziness, history from other observers about whether they

20
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

have noticed any driving behaviors that might drive versus on age per se. Identifying problems in
indicate unsafe driving (e.g., inappropriate speeds, these areas and managing them appropriately is
not stopping at stop signs, not slowing over curb one of the ways in which the clinical team may be
bumps, bumping into/scraping other cars). able to help older adults continue to drive safely
Age alone is not a red flag! Unfortunately, the rather than simply stopping them from driving.6
media often emphasizes age when an older driver
Inquire about driving during the social history
is involved in an injurious crash. This “ageism” is a
and health risk assessment.
well-known phenomenon in U.S. society.5 Although
many people experience a decline in vision, A health risk assessment is a series of questions
cognition, or motor skills as they get older, these intended to identify potential health and safety
changes occur at different rates, and older adults hazards in the older adult’s behaviors, lifestyle,
experience functional changes to different degrees. and living environment (Table 2.2). The health
Further, older adults have different perceptions of risk assessment is tailored to the older adult and
their own driving ability and perceptions of how generally focuses on physical activity, falls, drinking
others perceive their driving ability. These beliefs (alcohol), medication management, sleep, nutrition,
are related to self-regulatory driving ability.1 The and driving. Relevant questions about driving as
focus should be on functional abilities (cognitive part of the health risk assessment are shown in
and physical), symptoms, and medical fitness to Table 2.2. Alternatively, more open-ended questions

Table 2.2 - Questions About Driving

Exploratory Questions
How did you get here today? Questions for caregivers if concerns
Do you drive? are raised:
How often do you believe _____ drives?
How much do you drive?
Do you drive to the store? hairdresser? bank? Have you had the opportunity to ride with _____ in the
past month?
Do you drive at night?
Do you feel safe in the car when riding with _____?
Have you lost any confidence in your ability to
be a safe driver? Do you have any concerns about _____’s driving ability?
Have others expressed concern about your driving? If a patient presents a form from the licensing agency,
What would you do if you had to stop driving? the clinician should ask why they are being asked to
submit the form.
Are you comfortable when seated in your car?
Tell me about your ability to see signs when driv- Health Risk Assessment Questions
ing? To manage the steering wheel? To manage n Physical activity and diet history
the foot pedals? To visualize the traffic lights and n Daily alcohol intake
signs?
n Daily medication management concerns or use of
Do you often get lost while driving? sedating medications
Have you received any traffic violations or n History of falls
warnings in the past 2 years?
n Use of seat belts
Have you had any crashes or near-crashes in
the past 2 years? n Sleep history

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

can be asked such as: “Tell me how you obtain your diabetes) and medications that may affect driving,
groceries,” “How do you get to the hairdresser?” see Chapter 9.)
or “What do you do during the course of a routine If the older adult does not currently drive, ask if
day?” These can then lead into more specific he or she ever drove and what the reason was for
questions about driving and/or alternative options stopping. If the older adult voluntarily stopped
for transportation. driving because of medical reasons that are
If the older adult drives, then his or her driving potentially treatable, it may be possible to help
safety should be addressed if red flags are raised. him or her return to safe driving. In this case,
In addition, whenever there is any change in a formal assessment of function can be performed
medical condition or medication that could impact to identify specific areas of concern and serve as a
driving, the impact on driving safety should be baseline to monitor the individual’s improvement
considered. For example, Mrs. Bales should be with treatment. Referral to a driver rehabilitation
cautioned regarding driving because of starting on specialist in these cases is strongly encouraged (see
a narcotic for pain management, and she should Chapter 5).
be encouraged to initiate a short driving-free When exploring driving ability, it is very useful to
period while she evaluates the impact of the new also speak with a caregiver to confirm what the
medication on her driving skills. older adult has stated. As noted above, if the older
In contrast, for chronic medical conditions, driving adult lives in a retirement community or continuing
safety is addressed by formally assessing the care retirement community, the staff or colleagues
functions important for driving (see Chapter 3). and friends that have driven with the individual may,
Chronic medical conditions and their associated with permission, also be able to provide invaluable
symptoms should be considered when evaluating information because they have had the opportunity
driving ability and safety. For example, an older to observe the individual’s driving activities,
adult with congestive heart failure may have an techniques, and safety.
acute exacerbation with increased shortness of If caregivers are particularly concerned, it may be
breath, fatigue, and difficulty concentrating. The helpful to have them review the Fitness-to-Drive
exacerbation of the heart failure can result in the Screening Measure (http://fitnesstodrive.phhp.ufl.
need for increased use of diuretics and, therefore, edu/us/). These questions include situations such
risk of dizziness, fatigue, or electrolyte imbalance. as making left-hand turns, hazard detection, and
This individual might not be safe to drive and lane changes and classify the driver as being at-risk,
should be counseled to avoid driving until the routine, or accomplished. This can help to start a
symptoms of heart failure and the adverse effects conversation about driving safety.
from medication management have resolved.
Ongoing evaluation after stabilization is needed. Understand the older adult’s mobility needs.
The clinician should also recommend formal
Asking about the older adult’s mobility needs
assessment of function as described in Chapters
and encouraging him or her to begin exploring
3 and 4 if the older adult shows any signs of
alternative transportation options before it becomes
chronic functional decline. (For more complete
imperative to stop driving is advised. Resources
recommendations on medical conditions (e.g.,
such as the free program called CarFit (http://www.

22
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

car-fit.org) can help optimize the “fit” of the car to n If your car ever broke down, how would you
the individual to ensure that components like side get around? Is there anyone who can give you
and rearview mirrors are properly adjusted and a ride? Can you use public transportation, such
that the seatbelt fits properly. When a diagnosis is as a bus or train? Does your community offer
encountered that may lead to the need for adaptive a shuttle service or volunteer driver service?
equipment or driving cessation, the clinician should Have you heard of or ever used a transportation
advise the older adult of the potential impact on network companies such as Uber or Lyft?
driving. For example, an older adult with multiple n  re there walkable options for groceries,
A
sclerosis could be advised that hand controls medications, or other activities and services?
might be necessary in the future. Without ongoing
It can also be useful to explore the cost/benefit of
discussion, older adults who have not planned for
driving (such as car maintenance and insurance)
any forms of alternative transportation may feel
versus using a taxi service, a transportation network
that they have no choice but to continue driving,
company, or other type of public or community
increasing their likelihood of continuing to drive
transportation.
after they may have lost the capacity to do so. Even
if alternative transportation options are not needed Older adults should be encouraged to plan a safety
at this point, it is wise for older adults to plan ahead net of transportation options. It can be helpful
in case it becomes necessary. These are difficult to link independent mobility to clinical concern
conversations to have, and clinical team members for the older adult’s well-being with phrases such
should remember to be respectful and sensitive as “Mobility is very important for physical and
knowing that driving is often an integral part of emotional health. If you were ever unable to drive
independence. Some techniques include giving for any reason, I’d want to be certain that you could
specific examples of the reasons for the discussion still make it to your appointments, pick up your
rather than generalizations, and noting, for medications, go grocery shopping, and visit your
example, if the older adult is having a harder time friends.”
turning his or her head than previously. Explaining Sources of educational materials on alternatives
that this can make visualization problematic is likely to driving are listed in Appendix B and include
to be more helpful than just stating that the older resources from the National Aging and Disability
adult can’t drive anymore. Further, the clinical team Transportation Center.8 Other resources are
member should make sure to help find alternatives available through AARP (https://www.aarp.org/
to driving, such as recommending the use of taxi auto/driver-safety/driving-tips/) and the University
services or transportation network companies such of Michigan Transportation Research Institute (www.
as Uber or Lyft. The older adult may be so used umtri.umich.edu/critical-issues/senior-mobility).9 If
to driving that he or she has never considered an older driver must stop driving, the transition will
alternatives. be less traumatic if he or she has already created
Some questions to use to initiate this conversation a transportation plan. In addition, the handout
using the Hartford “We Need to Talk” discussion Getting By Without Driving, or Transportation
materials7 include: Options for Older Adults can help the older adult
get started (Appendix B). Useful options such as
n  ow do you usually get to shopping or health
H
Go Go Grandparent (https://gogograndparent.
care appointments?

23
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

com/) may be available and can be used for direct the Clinical Assessment of Driving Related Skills
transportation to appointments or activities, as well (CADReS) tests (Chapters 3 and 4).
as to get groceries delivered.
Acute Events
Counseling Older Adult Drivers in the Any acute health event, whether requiring
Inpatient Setting
hospitalization or not, is a red flag for immediate
When caring for older adults in the acute hospital assessment of driving safety. If the older adult
setting, it is critical to use this opportunity to has been hospitalized, it is particularly important
consider if the individual is currently safe to to counsel him or her as well as caregivers on
drive.10 Discharge from acute care is a good time driving safety issues. As noted above, acute
to review how the individual will get medications disease exacerbations can serve as an opportunity
and groceries and to their medical appointments. to address, or readdress, driving concerns. As a
Counseling may include recommendations for general recommendation, older adults should cease
temporary or permanent driving cessation or driving after an acute event until their primary care
for driving assessment and rehabilitation when provider indicates they are able to drive again. This
the individual’s condition has stabilized. Such is particularly important after any of the following
recommendations are intended to promote safety common acute events or associated treatments.
and, if possible, help the older adult develop a n Acute myocardial infarction
transportation plan during the recovery process
n Acute stroke or other traumatic brain injury
and, as appropriate, work toward regaining his or
her ability to drive. Case managers may be able n Arrhythmia (e.g., atrial fibrillation, bradycardia)
to assist with this process. The transportation plan n Lightheadedness, dizziness
should be included in the discharge summary that
n Orthostatic hypotension
goes to the rehabilitation/subacute setting and/or
to the older adult’s primary care provider. n Syncope or presyncope
n Vertigo
RED FLAGS FOR FURTHER ASSESSMENT
n Seizure
Older Adult Driver’s or Caregiver’s Concern n Surgery
Regardless of the setting of care, older adult drivers n Delirium from any cause
and their caregivers may express concerns about
n  ewly prescribed sedating medications or those
N
driving safety. If so, the cause of concern should
that can cause confusion or dizziness
be investigated, specifically if there have been
n  cute psychiatric diseases impairing cognitive
A
recent motor vehicle crashes, near-crashes, traffic
function or decision making
tickets, instances of becoming lost, trouble making
sudden lane changes, trouble with left hand turns,
Chronic Medical Conditions
drifting into other lanes, braking or accelerating
suddenly without reason, failing to use the turn Older adults may require focused assessments
signal, keeping the signal on without changing to determine the impact of the following chronic
lanes, or if there is poor night vision, forgetfulness, medical conditions on their level of function
or confusion. Function should be evaluated using (detailed information in Chapter 9).

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Table 2.3 - Chronic Medical Conditions that May Impact Driving

Medications
Medical Condition Examples
Many nonprescription and prescription
Diseases/ n Cataracts
conditions n Diabetic retinopathy
medications have the potential to impair
affecting vision driving ability, either alone or in combination
n Macular degeneration
n Glaucoma with other drugs. Combinations of drugs
n Retinitis pigmentosa may affect drug metabolism and excretion,
n Field cuts
and dosages may need to be adjusted
n Low visual acuity even after correction
accordingly. In addition, clinicians should
Cardiovascular n Unstable coronary syndrome always ask about alcohol and marijuana use
disease, n Arrhythmias
especially when and timing of intake (for more information
n Palpitations
associated with on each medication class that may affect
presyncope, n Congestive heart failure

syncope, or n Hypertrophic obstructive cardiomyopathy

driving, see Chapter 9). Medications with
cognitive deficits n Valvular disease strong potential to affect driving ability
Neurologic n Dementia include:
disease n Multiple sclerosis n Anticholinergics
n Parkinson disease
n Peripheral neuropathy
n Anticonvulsants
n Brain injury n Antidepressants
n Spinal cord injury
n Antiemetics
Psychiatric n Mood disorders
disease n Depression
n Antihypertensives
n Anxiety disorders n Antiparkinsonian agents
n Psychotic illness
n Personality disorders
n Antipsychotics
n Alcohol or other substance abuse n  enzodiazepines and other sedatives/
B
Metabolic n Type 1 and type 2 diabetes mellitus (espe- anxiolytics
disease cially with hypoglycemic attacks or severe
swings in blood glucose) n Hypoglycemic agents
n Hypothyroidism n Muscle relaxants
Musculoskeletal n Arthritis and foot abnormalities n Narcotic analgesics
disabilities n Contractures and decreased range of motion
n Inflammation
n Stimulants
n Pain n Hypnotics
Respiratory n Chronic obstructive pulmonary disease n Marijuana
disease n Obstructive sleep apnea
n Alcohol
Chronic renal n End stage renal disease
failure n Hemodialysis n  ver-the-counter agents with
O
Cancer and n Weakness and extreme fatigue anticholinergic adverse effects such
chemotherapy n Medication side effects as sleeping agents or allergy/cold
medications, which are often first-
Insomnia n Sleep apnea
n Restless leg syndrome
generation antihistamines
n Anxiety/depression/pain contributing to
insomnia

25
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Review of Systems n  ollowing a care transition (e.g., acute care to

F
The review of systems can reveal symptoms or subacute care or home setting; home setting
conditions that may impair driving performance. to a continuing care retirement community or
Symptoms associated with acute and chronic assisted living)
medical problems are critically important red flags
Table 2.4 - Organ Systems and Symptoms
and should be carefully explored.
Organ System “Red Flag” Symptoms
Assessment and Plan General n Fatigue n Dizziness
Clinicians should consider screening at-risk older n Weakness n Pain

adults using red flags and identifying common Head, ears, n Headache
eyes, nose, n Double vision
signs, symptoms, and medical conditions throat n Visual changes
associated with impairment of driving safety in (HEENT) n Vertigo
every clinical setting. When formulating a diagnosis n Change in ability to read

and treatment plan for older adults, driving n Change in visual acuity
n Decreased hearing
safety should be addressed whenever needed.
Identification of risk early on may facilitate primary Respiratory n Shortness of breath
n Use of oxygen
prevention and interventions to prevent the loss
of driving ability. Ongoing monitoring of chronic Cardiac n Chest pain
n Dyspnea on exertion
illness may facilitate secondary prevention efforts n Palpitations
to rehabilitate the loss of driving skills and attempts n Sudden loss of consciousness

to restore those skills. Red flag indicators and n Increased swelling in the legs

acute events may signal that loss of driving skills is Musculo- n Muscle weakness
irreversible , and tertiary prevention should include skeletal n Pain
n Joint stiffness
recommending alternatives to driving to avoid harm
n Decreased range of motion
to the older adult and others. It is also critically
Neurologic n Loss of consciousness
important to recognize that some older adults may
n Fainting
have impaired insight with regard to their driving n Seizures
safety, and self-reports should be confirmed with n Weakness
n Paralysis
caregivers or others who may be familiar with
n Tremors
the older adult’s driving ability.11 In summary,
n Loss of sensation
assessment of driving safety can and should be n Numbness
routinely integrated into the care plan when: n Tingling
n Changes in memory and ability to recall
n  new diagnosis or change occurs in any
A recent events, or difficulty with word
condition that has been associated with finding, way finding, decision making,
or concentration
impaired driving
n Changes in psychological stability or

n  new medication is prescribed, or the dosage

A orientation: confusion, psychosis, mania,
disorientation
of a current medication is changed
Psychiatric n Depression n Hallucinations
n A change in functional abilities is reported n Anxiety n Delusions
n Delirium n Psychosis
n As part of an annual wellness visit

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

REFERENCES

1. T
 uokko, H., Sukhawathanakul, P., Walzak, L., Jouk, A., Myers, A.,
Marshall, S., Naglie, G., Rapoport, M., Vrkljan, B., Porter, M., Man-
Son-Hing, M., Mazer, B., Korner-Bitensky, N., Gelinas, I., & Bedard,
M. (2016). Attitudes: Mediators of the relation between health and
driving in older adults. Canadian Journal on Aging, 35(51), 45-58.
https://doi.org/10.1017/S0714980816000076.
2. W
 ard, B. W., Schiller, J. S., & Goodman, R. A. (2014). Multiple chronic
conditions among US adults: a 2012 update. Preventing Chronic
Disease, 11:E62. https://doi.org/10.5888/pcd11.130389.
3. T
 he 2019 American Geriatrics Society Beers Criteria® Update Expert
Panel. (2019) The 2019 American Geriatrics Society Beers Criteria®
for potentially inappropriate medication use in older adults. Journal
of the American Geriatrics Society. Published online January 31,
2019. https://doi.org/10.1111/jgs.15767.
4. U
 niversity of Florida Institute for Mobility, Activity and Participation.
(2013). Fitness-to-drive screening measure online. Retrieved from
http://fitnesstodrive.phhp.ufl.edu.
5. N
 elson, T. (2002). Ageism: Stereotyping and Prejudice Against Older
Persons. Cambridge, MA: MIT Press.
6. G
 olisz, K. (2014, November-December). Occupational therapy
interventions to improve driving performance in older adults: a
systematic review. American Journal of Occupational Therapy, 68(6),
662-669. https://doi.org/10.5014/ajot.2014.011247.
7. T
 he Hartford Financial Services Group, Inc. (2015, July). Family
Conversations with Older Drivers. Retrieved from https://s0.hfdstatic.
com/sites/the_hartford/files/we-need-to-talk.pdf.
8. N
 ational Aging and Disability Transportation Center. Transportation
options for older adults: choices for mobility independence.
Retrieved from http://www.nadtc.org/resources-publications/
transportation-options-for-older-adults-choices-for-mobility-
independence/.
9. U
 niversity of Michigan Transportation Research Institute. (2007).
Senior Mobility. Retrieved from http://www.umtri.umich.edu/critical-
issues/senior-mobility.
10. Baker, A., Bruce, C., & Unsworth, C. (2014). Fitness-to-Drive
decisions for acute care and ADHD. Occupational Therapy
Practitioner, 19(10), 7-10.
11. Wood, J. M., Lacherez, P. F., & Anstey, K. J. (2013). Not all older
adults have insight into their driving abilities: evidence from
an on-road assessment and implications for policy. Journal of
Gerontology, Series A: Biological Science and Medical Science,
68(5), 559-566. https://doi.org/10.1093/gerona/gls150.

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

CHAPTER 3 S
 CREENING AND ASSESSMENT OF FUNCTIONAL
ABILITIES FOR DRIVING

KEY POINTS
n An assessment of underlying n Older adults with physical n The Clinical Assessment
functional abilities important and/or visual impairments of Driving Related Skills
for safe driving (e.g., vision, have a greater potential to (CADReS) is a toolbox of
cognition, motor) should benefit from intervention evidence-based practical,
determine the need for further to continuing safe driving office-based assessment tools
evaluation and subsequent than those with cognitive to screen for impairment in the
intervention, and/or for a more impairment, because adaptive key areas of vision, cognition,
specialized driving evaluation. equipment and compensatory and motor/sensory function as
n Significant functional strategies are available. they relate to driving.
impairment may necessitate n No single assessment can n Self-report or self-
cessation of driving and accurately predict the ability assessment has not been
the need for assistance in to drive safely; a target set of shown to be an adequate
developing a plan for safe assessment tools should be measure of fitness-to-drive.
alternative methods of used to determine risk in older
transportation to maintain adults based on functional
mobility. impairments.

I
Mr. Phillips has been accompanied to the clinic ncreasing longevity in the U.S. population means
by his son, who is in the examination room that, because of comorbid conditions, many
with him. Mr. Phillips tells you that he is a safe older adults may outlive their ability to drive
driver. You request and obtain permission to safely. Men are projected to live approximately
interview the son, who voices his concern. Four 6 years and women 10 years longer than their
months ago, Mr. Phillips was involved in a minor ability to drive.1 The implication of this projection
car crash, which was his fault. He has also had for clinical practice is the increasing need for an
several near-crashes in the past 2 years. He has evidence-based “decision” to be made about
never been lost while driving. driving safety, or stopping driving, for independent
In discussing Mr. Phillips’ transportation community-dwelling adults. This chapter focuses
options, you learn that driving is Mr. Phillips’ on the assessment of functional abilities needed to
main mode of transportation, and he drives safely operate a motor vehicle, or “fitness to drive.”
almost every day. Although Mr. Phillips is Fitness to drive is a description of a driver who has
certain—and his son confirms—that family an absence of any functional (sensory–perceptual,
members and neighbors would be willing to cognitive, or psychomotor) deficit or medical
drive him wherever he needs to go, he has condition that significantly impairs an individual’s
never asked for rides. “Why should I ask for ability to fully control the vehicle while conforming
rides when I can just drive myself? Besides, I to the rules of the road and obeying traffic laws.2
don’t want to impose on my family or friends.”
Chapter 2 outlined what factors or “red flags” to

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

observe if driving safety is of concern to the older predictable but allow time to build awareness
adult, caregiver, or clinical team member. This and knowledge in preparation for transition
chapter goes beyond the initial identification of through a transportation plan that shifts the
potential problems to describe the screening and focus to preservation of community mobility as a
assessment process of older adults who have been non-driver. This transition approach is helpful for
recognized as having a possible safety risk and need all older adults, but especially for those facing
further exploration of their fitness to drive. chronic medical conditions that may eventually
In determining fitness to drive, it is important affect driving (e.g., diabetes, dementia, Parkinson
to distinguish between screening and a disease). For example, in addition to explaining
comprehensive driving evaluation. When how to manage blood sugar levels with older adults
screening, the intention is to identify risk. The with diabetes, it may be helpful to explain how
screening is typically brief, with the outcome managing blood sugar levels may help to minimize
intended to monitor risk over time or refer for peripheral nerve damage and maintain eye health
further evaluation when appropriate. Further to prolong fitness to drive. This knowledge may be
evaluation will identify at-risk drivers who may potentially motivating and important as an incentive
benefit from intervention strategies or need to to optimize adherence.
cease driving. This more comprehensive evaluation Secondary prevention attempts to remediate
may include referral to occupational therapy or any loss of functional skills needed for driving.
driving rehabilitation to obtain the data necessary This may include hand controls to compensate for
to determine a client-centered, individualized plan. amputation or neuropathy, as well as management
The goal is to optimize the ability of older adults to of depression, vision loss, or cognitive flexibility to
continue to drive safely for as long as possible. prevent further loss of driving capacity.
The clinical team may detect problems that (1) Tertiary prevention requires a transportation plan
allow early intervention and may prevent disability because the loss of driving skills is irreversible
and prolong driving ability, (2) identify impairments and creates known risk to the individual and the
that can be remediated, (3) identify strategies community. Recommendation for cessation is
to compensate for a medical condition, and/or not enough, as the older adult needs assistance
(4) necessitate plans for the timely transition to to maintain community engagement through a
alternative means of transportation. transportation plan.
Primary prevention addresses issues to prevent
SCREENING VERSUS ASSESSMENT
the loss of driving ability. This includes providing
strategies to support driving abilities as well as Screening
early intervention or “starting the conversation”
The goal of screening is to broadly identify older
to introduce the importance of developing a
adult drivers who might be “at risk” of unsafe
transportation plan that for some may lead
driving. Screening tools should be brief and easy to
to driving retirement. Some transitions are
administer and must have evidence that supports
unpredictable and will require an abrupt but
their value in identifying the possibility of driving
supportive approach, such as driving cessation
risk. In the process of a broad screening, some
after a severe stroke. Other transitions are more
individuals who are not at risk will also be incorrectly

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

identified. However, because of the safety risk developed overlearned skills and abilities. Even a
to individuals and society, over-identification is driver with significant cognitive decline that includes
necessary. With this in mind, a screening must episodes of confusion or diminished judgment may
always be followed by an evaluation before fitness- be capable of demonstrating retained basic driving
to-drive can be determined. skills when the test is structured with each action
directed, such as “turn right at the stop sign.” In
Assessment contrast, a comprehensive driving evaluation
Assessment requires more in-depth evaluation to includes a clinical evaluation and an on-road portion
distinguish between individuals who are truly at risk to evaluate higher functioning abilities in the
and those who are not. Screening and assessment executive domains of decision-making, navigation,
tool scores do not by themselves predict crash risk and problem solving, essential for determining an
for several reasons, including the low occurrence of experienced older driver’s fitness to drive.
crashes, and that older adults tend to drive less and In response to the complexity of driving
engage in less risk-taking behavior (e.g., speeding, terminology, the Transportation Research Board of
drunk driving). It is the clinical skill, expertise, and the National Academies for Science, Engineering
reasoning of the health care provider using the and Medicine’s Committee for Safe Mobility for
screening outcomes of the older adult that allows Older Persons2 has developed definitions for
an educated judgment about probable driving screening, assessment, and evaluation (Table 3.1).
outcome.
While there is an increasing array of computer-
Multiple assessment tools are used for screening based testing tools, clinicians need to carefully
and assessment of driving.3 However, there is no consider their use with the older adult population. It
single tool that should be used to determine fitness is important to consider familiarity and acceptance
to drive.4-6 While the on-road assessment is widely by an individual who may not use technology
accepted as the gold standard, even a “driving frequently. Performance on this type of testing may
evaluation” has different contexts.7 For example, the result in test failure because of lack of familiarity
driving evaluation completed for licensure is more with the technology rather than the tools value in
commonly named a “driving test” and typically measuring deficits in fitness to drive.
requires 10-15 minutes to complete. The intention
of this test is typically to evaluate knowledge of Process of Screening and Referral
rules of the road and a checklist of skills required to As the first step of the process, clinical team
operate a vehicle. The focus of driving instructors at members identify driving as the patient’s primary
driving schools is on teaching driving competence mode of transportation and if their medical
though lessons or skill building to ensure that impairments will affect driving. If both are true, the
drivers adhere to the correct maneuvers for vehicle team members may use the screening/assessment
operation while obeying traffic laws. Thus, their tools described in this chapter to ascertain potential
driving evaluations focus on gaps in learning, driving risk. Although cut-off scores might be
learning new skills for managing a vehicle, and provided, it is important to remember that these
testing knowledge of roadway rules and laws. assessment tools document only the presence of a
Older adults have typically been driving for many potential impairment, not its cause or implications.
decades and are experienced drivers that have

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Table 3.1 - Screening, Assessment, and Evaluation Terminology

Term Defintions

Road test An examination of driving maneuvers and knowledge of rules of the road performed in a motor
vehicle on a public highway or street
Driving test An examination including specified driving maneuvers performed in a motor vehicle
Evaluation Obtaining and interpreting data to document results and inform an individualized mobility plan
Assessment Use of specific measurements, tools, or instruments during the evaluation process
Screening Obtaining and reviewing data to determine the need for evaluation
Self-screening An individual obtains and reviews his or her own data to determine the need for evaluation;
relies on insight and self-reflection
Proxy screening An individual obtains and reviews data to determine the need for evaluation for another person
Evaluator screening A professional skilled in a specific screening tool obtains and reviews data to determine the
need for evaluation of a specific individual
Driving assessment Use of an on-road test to measure and qualify driving skills and abilities, which may be trig-
gered by a screening outcome that indicates increased risk of driving impairment or crash
involvement
Driving evaluation Obtaining and interpreting data and documenting results to inform an individualized mobility
plan based on an individual’s driving abilities and/or potential to be an independent driver, or
inform a determination of fitness to drive
Clinical driving Obtaining and interpreting data and documenting results to determine fitness to drive through
evaluation assessment of sensory/perceptual, cognitive, and/or psychomotor functional abilities using
specific tools or instruments
Comprehensive A complete evaluation of an individual’s driving knowledge, skills, and abilities that includes (1)
driving evaluation medical and driving history; (2) clinical assessment of sensory/perceptual, cognitive, or psycho-
motor functional abilities; (3) on-road assessment, as appropriate; (4) an outcome summary; and
(5) recommendations for an inclusive mobility plan, including transportation options

Using the outcomes of several of the screening tools Examples include macular degeneration with
and the medical history, health care providers are visual acuity below state standards, progressive
in the best position to determine if the potentially dementias, or advanced Parkinson disease. In
at-risk older adult may benefit from a referral to these cases, recommendations may be for driving
another health care provider (e.g., ophthalmologist, cessation and referral to appropriate team members
occupational therapist, clinical neuropsychologist, for alternative transportation support. In contrast,
physical therapist) for evaluation of a specific when the results of screening indicate no potential
deficit (e.g., visual acuity, balance problem, problems, education for health and driving
instrumental activities of daily living [IADL] issues) promotion should be offered rather than further
before considering a referral for a comprehensive evaluation.
driving evaluation. Clinical team members may also Finally, when the older adult has a chronic, but
determine, based on the evidence from the medical stable medical condition and the outcomes from the
history and screening outcomes, that further assessment tools suggest potential impairments,
evaluation and/or intervention is not warranted. health care providers can then determine whether

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to refer the older adult to a driving rehabilitation licensing agency has that type of legal authority (see
specialist (DRS) for a comprehensive driving Chapter 7).
evaluation. In areas where DRSs are limited and/
or the history suggests other complex IADLs are
“Mr. Phillips, I’m concerned about how your
compromised, a comprehensive occupational
health condition is affecting your driving. Your
therapy evaluation of IADLs may be warranted. This
son tells me that you were recently in a car crash
is further described in Chapter 5.
and that you’ve had several near-crashes in the
Clinical team members and health care providers past 2 years. Although you have managed your
must function within their scope of practice and medical conditions, I believe their combined
use clinical judgment regardless of any test scores effect may have progressed to the point that it
to make decisions about fitness-to-drive of older may be affecting your driving skills and ability.
adults. All available information, including driving I am going to ask you to do a few simple tests
and medical history, should be considered. The that can measure functional abilities needed for
specific tools discussed here were selected for safe driving, such as walking down the hall while
their applicability and feasibility in an office setting, I time you. This will help us find out if there are
along with their correlates with impaired driving areas we need to look into further.
outcomes, but they cannot cover every important
“Based on your health condition and the
function needed for driving.
results of the tests, we’ll do our best to treat or
reverse any problems we find. For example, if
BROACHING THE ISSUE OF A DRIVING
SCREENING OR ASSESSMENT WITH THE you’re not seeing as well as you should, we’ll
OLDER ADULT see what we can do to improve your vision. If
you have difficulty turning your head, a referral
The primary message should be one of concern
to a physical therapist may be in order. If
and assistance, balancing the older adult’s or
there’s something we can’t improve, then we
caregiver’s concern about the safety of the older
may consult a driving rehabilitation specialist
adult and/or the public with the older adult’s need
to explore all possible solutions. This type of
for transportation. Care should be taken to avoid
specialist, typically an occupational therapist,
an adversarial position, because this may prompt
will offer you further testing and then may go
an unproductive reaction of defensiveness. The
out on the road with you to see how you’re
conversation should begin with a commitment
driving. The driving rehabilitation specialist can
to explore all reasonable options for keeping
develop a plan that will include, if at all possible
the older adult mobile in his or her community.
and safe, recommendations, strategies, and
Points to emphasize include that screening and
maybe adaptive equipment for you to consider.
assessment are necessary to identify ways to help
Whenever possible, the driving rehabilitation
the older adult continue to drive safely as long as
specialist will recommend ways to make your
possible and that current technology, roadways, and
driving safer. Our goal is to keep you on the
rehabilitation offer many helpful interventions to do
road for as long as you are safe to drive.”
so. If the older adult expresses fear that the clinical
team will “take away my driver’s license,” it may
be helpful to offer reassurance that only the state

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FUNCTIONAL AREAS ASSESSED FOR of the variability in visual requirements by state

DRIVING licensing agencies and/or visual acuity testing of
Three key functional areas are considered as the stationary targets does not represent the motion-
foundation for determining fitness to drive: vision, based driving environment.11 However, there is
cognition, and motor/somatosensory function. some evidence that visual screening laws are
Any impairment in these areas has the potential to associated with decreased motor vehicle crash
increase the older adult’s risk of being involved in fatality rates.13 Cataracts are a major concern
a crash and/or lost. Once these areas are assessed, associated with vision and driving. The gradual
the health care provider can determine if more development of cataracts results in a slow change
information is required in one or all areas or if in vision, which the older adult may not recognize.
referral to a specific specialist for further evaluation Identification and removal of cataracts can
or intervention is needed (e.g., ophthalmologist, effectively improve driving safety.14-16
neuropsychologist, occupational therapist, physical General visual acuity can be easily measured in the
therapist, DRS). office setting using readily available tools such as
a Snellen chart (www.provisu.ch/Age/Snellenchart_
Vision en.pdf). Near visual acuity can be assessed by the
A vision assessment includes assessment of visual Rosenbaum pocket chart, and there are several free
acuity, visual fields, and contrast sensitivity. apps available for mobile devices.
Vision is the primary sense used in driving and is Visual Field: Visual fields may decline as a result of
relied on heavily for successful execution of driving.8 natural aging changes such as ptosis, a drooping
All states require vision testing to initially obtain a of the eyelid most commonly found in the older
driver’s license, although the limits differ. Several population. Most visual field cuts, however, are
states also require vision testing at the time of the consequence of medical conditions such as
license renewal. For information on these laws, see glaucoma, optic neuritis, detached retina, and
Chapter 8. stroke/traumatic brain injury. Drivers with loss of
Visual Acuity: Visual acuity commonly declines peripheral vision may have trouble noticing traffic
with age, although no consensus exists on the rate signs or cars, vehicles in adjacent lanes, and/
of decline or decade of onset. Decline in acuity is or pedestrians on sidewalks or street crossings.
related to physiologic changes of the eye that occur However, although studies on driving indicated that
with age and the increased incidence of conditions drivers who had at least moderate to severe vision
such as cataracts, glaucoma, diabetic retinopathy, impairment were more likely to be involved with
and age-related macular degeneration (ARMD).9 crashes, not all studies have shown an association.11
Although distance visual acuity appears to be There are large individual differences when there
crucial to many driving-related tasks, declines in is field loss and evidence suggests that good
near visual acuity may be associated with difficulty drivers are able to compensate for field cuts;11,17 the
seeing/reading maps or gauges and controls inside science examining the relationship between visual
the vehicle. field loss and driving performance is still evolving.8
Visual fields are measured through confrontation
Most research studies show that visual acuity is not
testing and, if deficits are noted, formal visual field
linked to crash risk,4,8,10-12 which may be because

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perimetry scanning may be indicated, especially if language, and insight.

required by the state licensing authority. Driving requires timely visual and cognitive
Contrast Sensitivity: Contrast sensitivity decreases processing to make appropriate decisions in a
as a normal process of aging. While this loss is dynamic and complex environment. The best
not an issue during daylight, it becomes more assessment tools integrate several cognitive
difficult for older adults to see a target against processes (e.g., divided attention, visual processing,
similar background in low light. Thus, older adult processing speed) to test high-level cognitive
drivers may have problems distinguishing cars or processes or executive functioning.20 At the
pedestrians against the driving background during clinical team level of screening, specific cognitive
dawn and dusk hours, in foggy conditions, or abilities and skills can be assessed for performance
during storms. Although research has shown that indicative of risk. Because these functions are the
contrast sensitivity is associated with increased building blocks of more complex abilities, if an older
crash risk,8,18 the impaired contrast sensitivity adult has a significant issue with any basic cognitive
associated with crash is typically associated with skills, driving will likely be affected.
drivers who have cataracts (which improve with Attention: Because of the dynamic and changing
surgery) or Parkinson disease.11 Thus, more research environment, demands on attention can be
is needed to produce standardized, validated cut- significant, especially in areas of high traffic or
off points for contrast sensitivity and to identify the during rush hour traffic. Drivers must possess
level at which impairment results in higher crash sufficient selective attention (i.e., the ability to
risk. Education about this normal aging process is prioritize stimuli and focus on only the most
important and addressed by offering strategies that important) to attend to critical stimuli (e.g., traffic
include avoiding driving in early morning, dusk, or lights, other vehicles, pedestrians, bicyclists,
during fog or storms. Further evaluation for contrast scooters) without being distracted by irrelevant
sensitivity may be warranted if the older adult has ones (e.g., billboards, city sights). In addition,
frequent falls, because the same contrasts in the drivers must possess divided attention to focus on
walking environment are an issue and falls and the multiple stimuli required by most driving tasks.
driving risk are related.19 For example, the driver must be able to attend to
Several other visual functions are important vehicles surrounding him or her while changing
in driving (glare recovery, light adaptation, lanes for a turn, maintaining a safe speed, and
accommodation, dynamic visual acuity, color activating the turn signal in the correct direction.
perception), but office-based measures for Attentional functioning may decline with age,21
screening and assessment are neither easily with divided attention showing more pronounced
available nor linked to crash risk. Therefore, they are changes than selective attention.22 Interestingly,
not discussed here. recent studies have suggested that years of
experience with driving may enable older drivers
Cognition
to prioritize driving decisions and maximize driving
Cognitive assessment includes functional safety (i.e., experience-related compensation).21
assessments of memory, visual perception, However, regardless of age, driver distraction,
processing speed, attention, executive function, including use of cell phones, poses a clear and

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

significant safety risk to all road users. Older adults of focus to another.28 Executive skills are key
should be advised to avoid using cell phones determinants of driver strategies, tactics, and
(or other tasks that divide their attention) while safety,29 such as making the decision to stop at
driving because of the possibility of decreased a red light or what to do when the light is green
working memory, attention reserves, and decreased but a pedestrian is still in the path of the vehicle.
processing speeds. Although the capacity for this kind of logical
Visual Perception/Processing: Visual perception, analysis tends to decline with age,26 it is with brain
visuospatial skills, and processing speed are injury that the problems with executive functions
necessary for drivers to organize visual stimuli into become more evident in driving. Because of the
recognizable forms and understand where they overlearned ability of driving, many drivers with
exist in space. They also need to appropriately executive function deficits can demonstrate the
respond to incoming information in a timely way. ability to drive familiar routes without a problem.
Without these visual-motor skills, drivers would be However, if an unexpected event occurs (e.g., a
unable to recognize another vehicle and determine child running onto the street, a familiar road is
its distance ahead to maintain speed, slow, or stop closed because of construction), older adult drivers
in relation to that vehicle. In general, processing with poor executive functioning may not be able to
speed may slow8 and complex visuospatial skills spontaneously modify their expected route or safely
may decline with age, while visual perception alter their driving plan in response to a challenging
remains stable.23 situation, putting themselves or others at risk.
Examples of executive errors may be stopping at
Memory: To drive safely, drivers need to
a green light or stopping before a highway exit to
remember their destination, how to navigate to
allow extra time to make the decision to exit.
the destination, how to operate the vehicle, and
to obey traffic rules and regulations.24 In addition, Insight: Insight is the awareness that a person has
drivers must be able to retain certain information about himself or herself, including abilities and
while simultaneously processing new or unique limitations. It is important to determine the older
information (e.g., driving in a school zone or adult’s understanding of how his or her physical,
retaining and combining information gathered cognitive, and/or mental limitations may affect
from scanning right/left), using the skill of working fitness to drive. For example, the individual with
memory. Working memory (and the other cognitive glaucoma should understand and agree that he
skills to which it contributes) tends to decline with or she should refrain from driving at night but may
age25 and depends on the speed of processing, drive without significant risk during daylight and
which refers to the speed at which new information non-rush hours. Individuals with dementia often do
can be integrated and retrieved from the memory.26 not have adequate insight, believing they are fit to
drive when they are not.30
Executive Function: Executive function is an
umbrella term that refers to the coordination Motor and Somatosensory Function
of several cognitive subprocesses to achieve
Motor and somatosensory function assessment
a particular goal.27 Executive function includes
includes functional assessments of functional range
the ability to initiate a task, problem solve, plan,
of motion, proprioception, and endurance.
sequence, and seamlessly shift from one area

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Driving requires motor and somatosensory abilities. essential so that the driver can turn his or her
Because of improvements in technology (e.g., head quickly to check the blind spot. However,
antilock braking systems, power seats, power technology in newer-model vehicles is increasingly
steering, keyless ignition, traction control systems, compensating for many functional limitations.
backing cameras, cruise control, automatic Examples include backing cameras, fisheye/
emergency braking), driving has become much panoramic mirrors, and blind-spot warning systems
less physically demanding. Thus, even physically for limited neck range of motion; steering knobs for
frail older adults may have the capacity necessary one-handed driving; low effort steering for limited
to continue to operate a motor vehicle. Moreover, upper arm mobility; and hand controls for those
DRSs excel at prescribing and training in the use with lower limb loss or impairment.
of strategies, devices, or vehicle modifications Proprioception: Drivers must have the ability
to compensate for a wide range of physical and to know whether their foot is on the brake or
somatosensory impairments. Unfortunately, many accelerator pedal and be able to sufficiently
drivers may be over restricted when advised to stop modulate the amount of pressure needed on the
driving in response to a physical/ somatosensory pedal for any given driving situation. While the
limitation that may have been addressed through underlying issues with “pedal confusion” are not
compensation or equipment. clear, for older adult drivers, the problem may
Endurance: Before the act of driving, motor abilities possibly be with proprioception. It would be easy
are needed to approach and enter the car safely for a driver to become confused if he or she had to
and fasten the seat belt. The natural process of “look” to see where his or her foot was at to drive.
aging may involve a decline in muscle strength and Clearly, older adult drivers with sensory issues such
endurance, flexibility, and joint stability. In addition, as diabetic neuropathy would benefit from a test of
osteoarthritis and other musculoskeletal problems leg and foot sensation and proprioception.
are common in older adults. Individuals who suffer
pain and limitations from these conditions may REFUSAL OF ASSESSMENT
not only experience direct effects on their driving Older adult drivers and their caregivers may express
ability but also decrease their physical activity, fear, resistance, or refusal to participate in screening
causing further decline in motor function. Fatigue or assessment of functional abilities. The three most
can be an issue for older adults who are driving a common reasons include the older adult’s belief that
long distance, have undiagnosed sleep apnea, are he or she is a good driver, the fear that an outcome
undergoing significant medical treatment (e.g., may put the older adult’s license at risk, and/or
cancer therapy, kidney dialysis), or have advanced impaired insight of the older adult and/or caregiver.
functional loss from severe end organ disease. Caregivers may have conflicting priorities when
Functional Range of Motion: Drivers must be trying to balance their respect for the older driver’s
able to manipulate the steering wheel, operate wishes, level of risk, and the caregiver burden
the accelerator and brake pedals, and access the that cessation of driving can create, including
primary and secondary controls of the vehicle (e.g., responsibility in time and/or money for transporting
turn signal, headlights, wipers, climate controls). the older adult to appointments and activities.
Range of motion in the neck and shoulder is In these situations, it may be helpful to assure

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

the older adult that the concern and focus is on safety and support, both offering the older adult
optimizing fitness to drive and not on removing the and the family time to consider the consequences
ability to drive. Health care providers, considering and prepare them for next steps. If the older adult
clinical observations and using best judgment, appears to have deficits in all domains (i.e., vision,
may decide there is cause for concern but not an cognition, physical/motor), or primarily cognition,
immediate risk. In this case, the goal is to initiate a or caregivers report problems in complex tasks
conversation with the older adult and ideally with (e.g., finances, cooking, shopping), referral to an
the caregiver about driving risk. It will be important occupational therapist for an IADL risk assessment
to discuss, with permission, the medical condition(s) may be appropriate. Because rehabilitation services
of the older adult and the potential impact these are typically covered by medical insurance plans, an
can have on driving risk. The first steps may occupational therapy assessment can lead to a plan
focus on increasing self-awareness and a shared and interventions that may improve function before
understanding of driving risk for self and others. (or in preparation for) the next option, which is the
In addition, providers should ensure that the older specialized comprehensive driving assessment.
adult understands that the goal is to work together In contrast, if the older adult has only physical
to find solutions for him or her to continue driving, if and motor impairment, a referral to a DRS is
at all possible. prudent (see Chapter 5). The DRS will conduct a
It is well established that most older adults, comprehensive driving evaluation that includes a
regardless of age, intend to continue driving until complete clinical assessment covering the areas of
they decide “I have become an unsafe driver.”31 vision, perception, cognition, and motor abilities,
However, older adults who live in rural communities as well as an on-road assessment, if warranted.
may realize they are at risk but do not feel they have The DRS will assist the older adult and family with
any other option. Understanding that a transition determining if vehicle adaptation and learning will
from driver to non-driver may require time to assist in promoting driving safety.
anticipate and adjust, this early focus on counseling Some older adults will absolutely refuse to consider
and referral to explore alternative transportation evaluation and are intent on continuing to drive,
options may allow older adults to also consider the while others may agree to the evaluation but ignore
benefits of assessment at a later time. Nevertheless, any recommendation for cessation.32 For these
for some older adults, further evaluation now may individuals, insight into deficits is likely the problem.
be needed to determine fitness to drive, in the A discussion with a caregiver may offer more
best interest of the individual and the community. information as well as provide additional support for
In these cases, professional ethics should be used pursuing an evaluation or strategies for cessation
to guide the intervention plan. If the clinical team recommendations. Actions should be guided by
member is significantly concerned about driving risk professional ethics, and it may be necessary to
today, he or she should work with the older adult report the older adult to the appropriate driving
and/or family to establish an agreement to follow licensing agency, the agency that is responsible to
a course of stopping driving now until “we better make licensing decisions and is the only party with
understand your situation, gain the information the authority to cancel a license (see Chapters 7
required through evaluation, and then determine and 8).
the appropriate plan of care.” This message is about

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

SELF-ASSESSMENT TOOLS given as follow-up steps. Research has shown that

Many self-screening and caregiver rating tools feedback from the website correlates positively
are available to assist in building awareness of with driving risk. This tool is available at http://
the changes associated with aging as well as fitnesstodrive.phhp.ufl.edu/.
the symptoms of conditions that affect driving. n The SAFER Driving Survey, developed at the
Following up with older drivers after use of these University of Michigan Transportation Research
tools may improve their willingness to be formally Institute, is a web-based tool (available at http://
assessed by the clinical team. Regardless, it is um-saferdriving.org) that asks users about the
important to understand that use of self-assessment severity of health concerns they are experiencing
tools do not replace screening performed by due to medical conditions and medications.
professionals, because evidence is clear that self- The website then calculates the effects of these
assessment is not associated with determining health concerns on critical driving skills and
fitness to drive.33 gives users individualized feedback on how their
n Testing Driver Safety (see Appendix B). driving may be declining, what to do to continue
driving safely given these declines, and possible
n A 15-question self-rating driving questionnaire,
recommendations for more in-depth assessment.
AAA’s Drivers 65 Plus: Check Your Performance
Research has shown that feedback from the
Self-Rating Tool (see Appendix B).
website correlates positively with on-road driving
n The Driving Decisions Workbook, developed by scores and an assessment from an occupational
the University of Michigan Transportation Research therapist. Users also report that the site is easy
Institute, is a free self-assessment tool with to use, the information is helpful, and that they
evidence that the workbook scores are positively discovered declines in themselves of which they
correlated with on-road driving scores and several were not previously aware.34
clinical tests of functional ability. Both online
and print versions are available. Individualized CLINICAL TEAM ASSESSMENT TOOLS
feedback is provided to respondents based on
Current assessments used in fitness-to-drive
how they answer questions. The workbook can be
evaluations range from simple paper and pencil
downloaded at http://deepblue.lib.umich.edu/
tools that are performed by general clinicians in
bitstream/handle/2027.42/1321/94135.0001.001.
their offices to complex assessments that should
pdf?sequence=2&isAllowed=y.
only be performed in the scope of practice of a
n The Fitness to Drive Screening Measure, clinical neuropsychologist or DRS (e.g., on-road
developed by the University of Florida, is a free assessment). In contrast, the Clinical Assessment
web-based tool for caregivers of older adults to of Driving Related Skills (CADReS) is offered as
identify at-risk older drivers. The user needs to a toolbox of practical, office-based functional
have driven with the driver in the last 3 months assessment tools in the major areas of vision,
and then rates the driver on 54 driving skills. cognition, and motor/sensory function related
A rating profile of the driver is available and to driving for the clinical team member who is
includes a classification of the driver into one screening or assessing an older driver. Clinical
of three categories (at-risk driver, routine driver, team members should choose from tools in each
or accomplished driver) with recommendations

38
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

area that best address their patient’s needs and affect assessment findings, perhaps triggering red
document their encounters. flags that are temporary.
In the case of cognitive screenings, it is not always
Vision
necessary to do all the tests. Depending on the
outcome of the less challenging assessments, it n Visual acuity: Measured by vision charts, visual
may be unnecessary to progress further. Note: The acuity should be measured because it is the legal
justification of assessment tool selection and scoring criteria for most state licensing agencies. The
is addressed in Chapter 4. Snellen chart is described below and provided in
Appendix C.
General n Visual fields: Using a uniform manner of
n Driving history: A brief driving history can be confrontation testing as described below, visual
useful as an initial screen to identify the older adult’s fields can be assessed.
perception of his or her driving, as well as that of n Contrast sensitivity: Many charts are
a caregiver if available. Recent traffic violations, commercially available (e.g., Pelli-Robson contrast
crashes (including unreported), or near misses are sensitivity chart) to test the ability to perceive
all red flags for concern (see Chapter 2). The Driving objects in contrast to the environment.
Habits Questionnaire is available35 but is lengthy. A
modified version is available in Appendix C. Cognitive
n IADLs questionnaire: A checklist of other IADLs n Montreal Cognitive Assessment36 (MoCA
can also be used as an initial screen to identify [https://www.mocatest.org/]): The MoCA is a
if the older adult is having difficulties with other brief cognitive test designed to assist health
complex tasks of daily living. Driving uses the care professionals in detecting mild cognitive
same underlying functions (e.g., visual processing, impairment. Although it can be administered by
executive functioning, memory, processing speed) anyone, results should be interpreted only by
as other IADLs, similar to those for financial individuals with expertise in the cognitive field.37 It
management, shopping, or cooking. If the older rates cognitive performance, is available in multiple
adult is having difficulty with any IADL tasks, further languages, and has been validated for adults 55 to
evaluation is warranted. A report from a caregiver 85 years old. It tests memory, attention, language,
may also be helpful when the older adult appears abstract, recall, orientation, as well as visuospatial
to have cognitive impairment. An example is the skills by incorporating a shorter Trails B and a clock-
AD8TM Dementia Screening Interview, an eight- making task.
item caregiver questionnaire that differentiates n Trails A & B: This test of general cognitive
between dementia and normal aging (copyrighted function also specifically assesses working memory,
by Washington University) and has preliminary visual processing, visuospatial skills, selective and
data that suggests it is useful in combination with divided attention, and psychomotor coordination.
other tools to determine fitness to drive10 (https:// Numerous studies have demonstrated an
knightadrc.wustl.edu/CDR/ad8.htm). association between poor performance on the
n Medication review: Certain medications clearly Trail-Making Test Part A and B and poor driving
affect driving, and new or changing doses may performance4,38 (see below for directions and form).

39
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Neuropsychologists often recommend giving the technology (e.g., back up cameras, blind side
Trails A test (connecting just numbers) before giving warnings) and education/training can accommodate
the Trails B test. The rationale is two-fold: The Trails limitations of the neck. Limitations in any of the
A provides an appropriate warm-up to Trails B and extremities can be accommodated by adaptive
allows the older adult some practice on a simpler equipment recommended by a DRS. For directions
concept, and, in many of the driving studies that for a functional range of motion test, see below.
validated Trails B, the Trails A was given first.
n Clock-Drawing Test: This test may assess Although anxious, Mrs. Alvarez clearly wants to
long-term memory, short-term memory, visual keep driving. There may be some concern with
perception, visuospatial skills, selective attention, her confidence, potential change in her medical
abstract thinking, and executive skills. Preliminary condition, and effect of medications, because
research indicates an association between specific she had an unsteady gait as she walked in the
scoring elements of the clock-drawing test and poor office. You decide to do the CADReS.
driving performance.39
“Mrs. Alvarez, I am going to ask you to do a few
n Maze test: There are several versions of maze simple tests that can measure functional abilities
testing, including online versions. Depending needed for safe driving, such as walking down
on the type of test, it assesses visual perception, the hall while I time you, and a couple of paper
visuospatial skills, abstract thinking, and executive and pencil tests. These assessments will help us
skills. The Snellgrove maze40 is a one-page cognitive find out if there are any areas we need to look
screen for driving competence that was validated into further. Based on the results of the tests and
with older adults with mild cognitive impairment or your health condition, we will do our best to treat
early dementia. or reverse any problems we find.”

Motor/Sensory After scoring Mrs. Alvarez’s performance on

the CADReS toolbox assessments, you discuss
n Rapid Pace Walk and Get Up and Go: These
the results with her. You assure her that she
tests are measures of lower limb strength,
scored well on the vision and cognitive tests, but
endurance, range of motion, and balance. The
performance on the motor was impaired (Rapid
Rapid Pace Walk has been linked with driving
Pace Walk = 11 seconds) and you noticed her
outcomes,41,42 whereas Get Up and Go43 has been
unsteady gait as she walked in. When asked
more closely linked with falls and future disability
about falls, she admitted that she has fallen in
and long-term care placement. Because falls have
her home.
been associated with poor driving outcomes,19
either of these tests are appropriate measures for
assessing overall motor abilities. For directions, see
below. THE EVOLUTION OF COMPUTER-BASED
TOOLS
n Range of Motion: Performing a functional range
Two computer-based assessment tools are
of motion test is important for examining if and
commercially available. The cost of these tools is
how the motor vehicle can be adapted to meet
presently not covered by most insurance providers.
limitations of the older adult. Mirrors, vehicular

40
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

In general, more research is needed on these ASSESSMENT TOOL PERFORMANCE

computer-based assessments before they can be INSTRUCTIONS
used as tools for making licensing decisions. The
use of interactive driving simulators is also being Snellen eye chart
studied, with emerging evidence supportive for The Snellen chart is used to test far visual acuity.
their use as a potential assessment and intervention The standard chart measures 9” x 23” and is printed
tool.44,45 on a durable, tear-resistant latex sheet, with eyelets
n Useful Field of View: This is the most widely for easy hanging. Letters are printed on one side,
studied instrument for detection of impairment in and tumbling “E” symbols are printed on the
processing speed, divided attention, and selective reverse.
attention that has been moderately correlated This test is best performed in a hallway with good
with crash risk in older adult drivers. The strongest lighting. Floor tape can be used to mark a distance
evidence is for the Subtest 2, which tests processing of 10 or 20 feet (depending on the chart size).
speed,41,42,46 but not all studies supported With the chart hanging on a wall, the older adult is
the predictive validity of this instrument.4,10,47 instructed to stand 10 or 20 feet away. Wearing his
This assessment tool is available for purchase or her usual glasses or contact lenses, the individual
(information is available on the Visual Awareness reads the smallest line possible with both eyes
website (https://www.visualawareness.com/what- open. Visual acuity is based on the lowest full row
is-ufov/).48 Cost, time, and ability to bill, as well as that he or she successfully reads, and the process is
limited studies in a primary care setting, might be repeated for each eye individually. However, if the
potential barriers to use. best the individual can see in either eye is 20/40,
n DriveABLE: This assessment is only of cognitive then his or her acuity is considered to be 20/40 in
abilities for driving; it is computer-based and both eyes.
electronically scored (available at https://www. Far visual acuity can also be measured using
driveable.com/). Based on the performance of the another chart per the clinician’s preference, such as
older adult, results are generated from a computer the Snellen chart for a 10-foot distance or the Sloan
algorithm that returns a score between 1 and 99 low-vision letter chart for 6 meters (20 feet).50
and reflects the “Predicted Probability of Failing
Near visual acuity can be tested with commercially
an On-Road Evaluation,” with 1 being least likely
available charts and should be considered whenever
and 99 being most likely to fail. The computer
an older adult complains of difficulty seeing/reading
program designates upper and lower areas of risk.
maps or gauges and controls within the vehicle. This
Although the developers of the program maintain
can be checked using a Rosenbaum pocket chart.
the computer presentation of the tasks enables
precision measurements and objectivity and Some limitations have been noted in testing using
removes testing bias, there is contradictory research the Snellen chart. These include, but are not limited
evidence to support the claims of predicting driving to, the different number of letters per line, different
risk accurately.49 In addition, DriveABLE’s approach spacing between lines, the specific use of letters,
does not provide the clinician with information and the spacing between letters.51 A trend in the
that can be used to identify clinical solutions for field of eye care has been to use a newer chart
potential problems. called the Early Treatment Diabetic Retinopathy

41
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Study (ETDRS) that in some studies of eye diseases he or she picks up the first foot, and stops timing
appears to be more accurate.52 The ETDRS chart when the last foot crosses the finish mark. This test
improves on the Snellen test by having a similar is scored by the total number of seconds it takes
number of letters per line and standard spacing for the older adult to walk 10 feet and back.42 In
between the letters. addition, the examiner should indicate on the
scoring sheet whether the older adult used a
Visual Fields walker or cane. Scores longer than 9 seconds are
The examiner sits or stands 3 feet in front of the associated with an increased risk of at-fault motor
patient, at the individual’s eye level. The patient vehicle tasks.38
is asked to close his or her right eye, while the
examiner closes his or her left eye. Each fixes on the Get Up and Go
other’s nose. Instructions43
The examiner then holds up a hand in each visual Ask the patient to perform the following series of
field simultaneously, with a random number (usually maneuvers.
one or two) of fingers in each of the four quadrants, 1. Sit comfortably in a straight-backed chair.
and asks the patient to state the total number of
2. Rise from the chair.
fingers. With the fingers held slightly closer to the
examiner, the patient has a wider field of view than 3. Stand still momentarily.
the examiner. Provided that the examiner’s visual 4. Walk a short distance (approximately 10 feet/3
fields are within functional limits, if the examiner can meters).
see the fingers, then the patient should be able to
5. Turn around.
see them unless he or she has a visual field defect.
6. Walk back to the chair.
The process is repeated for the other eye (patient’s
left eye and examiner’s right eye closed). The 7. Turn around.
examiner indicates any visual field defects by 8. Sit down in the chair.
shading in the area of defect on a visual field
Scoring
representation.
Observe the patient’s movements for any deviation
Rapid Pace Walk from a confident, normal performance. Use the
A 10-foot path is marked on the floor with tape. following scale.
The examiner should first demonstrate the walk and 1 = Normal
then ask the individual to walk the 10-foot path, turn 2 = Very slightly abnormal
around, and walk back to the starting point. Then
3 = Mildly abnormal
the test begins. The individual is asked to walk the
same path as quickly as possible. If the older adult 4 = Moderately abnormal
normally walks with a walker or cane, he or she may 5 = Severely abnormal
use it during this test. The total walking distance is
“Normal” indicates that the patient gave no
20 feet.
evidence of being at risk of falling during the test
The examiner begins timing the individual when or at any other time. “Severely abnormal” indicates

42
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

that the patient appeared at risk of falling during and then complete the Maze Task. Performance
the test. Intermediate grades reflect the presence of is measured in time (in seconds), using a stop
any of the following as indicators of the possibility watch, and the total number of errors. Errors are
of falling: undue slowness, hesitancy, abnormal determined by the number of times a participant
movements of the trunk or upper limbs, staggering, enters a dead end or fails to stay in the lines. Time
or stumbling. to administer is 1–4 minutes. The Maze Test is in
A patient with a score of 3 or more on the Get Up Appendix C; it should be printed on an 8 × 11”
and Go Test is at risk of falling. paper with the Maze Test at least 5.5” square and
the practice 4.5”.
Functional Strength and Range of Motion To administer the test, the practice maze is placed
To test the functional range of motion for an older in front of the participant in the correct orientation.
adult, ask him or her to perform the below listed The participant is provided with a pen, and the
motions bilaterally. administrator says:
n Neck rotation: “Look over your shoulder like I want you to find the route from the start to the exit
you’re backing up or parking. Now do the same of the maze. Put your pen here at the start (point to
thing for the other side.” the start). Here is the exit of the maze (point to the
n Shoulder and elbow flexion: “Pretend you’re exit). Draw a line representing the route from the
holding a steering wheel. Now pretend to make start to the exit of the maze. The rules are that you
a wide right turn, then a wide left turn.” are not to run into dead ends (point to a dead end)
or cross solid lines (point to a solid line). Go.
n Finger curl: “Make a fist with both of your
hands.” The instructions are repeated, if required, and any
rule-breaks should be corrected. The participant is
n Ankle plantar flexion: “Pretend you’re stepping
permitted to lift the pen from the page. When the
on the gas pedal. Now do the same for the other
participant has attempted the maze, record whether
foot.”
the task was completed (yes or no), and the number
n Ankle dorsiflexion: “Point your toes toward of times the participant required repeating or
your head” reminding of the instructions.
The test is scored by evaluating the motion as either Next the Maze Task is placed in front of the
within functional limits or not within functional limits. participant in the correct orientation. The participant
The latter means that range of motion is done with is provided with a pen, and the administrator says:
excessive hesitation, pain, or very limited range of
“Good, now that I know you understand the task,
motion.
I’m going to time you as you find the route from the
start to the exit of the maze. Put your pen here at
Maze Test40
the start (point to the start). Here is the exit (point
The Maze Test was developed as a pencil and to the exit). Draw a line representing the route from
paper test of attention, visuoconstructional ability, the start to the exit of the maze. The same rules
and executive functions of planning and foresight. apply. Don’t run into any dead ends (point to a
Participants complete a simple demonstration dead end), or cross any lines (point to a solid line).
(or practice) maze first to establish the rule set, Are your ready? I’m starting the timer now. Go!”

43
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

The instructions are not repeated and rule breaks administrator says: “There are numbers in circles
are not corrected. If questions are asked, the on this page. Please take the pencil and draw a line
response should be: I can’t give you any more from one number to the next, in order. Start at 1
help. Do the task as best you can. Stop the timer [point to the number], then go to 2 [point], then go
immediately upon the participant’s completion of to 3 [point], and so on. Please try not to lift the pen
the task. There is a limit of 3 minutes for the Maze as you move from one number to the next. Work
Task. If the maze has not been completed in this as quickly and accurately as you can.” If there is
time, discontinue. The recording of the test includes an error: “You were at number 2. What is the next
whether the Maze Task was completed (yes or no); number?” Wait for the individual’s response and say,
the time in seconds to complete the Maze Task, and “Please start here and continue.”
the number of errors (entry into a dead end, and/or Test A: If Sample A is completed correctly, the
failure to stay within the lane). administrator repeats the above instructions for
Trails A. Start timing as soon as the instruction
Montreal Cognitive Assessment (MoCA)36
is given to begin. Stop timing when the Trail is
The MoCA is designed as a rapid screening completed, or when maximum time is reached (150
tool that measures attention and concentration, seconds = 2.5 min).
executive functions, memory, language,
Instructions for Part B. Using the sample of B,
visuoconstructional skills, conceptual thinking,
the administrator says: “There are numbers and
calculations, and orientation. Time to administer is
letters in circles on this page. Please take the pen
about 10 minutes.
and draw a line, alternating in order between the
The highest possible score is 30, with a score of numbers and letters. Start at number 1 [point],
26 or above considered normal. One point should then go to the first letter, A [point], then go to the
be added for individuals with 12 years or fewer of next number, 2 [point], and then the next letter, B
formal education. A score of 18 or less should raise [point], and so on. Please try not to lift the pen as
concerns about driving safety. you move from one number or letter to the next.
The original version and directions are in Work as quickly and accurately as you can.” If there
Appendix C. is an error: “You were at number 2. What is the next
letter?” Wait for the individual’s response and say,
Trail-Making Test for Screening, Part A and B “Please start here and continue.”
This test of general cognitive function specifically If Sample B is completed correctly, the administrator
assesses working memory, visual processing, repeats the above instructions for Trails B. Start
visuospatial skills, selective and divided attention, timing as soon as the instruction is given to begin.
processing speed, and psychomotor coordination. Stop timing when the Trail is completed, or when
In addition, numerous studies have demonstrated maximum time is reached (300 seconds = 5 min).
an association between poor performance
This test is scored by overall time (seconds) required
on the Trail-Making Tests and poor driving
to complete the connections accurately. The
performance.4,38,42
examiner points out and corrects mistakes as they
Instructions for Part A. Using the sample of A, the occur; the effect of mistakes, then, is to increase the

44
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

time required to complete the test. This test usually

takes 3–4 minutes to administer, but should be
stopped after 5 minutes.

Clock-Drawing Test
In this form of the clock-drawing test, the examiner
gives the individual 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 individual should be given a reasonable amount
of time to complete the drawing. The examiner
scores the test by examining the drawing for each
of seven specific elements found on the CADReS
score sheet (see Appendix C for score sheet).

Test Sequence
Although these tests may be administered in any
order, the following sequence is recommended:
(Note that the MoCA incorporates elements of the
Trail-Making Part B and Clock Drawing).
1. Snellen E Chart
2. Visual fields by confrontation testing
3. Rapid Pace Walk and/or Get Up and Go
4. Functional range of motion
5. Maze Test
6. Montreal Cognitive Assessment (MoCA)
7. Trail-Making Test, Part A and then Part B
8. Clock-Drawing Test
For a discussion of scoring these tests and
recommended interventions based on performance,
see Chapter 4.

45
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

29. Rizzo, M. & Kellison, I. L. (2010). The brain on the road. In T.D.M.I. 43. Mathias, S., Nayak, U. S. L., & Isaacs, B. (1986). Balance in elderly
Grant (Ed.) Neuropyschology of Everyday Functioning (pp. 168- patients: the “get-up and go” test. Archives of Physical Medicine
208). New York: Guilford Press. and Rehabilitation, 67, 387-389.
30. Adler, G., & Kuskowski, M. (2003). Driving cessation in older men 44. Stinchcombe, A., Maxwell, H., Gibbons, C., Dickerson, A.E., &
with dementia. Alzheimer Disease and Associated Disorders, Bédard, M. (2017). Simulated driving performance of older adults.
17(2),68-71. In: S. Classen (Ed.) Driving Simulation for Assessment, Intervention,
and Training (pp. 201-212). Bethesda, MD: AOTA Press.
31. D’Ambrosio, L. A., Coughlin, J. F., Pratt, M. R., & Mohyde, M.
(2012). The continuing and growing importance of mobility. 45. Dickerson, A. E., Stinchcombe, A., & Bédard, M. (2017).
In: J. Coughlin & L. A. D’Ambrosio (eds.), Aging America and Transferability of driving simulation findings to the real world. In: S.
Transportation: Personal Choices and Public Policy. New York: Classen (Ed.) Driving Simulation for Assessment, Intervention, and
Springer Publishing Co. Training (pp. 281-294). Bethesda, MD: AOTA Press.
32. Dobbs, B.M., Carr, D. B., & Morris, J. C. (2002). Evaluation and 46. Classen, S., McCarthy D. P., Shechtman, O., Awadzi, K. D., Lanford,
management of the driver with dementia. The Neurologist, 8(2), D. N., Okun, M. S.,…Fernandez, H. H. (2009). Useful field of view as
61-70. a reliable screening measure of driving performance in people with
Parkinson’s disease: results of a pilot study. Traffic Injury Prevention,
33. Dickerson, A. E., Molnar, L. J., Bédard, M., Eby, D. W.,
10, 593-598. https://doi.org/10.1080/15389580903179901.
Classen, S., & Polgar, J. (2017, October 1). Transportation
and Aging: An Updated Research Agenda for Advancing Safe 47. Weaver, B., Bédard. M., McAuliffe, J., & Parkkari, M. (2009). Using
Mobility. Journal of Applied Gerontology, online. https://doi. the Attention Network Test to predict driving test scores. Accident
org/10.1177%2F0733464817739154. Analysis & Prevention, 41, 76-83. https://doi.org/10.1016/j.
aap.2008.09.006.
34. Eby, D. W., Molnar, L. J., Shope J. T., & Dellinger, A. M. (2007).
Development and pilot testing of an assessment battery for older 48. Visual Awareness Research Group, Inc. What Is UFOV? A
drivers. Journal of Safety Research, 38(5),535-543. https://doi. Breakthrough in Cognitive Assessment and Rehabilitation. Retrieved
org/10.1016/j.jsr.2007.07.004. from http://www.visualawareness.com/Pages/whatis.html.
35. Owsley, C., Stalvey, B., Wells, J., & Sloane, M. E. (1999). Older 49. Bédard, M., Gagnon, S., Gélinas, I., Marshall, S., Naglie, G., Porter,
drivers and cataract: Driving habits and crash risk. The Journals of M., Rapoport, M., Vrkljan, B., & Weaver, B. (2013). Failure to predict
Gerontology, Series A: Biological Science and Medical Science, on-road results. Canadian Family Physician, 59, 727. Retrieved from
54A, M203-M211. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3710032/.
36. Kwok, J. C. W., Gélina, I., & Benoit, D., & Chilingaryan, G. (2015). 50. Staplin, L., Lococo, K. H., Stewart J., & Decina, L. E. (1999, April).
Predictive validity of the Montreal Cognitive Assessment (MoCA) Safe Mobility for Older People Notebook (Report No. DOT HS
as a screening tool for on-road driving performance. British 808 853). Washington, D.C.: National Highway Traffic Safety
Journal of Occupational Therapy, 78(2), 100-108. https://doi. Administration. Retrieved from https://one.nhtsa.gov/people/injury/
org/10.1177%2F0308022614562399. olddrive/safe/safe-toc.htm.
37. Nasredinne, Z. (2007). Frequently Asked Questions. Retrieved from 51. VectorVision. (2015). ETDRS Acuity. Retrieved from http://www.
the MOCA website at https://www.mocatest.org/. vectorvision.com/html/educationETDRSAcuity.html
38. Staplin, L., Gish, K. W., & Wagner, E., K. (2003). MaryPODS revisited: 52. Falkenstein, I. A., Cochran, D. E., Azen, S. P., Dustin, L., Tammewar,
updated crash analysis and implications for screening program A.M., Kozak, I., & Freeman, W. R. Comparison of visual acuity in
implementation. Journal of Safety Research, 34(4), 389-397. macular degeneration patients measured with Snellen and early
treatment diabetic retinopathy study charts. Ophthalmology, 115(2),
39. Freund, B., Gravenstein, S., & Ferris, R. (2002). Use of the clock
319-323. https://doi.org/10.1016/j.ophtha.2007.05.028.
drawing test as a screen for driving competency in older adults.
Presented at the American Geriatrics Society Annual Meeting,
Washington, D.C., May 9, 2002.
40. Snellgrove, C. A. (2005). Cognitive screening for the safe driving
competence of older people with mild cognitive impairment
or early dementia. Canberra, AU: Australian Transport Safety
Bureau. Retrieved from https://infrastructure.gov.au/roads/safety/
publications/2005/pdf/cog_screen_old.pdf.
41. Classen, S., Witter D. P., Lanford D. N., Okun, M. S., Rodriguez, R.
L., Romrell, J., Malaty, I. & Fernandez, H. H. (2011). Usefulness of
screening tools for predicting driving performance in people with
Parkinson’s disease. American Journal of Occupational Therapy, 65,
579-588. doi:10.5014/ajot.2011.001073.
42. Edwards, J. D., Leonard, K. M., Lunsman, M., Dodson, J., Bradley,
S., Myers, C. A., & Hubble, B. (2008). Acceptability and validity of
older driver screening with the Driving Health Inventory. Accident
Analysis & Prevention, 40, 1157-1163.

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

C H A P T E R 4 C LINICAL INTERVENTIONS

KEY POINTS
n The goal of clinical deficit until it becomes quite occupational therapists,
evaluation is to identify, significant. speech-language pathologists,
correct, and/or stabilize n Failure to pass any measure neuropsychologists, driving
any functional deficits that of cognition in the Clinical rehabilitation specialists, or
may impair an older adult’s Assessment of Driver-Related other medical specialists.
driving performance and to Skills (CADreS) toolbox should n Individuals who have
consider referral to a driver elicit a referral to provide issues only with motor and/or
rehabilitation specialist (DRS), opportunities for older adults somatosensory areas should
if appropriate. to optimize cognitive function be referred to a DRS to take
n Screening for visual field and perhaps explore their advantage of advancements
cuts is important, because potential to continue to in technology and possible
most older adults with visual drive safely. Local resources adaptive equipment for the
field loss are unaware of the will vary and may include vehicle.

Despite encouragement, Mr. Phillips (introduced You document all of this in Mr. Phillips’ record
in previous chapters) hesitates to go through and schedule a follow-up appointment. At Mr.
the assessment tools you recommend from Phillips’ next visit, you ask him if he has had a
the Clinical Assessment of Driver-Related Skills chance to review the materials provided on his
(CADReS) toolbox. He states, “I don’t see the last visit. He admits that he had another close
need for it.” You discuss your concerns for call while driving, and his son states he observed
his safety and counsel him with the following several driving errors, including turning left in
resources from Appendix B: front of an oncoming vehicle. These events
n NHTSA’s Driving Safely While Aging Gracefully have motivated Mr. Phillips to complete the
self-assessment. He believes the self-assessment
n AAA’s questionnaire Drivers 65 Plus: Check
recommendation for further evaluation is
Your Performance Self-Rating Tool
a reasonable idea and is now willing to be
n Testing Driver Safety assessed.
n Safety Tips for Older Drivers From the CADReS toolbox, Mr. Phillips takes
Mr. Phillips agrees to allow his son to observe his 13 seconds to perform the Rapid Pace Walk.
driving, and you advise the son on how to access His visual acuity is 20/50 on the right and 20/70
the online Fitness-to-Drive screening measure on the left. He has limited range of motion on
(http://ftds.phhp.ufl.edu/) as well as NHTSA’s neck rotation, but his ankle plantar flexion and
How to Understand & Influence Older Drivers dorsiflexion are within normal limits. It takes him
(https://www.nhtsa.gov/older-drivers/how- 182 seconds to complete the Trail-Making Test,
understand-and-influence-older-drivers). Part B, and his clock-drawing test is scored as
“normal” for all seven criteria.

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

N
ow that Mr. Phillips has been assessed, caregiver on how to compensate for a deficit. A
what does his performance indicate? This problem solely with contrast sensitivity does not
chapter provides information to support merit a report to the state licensing agency.
interpretation of CADReS assessment outcomes. Visual Acuity: Although many states currently require
However, recommendations stated here are subject far visual acuity of 20/40 for an unrestricted license,
to individual state reporting laws and state licensing there is little evidence that links static visual acuity to
agency requirements. Links to individual state crash risk. In fact, studies undertaken in some states
requirements are provided in Chapter 8. Examples have demonstrated that there is no increased crash
of interventions that may help manage and treat any risk between 20/40 and 20/70, resulting in several
functional deficits identified through CADReS are new state requirements.2,3 However, some studies
also provided. have found that states that require visual testing for
Remember that the goal of clinical evaluation is license renewal for older adults have lower crash
to identify, correct, and/or stabilize any functional rates.4
deficits that may impair an older adult’s driving General recommendations on visual acuity and
performance and to refer to a DRS, if appropriate driving are given below, but note that they are
(see Chapter 5). Contributing medical conditions subject to each state’s licensing requirements.
and potential medication effects as discussed in
For corrected visual acuity worse than 20/40 (i.e.,
the American Geriatrics Society Beers Criteria®1 are
more impaired), the clinical team member should:
discussed further in Chapter 9.
n Refer to a vision specialist (ophthalmologist
THE CLINICAL ASSESSMENT OF or optometrist) for diagnosis and treatment
DRIVER-RELATED SKILLS (CADRES) (if possible) of the underlying cause of vision
Motor and sensory ability, vision, and cognition are loss. The older adult should obtain and use the
all important for driving. However, they may not appropriate glasses or contact lenses. If the older
be equally important for a particular older adult. adult is not currently under the care of a specialist,
Depending on the older adult’s medical conditions, referral is recommended.
one area of function may require greater attention n Recommend that the older adult reduce the
than another. Depending on the assessment impact of decreased visual acuity by restricting
outcome in each area, the outcome action may be travel to low-risk areas and conditions (e.g.,
different. familiar surroundings, non-rush hour traffic,
low speed areas, daytime, and good weather
Vision
conditions). Although the evidenced-based
Screening for visual field cuts is important, because literature on restriction is equivocal, we still
most older adults with visual field loss are unaware believe this to be good practice.
of the deficit until it becomes quite significant, such
n Be aware that the older adult may require more
as in stroke, glaucoma, or macular degeneration.
frequent (e.g., yearly) assessment of visual acuity
In most cases, referral to an ophthalmologist is the
to detect further visual decline caused by chronic,
best outcome if there is any cause for concern.
progressive diseases such as age-related macular
Contrast sensitivity is a good screen for all older degeneration, diabetic retinopathy and glaucoma.
adults, followed by providing appropriate education
For corrected visual acuity worse than 20/100 (i.e.,
and information to the older adult driver and
more impaired), the clinical team member should:

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

n Follow the recommendations above. For visual field defects noted on confrontation
n Recommend that the older adult not drive testing, the clinical team member should:
unless safe driving ability can be demonstrated n Refer to a vision specialist (ophthalmologist
in an on-road assessment performed by a DRS or optometrist) for diagnosis and treatment (if
who has low vision expertise, where permitted. possible) of the underlying cause of vision loss. In
Check to see if low-vision driving rehabilitation is addition, automated visual field testing may help
available in your area. define the extent of the defect; ophthalmologists
Visual Fields and Contrast Sensitivity: Research have specialized instruments for measuring visual
shows that visual field loss and impaired contrast fields.
sensitivity can significantly affect driving safety. n For older adults with a binocular visual field
Patients with worse central vision loss and impaired of questionable adequacy (as deemed by
contrast sensitivity from age-related macular clinical judgment), strongly recommend an
degeneration tended to be older and were more comprehensive driving evaluation performed by
likely to have ceased driving.5 In other studies, a DRS. Through driving rehabilitation, the older
however, most drivers with moderate binocular adult may learn how to compensate for decreased
visual field loss displayed acceptable on-road visual fields. In addition, the DRS may prescribe
driving skills.6 Recently, in studies focused on a equipment such as enlarged side- and rear-view
more homogeneous group of older adults with a mirrors and train the older adult in their use.
specific condition known to impair visual fields (e.g., n Consider contrast sensitivity testing, which is
glaucoma), increased crash risk was correlated with a good screen for all older adults, followed by
moderate to severe field defects.7,8 providing education and information to both
Although an adequate visual field is important for the older adult driver and caregivers on how to
safe driving, there is no conclusive evidence to compensate for a deficit by minimizing low-light
define “adequate.” Most likely, this varies widely driving conditions (at night, in bad weather). Vision
from person to person and may depend on the specialist referral is desirable, but a problem solely
presence of other comorbidities. For example, a with contrast sensitivity does not merit a report to
driver with a restricted visual field but excellent the state licensing board.
scanning ability may drive as safely as a driver Visual fields may need to be retested in the
with an unrestricted visual field but poor neck future for visual field defects caused by chronic,
rotation.9 Because most older adults with visual progressive diseases.
field loss are unaware of the deficit until it becomes
quite significant, screening for visual field cuts is Cognition
important, especially if their medical condition Screening for cognitive deficits is essential, along
warrants examination (e.g., stroke, macular with careful interpretation of the findings. There is
degeneration). clear evidence that the Mini–Mental State Exam
General recommendations on visual field and is not related to outcomes in crashes or driving
driving are stated below. Physicians and other abilities.10,11 However, the tools recommended
clinical team members should be aware of in the CADreS have been particularly chosen to
and adhere to their states’ specific visual field provide reasonable information in the office-based
requirements. setting on skills known to be related to driving. Any

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

cognitive screen that clearly demonstrates the older administer the MoCA is approximately 10 minutes.
adult has moderate or severe cognitive impairment The total possible score is 30 points; a score of
is sufficient evidence for a provider to recommend 26 or above is considered normal. One point is
driving cessation.12 No further referral is necessary added for any individual who has 12 years or fewer
for evaluation of driving performance. A referral to of formal education.13 In individuals with cognitive
a general practice occupational therapist for further impairment, there was a significant relationship
evaluation of instrumental activities of daily living between MoCA score and on-road outcome.
(IADLs) or to a neuropsychologist for appropriate Specifically, an individual was 1.36 times as likely
testing and diagnosis is indicated and may be an to fail the road test with each 1-point decrease in
important resource for improving or extending MoCA score, with a score of 18 or less of concern
quality of life and safe mobility. regarding driving safety.14 The MoCA may be used,
For older adults with mild cognitive impairment or reproduced, and distributed without permission by
early dementia (with or without motor impairment), health professionals, and it is available in multiple
more information should be obtained to explore languages online.
the reversibility of the cognitive impairment, Trail-Making Test, Part B (TMT-B): A time for
the etiology, the potential remaining abilities, completion of >3 minutes (>180 seconds) indicates
and strategies for compensation by having a a need for intervention,15 such as a review of
thorough evaluation for dementia as below. causes for the abnormal result (e.g., dementia,
Failure to pass any measure of cognition in sedating medication, depression), and/or referral
the Clinical Assessment of Driver-Related Skills to a DRS. Numerous studies have demonstrated an
(CADreS) toolbox should elicit a referral to provide association between performance on the TMT-B and
opportunities for older adults to optimize cognitive cognitive function and/or driving performance.16 A
function and perhaps explore their potential to study of 83 drivers with a mean age of 60.8 years
continue to drive safely. Local resources will vary referred specifically for evaluation of fitness to
and may include occupational therapists, speech- drive showed that on-road driving performance
language pathologists, neuropsychologists, as evaluated by a DRS was predicted 78% of the
driving rehabilitation specialists, or other medical time by the drivers’ TMT-B performance.17 Further
specialists. Although the following cognitive data from the Maryland Pilot Older Driver Study18
tests are scored separately, interventions are demonstrated a significant correlation between
recommended if the older adult reaches any of the TMT-B performance and future at-fault crash in the
designated cut-off values described below. Potential license renewal sample.
interventions will vary depending on the domain of Clock-Drawing Test, Freund Clock Scoring for
cognitive impairment demonstrated (impulsiveness, Driving Competency: Any incorrect or missing
judgment, memory, visuospatial, etc.). element on the Freund Clock Scoring criteria signals
Montreal Cognitive Assessment (MoCA): a need for intervention, such as a review of causes
The MoCA was designed as a rapid screening for the abnormal result (e.g., dementia) and/or
instrument for mild cognitive dysfunction. It referral to a DRS.
assesses different cognitive domains: attention Clock-drawing tests have been found to correlate
and concentration, executive functions, memory, significantly with traditional cognitive measures and
language, visuoconstructional skills, conceptual in some studies discriminate healthy individuals
thinking, calculations, and orientation. Time to from those with dementia.19 Of all the measures

51
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

that have been correlated with impaired driving n Identify or interview a reliable informant (e.g.,
performance in older adults with dementia, tests family member or caregiver) who can assist with the
of visuospatial skill ability have had the highest evaluation.
predictive value.20 Several versions of the clock- n Work with the older adult’s clinical team for further
drawing test are available, each varying slightly in diagnostic evaluation aimed at identifying the cause
the method of administration and scoring.21 The of the cognitive decline.
Freund Clock Scoring is based on seven “principal
n Evaluate for reversible causes of cognitive decline.
components” (as outlined on the CADReS Score
Based on history, examination, and cognitive
Sheet in Appendix C) that were derived by analyzing
testing, order laboratory tests as needed, including
the clock drawings of 88 drivers ≥65 years of age
CBC for anemia or infection, comprehensive
against their performance on a driving simulator.22
metabolic profile for electrolyte imbalance and
Errors on these principal components correlated
renal function, urinalysis for urinary tract infection,
significantly with specific hazardous driving errors,
finger stick for blood sugar, pulse oximetry for
signaling the need for formal driving evaluation.
hypoxia, thyroid-stimulating hormone (TSH) for
Maze Test: The Snellgrove Maze Test measures hypothyroidism, liver function tests, vitamin B12
only those skills required for safe driving: attention, and folate for vitamin deficiency, and based on prior
visuoconstructional skills, and executive functions of probability, noncontrast CT or MRI scan.
planning and foresight. In a sample of older adults
n Screen for depression and treat if positive.29
with mild cognitive impairment or early dementia,
the Maze Test time and error scores predicted n Review the older adult’s medication regimen
on-road driving competence with high sensitivity, and assess for potential adverse effects of the
specificity, and overall accuracy.23, 24 medications on cognition, and ask the older adult
and caregivers about the onset of cognitive decline
Again, these tests should not be the sole
as related to new medications or dosage changes.
determinant as to whether an older adult should
Older adults may be unaware of the potential effects
drive.25 However, impairments on these tests are
of medications on cognitive ability and driving.
associated with increased risk, and referral for
further evaluation, such as for IADL evaluation n If possible, treat the underlying disorder and/
or performance-based road testing, should be or adjust the medication regimen as needed.
considered. In addition, it is unlikely that future Remember, it is critical that every older adult have
fitness-to-drive evaluations will rely on one test a complete evaluation to identify the underlying
but likely will use a battery of tests such as those cause(s) and receive proper treatment.
currently being evaluated as part of multicenter n If needed, refer the older adult to a neurologist,
prospective cohort studies such as CANDRIVE II/ psychiatrist, or neuropsychologist for additional
Ozcandrive and LongROAD.26, 27 diagnosis or treatment as needed.
If an older adult’s performance warrants n Recommend a comprehensive driving evaluation
intervention, the clinician should: performed by a DRS to assess the older adult’s
n Gather (or refer for) more information to include performance in the actual driving task. An initial
detailed history and examination of cognitive and comprehensive on-road assessment with retesting at
functional abilities, as needed.28 regular intervals is particularly useful for those with
progressive dementing illnesses.

52
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

n Strongly recommend that the older adult begin these discussions.

exploring alternative forms of transportation now, See the Plan for Older Drivers’ Safety (PODS)
and encourage him or her to involve caregivers in diagram below.
Plan for Older Drivers’ Safety (PODS)
Plan for Older Drivers’ Safety (PODS)

Plan for Older Drivers’ Safety (PODS)

Step 1: Screening and Observation
Medical condition of concern?
Symptoms on review of systems?
Current/former driver? Wants to drive?
Driving incidents or changes in the past 5 years? Not At Risk: Minimal to No Positive Risk Factors Identified
Step 1: Screening and Observation
Older adult/caregiver concerns? Discuss transportation plans and health
Medicalmaintenance
condition of concern?
Symptoms on review of systems?
Current/former driver? Wants to drive?
Driving incidents or changes in the past 5 years? Not At Risk: Minimal to No Positive R
At Risk: Positive Risk Factors Identified
Older adult/caregiver concerns? Discuss transportation plans and he
Step 2: Use Clinical Assessment of Driving Related Skills
(CADReS) to Identify Impairments and Seek Remediation
+ + + +At Risk: Positive Risk Factors Identified
Step 2: Use Clinical Assessment of Driving Related Skills
(CADReS) to Identify Impairments and Seek Remediation
+ Motor/Sensory: + + +
General: Cognitive:
Vision: Range of Motion,
Driving History, IADLs MoCA, Trails B, Proprioception, Get Up
Fields, Acuity, Motor/Sen
Questionnaire, Clock Drawing, and Go, Rapid Pace
General: Cognitive:
Contrast Vision:
Medication Review Maze Walk
Range of M
Driving History, IADLs MoCA, Trails B, Proprioception
Fields, Acuity,
Questionnaire, Clock Drawing, and Go, Rapi
Contrast
Medication Review Maze Walk

Step 3: Analysis of Screen and CADreS Not At Risk

Step 3: Analysis of Screen and CADreS Not At Risk
At Risk
At Risk

Clinical Specialist Evaluation and Driving Rehabilitation Evaluation

Intervention* Clinical Specialist Evaluation and Driving Rehabilitation Evaluation
Intervention*

Rehab/ Vehicle Rehab/ Ve

Medical Medical Intervention Adaptation/
Medical Medical Intervention Adap
Conditions Conditions Needed: Training Needed:
Conditions Conditions Needed: Trainin
Uncompensated Optimized Uncompensated Optimized
Refer to a Refer to Available Refer to a Refer to
or In Recovery Specialist or In Recovery
Resources Specialist Res
Phase Phase

Step 4: Driving Deficit Results

Step 4: Driving Deficit Results

No Significant Driving Deficit Identified: Fit To D

Driving Deficit Identified
No Significant Driving Deficit Identified: Fit To Drive Discuss transportation plans and health mainten
Driving Deficit Identified
Discuss transportation plans and health maintenance
Cessation of Driving:
Fit to Drive with No Driving Yet:
Restrictions: Counsel on
Refer for Recovery
Cessation of Driving: Alternative Modes of
Fit to Drive with No Driving Yet: Perform Interval
Transportation; Call Plan to Revisit Driving
Restrictions: Counsel on Re-evaluations Repeat Step 3
Refer for Recovery for Family Meeting
Alternative Modes of
Perform Interval Plan to Revisit Driving
Transportation; Call
Re-evaluations Repeat Step 3
for Family Meeting

IADLs Instrumental Activities of Daily Living

MoCA Montreal Cognitive Assessment
Pathway step may be repeated if progressive assessment necessary
IADLs Instrumental Activities of Daily Living * Clinical specialists may include medicine, nursing, pharmacy, social work,
MoCA Montreal Cognitive Assessment occupational or physical therapy, psychology and others, depending on the
clinical setting
Pathway step may be repeated if progressive assessment necessary
---- Time Lapse
* Clinical specialists may include medicine, nursing, pharmacy, social work,
occupational or physical therapy, psychology and others, depending on the
clinical setting 53
---- Time Lapse
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Motor Ability The clinical team member should also be aware that
If the only problems are with motor and/or somato- the amount of strength required for safe driving may
sensory areas, these individuals should be referred depend on the type of vehicle being driven. For
to a DRS to take advantage of advancements in example, greater strength may be required to safely
technology (see Chapter 5). For older adult drivers drive older cars that do not have power steering or
who are cognitively intact, learning to compensate large vehicles (e.g., an RV, which is not uncommon
for motor and/or somatosensory deficits justifies for retirees).
getting expert advice on strategies, available vehi- Functional Range of Motion: If the older adult’s
cle adaptations or devices of the type best suited range of motion is not within normal limits (i.e.,
for individual issues, and the training to use them for range of motion is very limited, or good only with
continued driving. Data from the LongROADS study excessive hesitation or pain), this may signal the
indicates that women were more likely to have a need for intervention. The inability to recognize
musculoskeletal diagnosis and twice as likely in the an object presented directly behind an older adult
past 12 months to reduce driving as a result. The (e.g., impaired cervical range of motion) has been
highest rates of driving reduction were due to joint correlated with increased risk of a motor vehicle
replacements, while the greatest number were due crash.18
to joint pain and swelling and arthritis.30 Although Scoring for range of motion is rated as normal ver-
the following tests are scored separately, interven- sus impaired (rather than recording the actual range)
tions are recommended if the older adult shows for several reasons:
significant difficulty as described below on any of
n Most clinicians are neither trained in use of
the individual tests.
goniometers nor have the devices in the office
Rapid Pace Walk or the Get Up and Go: Because setting.
each of these measure overall lower extremity
n Range-of-motion requirements vary with auto-
strength, coordination, and proprioception in a func-
mobile design, and thus it is difficult to specify
tional task, they also serve to screen how well an
exact requirements. Vehicle adaptation to com-
older adult can function despite individual motor or
pensate for limited range may also be possible.
range of motion deficits. Older adults with a history
of falls have been noted to be at increased risk of n The impact of limited range of motion on
motor vehicle crashes.31 A Rapid Pace Walk score >9 driving safety also depends on other functions (as
seconds should trigger a referral to physical therapy discussed in the visual fields section).
for evaluation and treatment, as well as further eval- n As with all the other tests from the CADReS
uation by the clinical team for potential causes and toolbox, an older adult’s poor performance
treatments. A score of ≥3 on the Get Up and Go should be a stimulus for optimization of function
test should similarly be considered an indication for rather than for immediate driving restrictions.
referral and treatment. If functional disability is quite
If an older adult’s performance on this test is not
severe, it may be wise for the older adult to refrain
within normal limits, the clinician should elicit the
from driving until such time as their condition can
reason: Do these movements cause muscle or joint
be optimized or adaptive devices (e.g., hand con-
pain? Does the older adult complain of tight mus-
trols) can be installed and the older adult trained in
cles or stiff joints? Do these movements cause a loss
their use.
of balance? Knowing the answers to these questions

54
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

will help in management of the older adult’s physical romuscular problems. Individuals who have had a
limitations. stroke may have residual deficits that interfere with
If an older adult’s performance indicates a need for their handling of car controls and should also be
intervention, the clinical team member should: referred.

n Encourage the older adult to drive a vehicle with n Recommend a comprehensive driving assessment
power steering and automatic transmission, if he or (including an on-road assessment) performed by a
she does not already do so. DRS. A comprehensive on-road assessment is partic-
ularly useful for assessing the impact of physical fa-
n Recommend that the older adult maintain or be-
tigue, flexibility, and pain on the older adult’s driving
gin a consistent regimen of general physical activity,
skills. The DRS may prescribe adaptive devices as
including cardiovascular exercise, strengthening
needed (e.g., a spinner knob on the steering wheel
exercises, and stretching. Excellent resources are
to compensate for poor hand grip or an extended
available through the Go4Life program sponsored
gear shift lever to compensate for reduced reach)
by the National Institute on Aging (https://go4life.
and train the older adult in their use.
nia.nih.gov/).
n Refer the older adult to a physical therapist Mrs. Alvarez’s medications include metformin,
as needed for training and exercises to improve acetaminophen, gabapentin, hydrochlorothia-
strength and/or range of motion, or to an occupa- zide, lisinopril, zolpidem, and aspirin. Consid-
tional therapist if impairment is affecting daily tasks. ering Mrs. Alvarez’s fall risk and medical history
n Check with the older adult’s primary care provider of peripheral neuropathy, you discuss the need
on providing effective pain control if pain is limit- for further evaluation and treatment. She agrees
ing range of motion or mobility. This may include that she can try to wean off of zolpidem and
prescribing analgesics or medications that treat an reduce the dose of gabapentin to improve her
underlying disorder, or changing the time that the stability and speed of response. You recom-
older adult takes pain medications so that relief mend a referral to physical therapy for improv-
is achieved before driving. Note that while many ing balance and fall prevention and a referral
analgesics may improve driving through symptom to a DRS for evaluation and potential adaptive
relief, some (including narcotics and skeletal muscle equipment.
relaxants) have the potential to impair driving ability “Mrs. Alvarez, I am going to recommend that
and may adversely affect driving performance more you work with a physical therapist for a full eval-
than the instigating symptoms. These medications uation of your neuropathy and teach you some
should be avoided, if possible, or prescribed at the exercises to improve your balance to prevent
lowest effective dose. Older adults should be ad- future falls. However, I’m also concerned about
vised to refrain from driving when first taking these driving. It may be that you have lost too much
medications until they know how the medications feeling in your feet to be able to tell which pedal
are tolerated. Non-sedating and non-pharmacologic you have your foot on and could mistake the
strategies for pain management are preferred when- gas for the brake and have a crash.”
ever possible.
nRefer the older adult to a specialist for manage-
ment of any joint disease, podiatry issues, or neu-

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

NEXT COURSE OF ACTION The CADReS toolbox is useful when supporting

After administering CADReS assessment tools, an in-office assessment, but it does not evaluate
three courses of action are possible (see also Plan the older adult’s performance in the actual driving
for Older Drivers’ Safety, Chapter 1): task. Results, even if abnormal, are not sufficient
to recommend driving cessation, except for vision
n If the older adult performs well in all three
and moderate/severe cognitive impairment. For all
areas from the CADReS toolbox, he or she can
other cases, comprehensive driving evaluation with
be advised that there are no medical contrain-
an on-road assessment performed by a DRS is indi-
dications to safe driving and offered counseling
cated. The DRS can more specifically determine the
regarding health maintenance and future trans-
older adult’s level of driving safety and potentially
portation planning. Older adults should be coun-
correct his or her functional impairments, if possi-
seled on health maintenance by providing infor-
ble, through adaptive techniques or devices (see
mation such as the Ten Tips for Aging Well and
Chapter 5 and Appendix C).
Tips for Safe Driving handouts, and the clinician
should periodically follow-up on the older adult’s State licensing policies are evolving, with each state
driving safety. However, if there is evidence of a establishing guidelines for issuing and revoking
new onset of impaired driving behaviors (e.g., a driver’s licenses. Health care providers must be
decline from baseline) as described by the older aware of the guidelines in their state and ideally
adult and/or caregiver, further evaluation may be also other states in which the older adult drives (see
warranted despite a normal score. Chapter 8). The first responsibility, regardless of the
state processes, is the identification of drivers who
n If the older adult performs poorly on any area
exhibit a level of impairment potentially incompat-
of CADReS, but on clinical specialist evaluation
ible with continued driving. For those individuals,
the causes of poor performance are medically
the message must be clear that driving must stop
correctable, medical treatment and intervention
until further information is obtained. If the concern
should be pursued until the older adult’s function
is medical (e.g., seizures, confusion), the individual
has been optimized. The older adult may need
must not drive until medical reports meet the state
to be counseled to limit driving as treatment
requirements for continued driving. If function on
proceeds. The level of improvement should be
the road is in question, a comprehensive driving
assessed with repeat administration of CADReS
evaluation by a DRS provides the necessary evalua-
tools. Once the older adult performs well in all
tion data and intervention plan.
areas, he or she should be counseled on health
maintenance (as above). The recommendation for further evaluation is typ-
ically the result of a series of steps (as described
n If the poor performance on the CADReS toolkit
in this chapter). Therefore, the driver should be
cannot be medically corrected, or if no further
informed both verbally and in writing that declining
potential for improvement with medical inter-
recommendations for further evaluation may put
ventions is anticipated, the older adult should be
the patient and/or the public at risk of a crash or
referred to a DRS. The older driver may need to
injury and could possibly start the state process for
be counseled to restrict driving until evaluation
license revocation, including potential reporting to
by a DRS is accomplished.
the state’s Medical Review Board.

56
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

There will be cases when, in his or her best ethical censure raises questions of who, exactly, is licensed
judgment, the health care provider believes that the to drive; how the presence of the copilot can be
risk is very high and that the older adult will con- ensured; and what standards for medical fitness-to-
tinue to drive despite the recommendation to stop drive should be applied to the copilot.32
driving. Clinicians must follow state laws for report- Older adults who are not safe to drive should be
ing to state licensing agencies and program/facility recommended to stop driving, regardless of their
guidelines for informing the older driver and/or need or use of a copilot. Copilots should not be
caregivers. Depending on the state’s reporting laws, recommended to unsafe drivers as a means to con-
clinicians may be legally responsible for reporting tinue driving. Instead, efforts should focus on help-
“unsafe” drivers to the state licensing agency (for ing older adults find alternative transportation for
descriptions of legal and ethical responsibilities, themselves and others who may depend on them.
see Chapters 7 and 8). In terms of best practice,
This is not to be confused with safe drivers who
the older adult should also be informed about this
may feel more comfortable driving with a passen-
report.
ger who provides company and helps only with
THE COPILOT PHENOMENON navigation directions. Although using a passenger
to assist as a navigator is an acceptable practice,
Copiloting refers to a situation in which an individ-
use of a copilot to provide instruction on how to
ual drives with the assistance of a passenger who
perform the driving task itself is not.
provides navigational directions as well as instruc-
tions on how to perform the driving task itself. NAVIGATION DEVICES/GLOBAL
Older adults with cognitive impairment may rely on POSITIONING SYSTEM (GPS)
passengers to tell them where to drive and how to
A recent NHTSA funded study studied 1) if GPS
respond to driving situations, whereas older adults
improved older drivers’ safety on unfamiliar routes,
with vision deficits may ask passengers to alert
2) how performance compares between drivers who
them to traffic signs and signals.
are familiar and unfamiliar with GPS, and 3) how
The use of copilots is not rare. In a survey of 534 training with GPS impacted performance.33 Results
community-dwelling current drivers aged 65 years demonstrated that when traveling in unfamiliar
and older (without dementia or Parkinson disease), areas, all drivers made fewer driving errors when
about 24% self-reported regularly using passenger using GPS compared with using paper directions,
guidance.32 Older adults should be advised to not although those who were familiar with GPS did
continue driving unless they are capable of driving better. Results also showed that drivers in their 60s
safely without the use of a copilot for coaching on exhibited safer behaviors than those in their 70s.
how to handle driving situations. In many traffic When entering a destination into a GPS, drivers
situations, there is insufficient time for the copilot who were familiar with GPS did much better than
to detect a hazard and alert the driver, and for the those who were not. These findings, which support
driver to then respond quickly enough to avoid a previous studies’ results,34 suggest that age is an
crash. In such situations, the driver places not only important factor in driving safety using GPS. In a
himself or herself in danger but also the copilot, follow-up study, training by video, hands-on train-
other passengers, and other road users. Further- ing, and a control group found that older adults
more, the use of copilots to meet standards for li-

57
CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

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C H A P T E R 5 D RIVER REHABILITATION

KEY POINTS
n Because driving is the and includes a medical and provide an evaluation of
most complex instrumental driving history, a clinical functional risk through analysis
activity of daily living (IADL), assessment of underlying of complex activities of daily
individuals who have difficulty component abilities, and an living, generating evidenced-
performing activities of daily on-road evaluation that results based recommendations
living (ADLs) and IADLs are in a range of client-centered that may include referral
likely to be at-risk drivers. recommendations. for specialized services,
n A driver rehabilitation n Older adult driving a comprehensive driving
specialist (DRS) with a programs vary widely in terms evaluation, or recommendation
professional medical degree of services offered, provider to cease driving.
is best qualified to make credentials, knowledge and n Before referring to a DRS,
a fitness-to-drive decision education, costs, availability, advise the older adult about
when an at-risk older adult and outcomes. the reason for the referral, the
has functional impairments in n Because the role of an goals of the assessment and
physical, visual, or cognitive occupational therapist is to associated rehabilitation, the
abilities. evaluate and plan interventions evaluation tests that will likely
n A comprehensive driving for patients with impairment be done in clinic and on the
evaluation is completed by a of ADL and IADLs, a referral road, and the expected out-of-
DRS and occupational therapist to occupational therapy will pocket cost for these services.

T
his chapter provides information about abilities and/or functional IADL performance
driving rehabilitation, the range of services (independence in self-care, cooking) as the initial
that may be available in a community, and step to determining the intervention plan and
what data is required to respond to the question, determine whether further evaluation specific to
“When can I drive?” For the clinical team, this driving is needed. The driver may be too impaired
question may come from the older adult driver or to be able to independently manage medications
as a request from his or her caregiver. or finances, cook independently, or be left alone
for two hours; in that case, all risk factors clearly
Driving is a complex IADL1 that is impacted by
support the included recommendation of driving
many medical conditions and advanced aging,
cessation. At other times, the skilled expertise of
just like all other ADLs and IADLs.2-4 Thus, as
the DRS is essential to better understand capacity
discussed in Chapter 3, if the patient presents
for compensation, intervention, and equipment or
with suspected impairments in ADLs/IADLs, it
vehicular modifications. This chapter will describe
may be more practical and ethical to refer to
the scope of driving rehabilitation, the diverse
a general practice occupational therapist first
types of driving programs and services, criteria
before the highly specialized services of the DRS.
for determining when the DRS is essential, and
The occupational therapist can evaluate the
strategies to address driving as an IADL.
underlying visual, sensory, physical, and cognitive

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

After scoring Mr. Phillips’ (introduced in and neck rotation, however, remains restricted
previous chapters) performance on the and his Trails B test has not improved. With
CADReS toolbox assessments, you discuss Mr. Phillips’ agreement, you refer him to
the results with him. You assure him that he occupational therapy to evaluate other complex
scored well on the cognitive tests, but that his IADLs, keeping in mind that he might need
performance on the visual and motor tasks further help from a DRS for an evaluation and
indicates a need for further evaluation and adaptive equipment.
treatment. You recommend that Mr. Phillips
“Mr. Phillips, I’m pleased that you can see
make an appointment with his ophthalmologist,
better with your new glasses and that your
whom he has not seen for over a year. You also
physical fitness has improved with your walking.
recommend that he begin exercising regularly
Keep up the good work! However, I’m still
by walking for 10-minute intervals, three times
concerned about your brain’s slower ability to
a day, and stretching gently afterward. His
process information and your reduced ability to
son, who is present at the clinic visit, offers to
move your neck. I’m worried that you can’t see
exercise with him several times a week.
around you well enough to drive safely. I’d like
When Mr. Phillips arrives for his follow-up to send you to someone who can assist us with
appointment, he is wearing new glasses. His understanding your complex daily activities and
vision with the new glasses is 20/40 in both give us some insight about your driving abilities.
eyes. You retest his motor skills, and he is now Depending how it goes, you might benefit from
able to complete the Rapid Pace Walk in 8.0 also seeing a driving rehabilitation specialist.”
seconds. His range of motion on finger curl

Mrs. Alvarez informs you she often looks at her controls and teach you how to use them.
feet to make sure she is using the right pedal.
“The cost of a professional driving evaluation
“Mrs. Alvarez, looking at your feet during
ranges anywhere from $300 to $600, and
driving is dangerous, because your eyes are not
there may be additional costs for accessories
on the road. I’d like to send you to someone
or rehabilitation training. However, it is
who can professionally evaluate your driving
possible that insurance may pay for part of
abilities. They will do a full evaluation and assist
the assessment and training. I know this may
you in finding ways to safely use the pedals.
sound like a lot of money, but I think this is
A person called a driver rehabilitation specialist important for your safety and offers you the
will ask you some questions about your medical best chance to keep your license as you face
history and test your vision, strength, range sensory changes in your feet. If you were in a
of motion, and thinking skills—similar to what serious car crash, you or someone else could
we did the last time you were here. He or she be injured, and the medical costs could end
will also take you out on the road and watch up costing you considerably more money. We
your driving. He or she might recommend should try to prevent that from happening.”
some modifications for your car, such as hand

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OLDER ADULT DRIVERS WHO CAN installation and training in the use of adaptive
BENEFIT FROM DRIVING REHABILITATION equipment.
Driving evaluation and rehabilitation are appropriate Recovery and rehabilitation are sometimes lengthy
for older adult drivers with a broad spectrum of and complicated when the patient has a condition
sensory (i.e., visual, perceptual), physical, and/ that can affect all underlying skills needed for
or cognitive impairments. Driving rehabilitation driving (e.g., stroke, diabetes, head injury) or has
specialists work with drivers diagnosed with a progressive disease (e.g., dementia, Parkinson
dementia, stroke, arthritis, low vision, learning disease). In these cases, the decision to refer
disabilities, limb amputations, neuromuscular is much more complex. The clinical team must
disorders, spinal cord injuries, mental health question if return to driving will be an option,
problems, cardiovascular diseases, and other causes evaluate the evidence available from the screening
of functional deficits, including changes of normal tests, and determine when in the recovery or
aging. disease process referral to a DRS would be
Previously, it was assumed that all individuals with warranted. In an effort to address these questions,
driving concerns should be seen by a DRS, or at a translational model was developed called OT-
minimum be evaluated “on the road.” However, DRIVE, a framework for risk identification, treatment
current research evidence supports making a planning, and referral.9
driving decision for some older adults after a careful
DECISION INDICATORS FOR DRIVING
assessment of vision, cognition, and physical ability
as applied to functional ADL/IADL activity. This The profession of occupational therapy considers
evidence supports acknowledging that when an driving under the broader IADL of driving and
individual shows deficits in other complex tasks of community mobility,1 acknowledging that ADLs and
daily living, driving cessation should be considered, IADLs are the mainstay of occupational therapy
because driving is the most complex IADL.4-7 In practice. The “typical” occupational therapy
these cases, referral to the DRS is probably not evaluation begins with an interview of the patient’s
warranted, unless the family needs the confirmation. desires and goals (i.e., the occupational profile)
as well as an assessment of the patient’s visual,
In general, in cases when the older adult has
sensory, motor, and cognitive function using many
relatively intact cognition, but visual or physical
of the same assessment tools used by the DRS. The
impairment that will impact driving (e.g.,
outcome of this evaluation is the first step in the OT-
amputation, neck fusion), a direct referral to the DRS
DRIVE model (the “OT”); the therapist determines
is warranted.8 Advancement in vehicle technology
whether driving is important to this client and
allows compensation for a wide range of physical
whether driving will be a risk.9
and some visual impairment. Vehicle modifications
include extended gear-shift levers where reach While developed to illustrate a framework for
is limited, padded steering wheel covers for occupational therapy practitioners to use to
pain or weakened grip, foot pedal extenders determine driving risk and interventions,9 Figure 1
to compensate short leg length, or extra/larger can be used by general clinicians to describe the
mirrors for patients with restricted range of motion current status of patients in terms of driving risk
or flexibility, such as in arthritis. The specialist will and the most appropriate interventions. The “red”
oversee the process, including ensuring proper proposes that there is strong evidence from the

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Figure 1 - Framework for OT-DRIVE

SPECTRUM OF DECISION INDICATORS

FOR DRIVING & COMMUNITY MOBILITY
Risk Determination Based on Evidence and Clinical Judgment
Normal Aging Medical issues with increasing complexity

Occupational Therapy
Intervention With Individualized
Occupational Profile: Plan for Mobility Includes:

Higher Risk: Evidence is Strong;

Above thresholds of impairment NON-DRIVER • Promote driving retirement
in most areas. Impairments exceed
threshold for • Mobility preservation through
safe driving. supportive transportation

Risk: Degree to which

impairment affects • Rehab: To optimize subskills
fitness-to-drive must be addressed.
• Assess readiness for comprehensive
• Determine driving potential now driving evaluation “at the right time”
and in the future
• Consider need for services to improve
• Consider need for Comprehensive Fitness to Drive
Driving Evaluation

• Encourage fitness, strength,

Lower Risk: Evidence is weak; DRIVER flexibility
below threshold for impairment that No impairment indicators • Promote driver safety programs
would affect Fitness to Drive. to report restriction & CarFit
on driving.
• Discuss warning signs

Modified from Dickerson & Schold Davis, 2017.

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

medical perspective and is supported by evaluation categorized as “yellow,” supporting a specialized

that driving risk is high in all or most areas (vision, evaluation best done by the DRS. Using evidence
perceptual, cognition) and that impairments exceed from evaluations and clinical judgment, the general
the threshold for safe driving. Patients in the “red” practice occupational therapist can determine
include individuals with moderate/severe dementia if it is best to 1) optimize subskills for driving in
or whose insight and judgment have been impaired rehabilitation, 2) consider other services to improve
by major trauma. A referral to the specialized fitness to drive, or 3) determine the readiness for
services of a DRS is not warranted, because the a comprehensive driving evaluation by a DRS,
generalist occupational therapist and/or other scheduled at the “right time.”9
service providers such as social workers can develop
an intervention plan for mobility that includes Mr. Phillips returns for a follow-up visit after
driving cessation, turning the focus to mobility undergoing the occupational therapist’s
preservation through exploration of supportive IADL evaluation. The results indicated that
transportation. Mr. Phillips scored below normal limits on
several cognitive assessments. When observed
The “green” describes patients who may have
performing complex IADL tasks, Mr. Phillips had
temporary health issues that preclude driving for a
difficulty with completing tasks as directed and
period of time but have no evidence of impaired
organizing the elements of tasks; there were also
capacity or fitness to drive. Examples may be
issues with safety. The occupational therapist
patients recovering from hip or knee replacement
recommended that someone assist Mr. Phillips
or hand or arm injuries. While these patients
with medication management and his finances,
currently haves physical impairments that limit
and that he should actively plan alternative
driving now, their cognitive capacity to self-restrict
transportation options.
during this interval is intact. For these individuals, an
appropriate typical recovery recommendation may
be to “return to driving slowly when you feel able DRIVER REHABILITATION
to do so.” However, through addressing short-term
The goal of driver rehabilitation is to assist
mobility options during the period of non-driving,
individuals with disabilities or age-related
the clinical team should also encourage physical
impairments in maintaining independent driving
exercise, promote driver safety programs, and
through use of specialized mobility equipment and/
discuss warning signs for the future.
or training.10
When diminished visual, cognitive, or physical
Driving rehabilitation specialists have advanced
abilities indicate concern for independence in
education in clinical and on-road evaluation,
managing complex IADLs, driving should be
driving education, adaptive strategies and means
addressed. Recognizing these concerns is the first
for compensation, an extensive understanding of
responsibility of the clinician/healthcare provider.
the vehicle, and the array of aftermarket options
Seeking data to better understand the level of
including vehicle modification. It is important
impairment and its impact on driving is a prudent
to understand this service is highly specialized,
next step. When there is not clear evidence (i.e.,
and some states require licensing as a driving
not “red” or “green”), determining the degree
instructor to take patients on the road. While
to which the impairments affect fitness to drive is
driver rehabilitation is a multidisciplinary field,

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

the majority of DRSs are occupational therapists history, driving needs, and license status; review
who have completed additional training in driver of medical history and medications; functional
rehabilitation while others have degrees in medical assessments of vision/perception (e.g., acuity,
fields such as physical therapy or psychology. Those contrast sensitivity, visual fields, ocular range
with nonmedical backgrounds tend to come from of motion, saccades, phorias, convergence/
education, transportation or community mobility divergence, depth perception, visual closure);
backgrounds, such as driving school instructors physical abilities (e.g., balance, range of motion,
or driver education programs. The diversity of motor strength, coordination, sensation, reaction
programs and service providers will be discussed time); and cognition (e.g., memory, divided and
later in this chapter along with the implications for selected attention, judgment, executive function,
cost and appropriate referral. processing speed, multi-tasking, insight).
n On-road evaluation to determine the degree of
THE ROLE AND FUNCTIONS OF DRIVER
REHABILITATION SPECIALISTS (DRS) driving risk, including vehicle control, adherence
to traffic rules and regulations, environmental
A DRS provides “clinical driving evaluations
awareness and interpretation, defensive driving,
and driving mobility equipment evaluations and
wayfinding, and consistent use of compensatory
intervention to develop or restore driving skills and
strategies for visual, cognitive, physical, and
abilities.”11
behavioral impairments. Vehicle ingress/egress,
The DRS with a medical background performs a mobility aid management (e.g., ability to transport
comprehensive driving evaluation that includes a wheelchair or scooter), and vehicle preparation
an in-depth clinical assessment of functional and maintenance are also evaluated. The on-road
abilities plus an on-road performance evaluation. evaluation is typically performed in the evaluation
A comprehensive driving evaluation can last vehicle equipped with dual brakes, a rearview
one to four hours, depending on the older mirror and eye-check mirror for the DRS, and
adult’s disabilities, driving needs, and the driver any necessary adaptive equipment. (Note: Some
rehabilitation program model. Typically, after programs separate the clinical and on-road portions
the clinical assessment, the on-road evaluation of the evaluation on different days for several
is performed if the older adult driver meets the reasons: in consideration of fatigue, require on-road
minimum state standards for health and vision and driving on two separate occasions to evaluate for
holds a valid driver’s license or permit. consistency, or for team scheduling with the on-road
Based on the data gathered through these two evaluation provider).
components, a DRS develops a summary of the n Communication of assessment results and
evaluation results and an individualized plan for recommendations is typically provided directly to
preserving safe mobility, be it as a driver or non- the older adult, the caregivers, and/or referring
driver. Although driver rehabilitation programs vary, health care provider/agency; the process for
most typically consist of a comprehensive driving communication of the DRS evaluation of outcomes
evaluation that includes these important elements: and recommendations may vary by program
model and local referral agreement. Variations
Comprehensive Driving Evaluation11 include sending driving evaluation results to the
n Clinical assessment, including review of driving clinical team to relay to the older adult driver and

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

caregivers. perceptual, or cognitive deficits essential to safely

n Recommendations following a comprehensive resume driving, and the potential for improvement,
driving evaluation may include: even with intervention, is poor. In these cases, the
message conveys that all options were explored
- No restrictions. The older adult demonstrates
and considered, but the decline the older adult
adequate skills to drive with no currently
has experienced has made operation of a motor
diagnosed medical condition known to increase
vehicle unsafe for self and community. Alternative
risk over time.
transportation options and a support network
- Return to driving after the vehicle is equipped should be addressed with the older adult by
with adaptive driving equipment to match the referring to appropriate providers, including the
older adult’s individual needs and instruction/ generalist occupational therapist.
training after installation.
- Continue to drive with restrictions that are The Vehicle
consistent with state laws. Some states do not offer n For some, the mobility solution may center on
restrictions, whereas others may offer a restricted the vehicle. Aftermarket adaptations or vehicle
license that would define, for example, a limitation modification may address personal vehicle
to geographic areas (e.g., 5-mile radius from mobility for the patient as driver or support access,
residence or local routes) or conditions (e.g., no securement, and caregiver support for mobility as
night or highway driving) in which the older adult passenger. The patient and family/care partners are
drives. (Note: Recommendations may be offered considered when addressing driving and community
that are informal, but “Restrictions” describe a mobility.
licensing action associated with the license similarly n Services may include:
to how a required vision correction is part of
- Assessment of vehicle, vehicle modifications, and
licensure.)
equipment for the older adult’s safe transport as
- Reevaluation on a regular basis is indicated when a passenger or driver. Modifications may include
an older adult demonstrates adequate skills to accommodations for transportation of power
drive at present but has been diagnosed with a wheelchair or other mobility device or if the
progressive disorder that may cause future decline individual is to be a wheelchair passenger or driver.
(e.g., dementia, Parkinson disease).
- Address the needs of caregivers as the driver
- Temporary driving cessation, noting potential for responsible for transporting the individual as a
improvement and driving in future. Recommended passenger (e.g., inability to assist with transfer
intervention to improve deficits in vision, because of arthritis, limitations in stowing mobility
perception, motor and/or cognition is advised devices, transporting scooter). In these cases,
when the older adult has medical condition(s) mobility equipment solutions such as scooter
that can improve over time (e.g., stroke, heart or wheelchair lifts or tie-down systems may be
attack, traumatic brain injury) and can return for recommended to preserve mobility by proactively
reevaluation. addressing the caregiver’s physical capabilities,
- Permanent driving cessation. This is advised limitations, and mobility goals.
when an older adult does not demonstrate Older adults who perform poorly on the clinical
the necessary skills to compensate for visual,

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assessment may or may not be offered an on-road adult and mobility equipment dealer in a final
evaluation. If the older adult driver is deemed too fitting to ensure training in the use of equipment
impaired, the risk to the driver and evaluator may and optimal functioning of the recommended
preclude an on-road evaluation for safety reasons. vehicle/equipment. (For more information on
However, even after poor performance on the mobility equipment dealers [MEDs], see www.
clinical driving evaluation, the DRS may still conduct nmeda.com, the website of the National Mobility
an on-road evaluation in some cases: Equipment Dealers Association).
n Older adults who perform poorly on some n Driving simulators have a growing role in older
individual components of the clinical driving adult driving evaluation, training, and intervention.14
evaluation may still demonstrate safe driving Although simulator sickness is an issue for some
because there is no clinical assessment tool that older adults,15 simulators are emerging as an
accurately predicts on-road performance as clearly effective tool for driving assessment16 and more
as the on-road assessment and driving is an importantly, as an intervention tool for older
overlearned skill.6,12-13 adults with medical conditions.17-20 The numbers
n Older adults and their family and caregivers of occupational therapy departments in hospital
may need concrete evidence of unsafe driving. settings purchasing driving simulators are
However, in the case of the older adult with increasing; thus, research in this area is needed.
cognitive impairment who lacks insight, the on-road
Mrs. Alvarez is referred and evaluated
evaluation may in fact serve to change only the
by the DRS.
perception of the family but not that of the driver.
The DRS completes a comprehensive driving
Treatment and Intervention
evaluation for Mrs. Alvarez. Vision and cognition
n Adaptive driving instruction or driver retraining, are within normal limits for someone her age.
with or without vehicle modifications. However, she demonstrates slower reaction
n Coordination of vehicle modifications: times, especially for motor tasks. She informs
the DRS she often looks at her feet to make
- Vehicle consultation: The DRS often serves as
sure she is using the right pedal. Physical results
a consultant to older adults who are purchasing
indicate that she has poor proprioception
a new vehicle to ensure that the vehicle will
in her feet and cannot safely use the pedals
accommodate the necessary mobility limitations
without visually watching her feet. Because
(door opening or seat height to optimize ease
of her strong cognitive skills and motivation
in transfer, ease in applying adaptive equipment
to maintain driving, the DRS believes she is a
now or in the future).
good candidate for hand controls, so a second
- Vehicle modification recommendations: The appointment is scheduled with the DRS to try
DRS provides written recommendations for all a few different types of controls to see which
vehicle/equipment needs to the older adult works best for her (and her vehicle). Once the
driver, third-party payer, and vehicle/equipment hand controls are fitted into her vehicle, Mrs.
dealer. Alvarez will take a series of lessons with the DRS
- Adaptive equipment/vehicle modification to ensure the equipment is fitted properly to her
inspection: The DRS is involved with the older vehicle and she has the appropriate training.

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Making the Referral to the DRS alternative forms of transportation or choices in case
Before making the referral, advise the older adult they experience temporary or long-term changes
about your reasons for recommending a specialist that may limit driving in the future. If the older adult
evaluation, the goals of the assessment and is not considered fit to drive, then this information
rehabilitation, the evaluation and tests that will likely must be conveyed clearly to the older adult and
be offered, and the expected out-of-pocket cost for caregivers, and followed up with services that
these services. support driving cessation and address continued
mobility as a non-driver (see Chapter 6).
Some programs require a written healthcare
provider prescription while others may not. Special mention is made of other rehabilitation
Understanding your local requirements or specialists who may help address impairments
clinic policies is important to appropriately and that are common in older adults. For instance,
efficiently refer the older adult. A driving evaluation physical therapists may be able to improve muscle
prescription should list specific reasons and needs weakness, range of motion, or physical frailty.
that justify the evaluation and/or rehabilitation. For Visual rehabilitation may be available in some
example, “OT driver evaluation for hand weakness specialized centers. Neuro-ophthalmologists or
with poor finger flexion or for limited neck rotation optometrists may provide vision training, especially
secondary to arthritis,” “driving evaluation for for older adults with neurologic insults that affect
hemianopsia secondary to stroke,” or “driving convergence, alignment, nystagmus, eye apraxia,
evaluation for cognitive impairments secondary to and/or visual neglect from stroke, head injury, brain
Alzheimer disease” provide guidance for the DRS tumors, and trauma.
and are more likely to be reimbursed by insurance.
CONDITIONS COMMONLY SEEN
In contrast, vague orders for “an older adult,” IN DRIVING PROGRAMS
“debilitated,” or “frail” older adult do not provide
Normal aging happens to everyone at different
adequate guidance to the DRS and can complicate
rates, and research has shown that age alone does
insurance reimbursement. In addition, the DRS will
not justify a driving evaluation.13 In fact, most older
also need information on current diagnoses and
adults appropriately self-restrict and do not engage
medications.
in risky driving behaviors (e.g., speeding, tailgating,
If appropriate and feasible in the clinical team drinking and driving).13,21 However, many medical
setting, a follow-up appointment should be conditions require the clinical team to consider how
scheduled after the driving evaluation. If the the condition and/or its medications affect driving,
recommendation from the DRS is continued driving as outlined specifically in Chapter 9. The most
with or without restrictions, adaptive devices, common conditions of older adults referred to a
and/or rehabilitation, the recommendations DRS include the neurological progressive conditions
should be reinforced by the clinical team. When (e.g., dementia, Parkinson disease), stroke and/or
applicable, caregivers should be informed of these acquired brain, and advanced aging.
recommendations. Also remember that older adult
drivers should be counseled on health maintenance Dementia or Other Progressive Conditions
and safe driving behaviors and encouraged
For the progressive conditions, it is “not if, but
to develop a transportation plan that includes
when” to cease driving.22 Early in the disease

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stages, intervention by an occupational therapy Acquired Brain Injury or Stroke

practitioner may include assisting the older adult In contrast to dementia, individuals who have had
and family in developing a transportation plan likely an acquired brain injury such as a stroke have great
to include criteria indicative of eventual cessation. potential for recovery and rehabilitation. Research
This plan may focus on determining the individual’s has shown that recovery can be up to months
current driving needs, incorporating strategies for or years following the initial stroke, especially
compensation such as finding altered driving routes if rehabilitation services are ongoing. Because
(e.g., avoiding left hand turns or busy intersections), returning to driving is one of the most valued
guiding family to gather performance data by IADLs of individuals with stroke,23 individuals with
observing practice drives, and recommending close brain injury who have insight and meet visual state
and extended follow-up by the medical provider standards need to be evaluated by the DRS at the
or seeking the services of a DRS as the condition right time in recovery. Evidence supports individuals
progresses. The transportation plan offers the with stroke successfully returning to driving16, 24-25 if
older adult and family the opportunity to anticipate evaluation and intervention occur at the right time
and plan for transition, framing driving cessation with the appropriate equipment.
as a process and not an arbitrary or “too late”
decision. The conversation of cessation must be Mr. Phillips returns for a follow-up visit after
followed by access to local providers to explore undergoing driver assessment. The DRS
resources, alternative forms of transportation, and recommended that wide-angle rearview
the supports the older adult requires (e.g., escort, mirrors be fitted on Mr. Phillips’ car and install
curb-to-curb, or door-to-door). An example may be a back-up camera (if possible). Additionally,
found in Appendix C. For those unwilling or unable the DRS recommended strategies to reduce
to understand the cessation recommendation, distractions and cognitive fatigue that included
caregivers should be provided with strategies to no longer listening to the radio, only driving
prevent access to the car and to manage ongoing in familiar places and/or using a GPS for
resistance and arguments demanding access to unfamiliar places, and not using interstates.
the car. Other clinical team members may also The DRS also recommended and reviewed the
be helpful when supporting older adults and high-risk intersections that should be avoided.
caregivers who lack insight. In some instances when Mr. Phillips states that he is driving more
compliance with cessation is questioned, a process comfortably with his adaptive device and use
for reporting the unsafe driver to the state licensing of strategies, and his son says that he appears
authority may be required (see Chapter 7). Clinicians to be focusing better on his driving tasks.
in particular may be asked to respond if the older You counsel him on the Tips for Safe Driving
driver receives a letter from a medical review board, and Ten Tips for Aging Well resources, advise
vehicle licensing agency, or law enforcement. An him to continue walking, and encourage him
example may be found in Appendix C. Health care to start planning alternative transportation
providers may be asked to complete a state medical options. His daughter is recruited to assist Mr.
reporting form (for an example, see http://dor. Phillips and his son with these discussions and
mo.gov/forms/1528.pdf). interventions.

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PROGRAMS THAT ADDRESS DRIVING: n The outcome of each program type is clearly
FROM EDUCATION TO REHABILITATION stated. Because driver safety programs provide
Driving rehabilitation encompasses a range of education and awareness and driving schools
programs and providers. The interprofessional enhance skills for healthy drivers, these two
nature of driving rehabilitation involves services categories should not be the intervention resource
equipped to address a range of needs. Most for those with medical conditions. The medically
health care professionals understand that driving based assessment, education, and referral programs
rehabilitation should only involve medical providers; that indicate risk or the need for referral to the
however, sometimes other driving services are specialized programs are the appropriate programs
assumed to be included. The Spectrum of Driver for these individuals.
Services26 document was developed to define and Thus, the clinical team member’s task is to
describe the range of driver services, including determine if the need is related to:
providers’ education and credentials, required
1. knowledge and learning (e.g., knowing how,
providers’ knowledge, typical services provided,
road knowledge to navigate the complex driving
and outcomes of each program type. Figure 2
environment),
differentiates the programs and can assist the
clinical members in referring to appropriate levels of 2. lack of confidence (due to limited driving), or
service.26 The significant features include: 3. capacity (e.g., visual processing, speed and
n The differentiation between community-based flexibility to use vehicle controls, cognitive
education; medically based assessment, education, capacity to judge and manage the unexpected,
and referral; and specialized evaluation and training stamina to remain alert and attentive throughout).
with driver rehabilitation programs. If the issue is capacity, because the older adult
n There are five major types of program (i.e., driver demonstrates impairments through use of the
safety programs, driving schools, driver screening, clinical screening (CADReS) and/or by performance
clinical IADL evaluations, and driving rehabilitation in other IADLs, the clinician should consider referral
programs), with typical providers described with to a general practice occupational therapist who can
their credentials. This will assist in determining offer a traditional professional evaluation of IADLs,
which programs use providers with a medical including high-level/complex IADLs, to determine
background. driving risk and safety. If an older adult is unable
to be left alone for 2 hours, for example, this level
n Under each program type, the required providers’
of IADL impairment may offer adequate data to
knowledge and typical services will assist the reader
make driving recommendations based on impaired
in being able to differentiate preventive services
capacity for living independently as well as driving.
(i.e., updating driving skills or acquiring a driver’s
If the IADL status offers a mix of strengths and
license) from medically based assessment. These
impairments, the older adult could then be referred
sections also articulate the differences between
on to a comprehensive driving evaluation. The
screening at a physician’s office, a clinical (or IADL)
question of driving competence may be the first
assessment that might be done by a generalist
clue the clinical team has that may lead to a general
occupational therapist, and the specialized services
review of IADL status and eventual diagnosis of
provided by the DRS.

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Figure 2 - Spectrum of Driver Services

Spectrum of Driver Services: Right Services for the Right People at the Right Time
A description consumers and health care providers can use to distinguish the type of services needed for an older adult.
COMMUNITY-BASED MEDICALLY-BASED ASSESSMENT,
SPECIALIZED EVALUATION AND TRAINING
EDUCATION EDUCATION AND REFERRAL
Program Driver Safety Driver Rehabilitation Programs
Type
Driving School Driver Screen Clinical IADL Evaluation
Programs (Includes Driver Evaluation)
Typical Program specific Licensed Driving Health care professional Occupational Therapy Practitioner Driver Rehabilitation Specialist#, Certified Driver
Providers credentials Instructor (LDI) (e.g., physician, social worker, (Generalist or Driver Rehabilitation Rehabilitation Specialist*, Occupational Therapist with
and (e.g. AARP and certified by state neuropsychologist). Specialist#). Specialty Certification in Driving and Community Mobility+.
Credentials AAA Driver licensing agency
Other health professional degree
Improvement or Dept. of
with expertise in Instrumental
Program). Education.
Activities of Daily Living (IADL).
Required Program specific Instructs novice Knowledge of relevant Knowledge of medical conditions Applies knowledge of medical conditions with implications
Provider’s knowledge. or relocated medical conditions, and the implication for community to driving.
Knowledge drivers, excluding assessment, referral, and / or mobility including driving.
Assesses the cognitive, visual, perceptual, behavioral and
medical or aging intervention processes. Assess the cognitive, visual, per-
physical limitations that may impact driving performance.
Trained in course conditions that ceptual, behavioral and
Understand the limits and
content and might interfere physical limitations that may Integrates the clinical findings with assessment of on-road
value of assessment tools,
delivery. with driving, for impact driving performance. performance.
including simulation, as a
purposes of
measurement of fitness to Knowledge of available services. Synthesizes client and caregiver needs, assist in decisions
teaching / training
drive. about equipment and vehicle modification options available.
/ refreshing / Understands the limits and value
updating driving of assessment tools, including Coordinates multidisciplinary providers and resources,
skills. simulation, as a measurement of including driver education, health care team, vehicle choice
fitness to drive. and modifications, community services, funding / payers,
driver licensing agencies, training and education, and
caregiver support.
Typical 1) Classroom 1) Enhance 1) Counsel on risks associated 1) Evaluate and interpret risks as- Programs are distinguished by complexity of evaluations,
Services or computer driving with specific conditions sociated with changes in vision, types of equipment, vehicles, and expertise of provider.
Provided based performance. (e.g., medications, fractures, cognition, and sensory-motor
1) Navigate driver license compliance and basic eligibility
refresher for post-surgery). functions due to acute or chronic
2) Acquire driver through intake of driving and medical history.
licensed conditions.
permit or 2) Investigate driving risk
drivers: review 2) Evaluate and interpret risks associated with changes in
license. associated with changes 2) Facilitate remediation of deficits
of rules of the vision, cognition, and sensory-motor functions in the
in vision, cognition, and to advance client readiness for
road, driving 3) Counsel driving context by the medically trained provider.
sensory-motor function. driver rehabilitation services.
techniques, with family
3) Perform a comprehensive driving evaluation (clinical and
driving strate- members for 3) Determine actions for the 3) Develop an individualized
on-road).
gies, state student driver at-risk driver: transportation plan considering
laws, etc. skill develop- • Refer to IADL evalua- client diagnosis and risks, 4) Advise client and caregivers about evaluation results,
ment. tion, driver rehabilitation family, caregiver, environmental and provides resources, counseling, education, and / or
2) Enhanced self-
program, and / or other and community options and intervention plan.
awareness, 4) Recommend
services. limitations:
choices, and continued 5) Intervention may include training with compensatory
capability to training and / • Discuss driving cessation; • Discuss resources for vehicle strategies, skills, and vehicle adaptations or modifications
self-limit. or undergoing provide access to counsel- adaptations (e.g., scooter lift). for drivers and passengers.
licensing test. ing and education for • Facilitate client training on
alternative transportation community transportation 6) Advocate for clients in access to funding resources
5) Remedial options. options (e.g., mobility and / or reimbursement.
Programs managers, dementia-friendly
4) Follow reporting / referral 7) Provide documentation about fitness to drive to the
(e.g., license transportation).
structure for licensing physician and / or driver-licensing agency in compliance
reinstatement
recommendations. • Discuss driving cessation. with regulations.
course for
teens / adults, For clients with poor self- 8) Prescribe equipment in compliance with state regulations
license point awareness, collaborate with and collaborate with Mobility Equipment Dealer^ for
reduction caregivers on cessation fitting and training.
courses). strategies.
• Refer to driver rehabilitation 9) Present resources and options for continued community
program. mobility if recommending driving cessation or transition
from driving.
4) Document driver safety risk and
recommended intervention plan Recommendations may include (but not restricted to):
to guide further action. 1) drive unrestricted; 2) drive with restrictions; 3) cessation
of driving pending rehabilitation or training; 4) planned
5) Follow professional ethics on re-evaluation for progressive disorders; 5) driving cessation;
referrals to the driver licensing 6) referral to another program.
authority.
Outcome Provides Enhances skills for Indicates risk or need for follow-up for medically at-risk drivers. Determines fitness to drive and provides rehabilitative services.
education and healthy drivers.
awareness.
#DRS – Health professional degree with specialty training in driver evaluation and rehabilitation. *CDRS – Certified Driver Rehabilitation Specialist-Credentialed by ADED (Association for Driver Rehabilitation
Specialists). +SCDCM – Specialty Certified in Driving and Community Mobility by AOTA (American Occupational Therapy Association).
^Quality Approved Provider by NMEDA (National Mobility Equipment Dealers Association).

Driver Rehabilitation Programs: Defining Program Models, Services, and Expertise.

Occupational Therapy In Health Care, 28(2):177–187, 2014

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degenerative processes such as Alzheimer disease.

By distinguishing knowledge (i.e., rules of the road) Clinician: I’m pleased to see you Mrs. Alvarez,
from capacity (i.e., physical and cognitive abilities), and I understand you drove yourself to this
the clinician will be better equipped to select appointment with your new, adapted vehicle.
from the array of support or evaluation services How is it working out?
available. The CADReS screening tool will offer data Mrs. Alvarez: It is working, but it takes a lot of
to consider when selecting programs that address practice. It was hard to learn, but I really want to
knowledge and skills, or capacity for patients be independent, so I worked with the DRS for
considered medically at risk. all the hours she recommended, and I feel more
Many relatively healthy aging drivers may have comfortable than I did in the beginning.
their needs best addressed through education. Mrs. Alvarez: It is surprising how cars can be
However, it is important to remember the needs or adapted, even my old car! I do think I am safer
safety concerns of the experienced (older) driver are now than when I was always looking for where
distinctly different from those of the new learner or my feet were on the pedals. I am slowly getting
“novice driver” (the primary focus of most driving out more than before. However, the DRS did
schools). While some driving schools offer driving recommend that I start making a transportation
lessons to adults who have never driven, are new to plan for the future.
the region or country, or are hesitant because they
Clinician: That is a really good idea, and we can
have not driven for many years, the more common
give you materials to help you with that plan.
education types are the low-cost, group education
“refresher” courses offered in communities by AAA,
AARP, or other providers. VARIETY OF DRIVING REHABILITATION
In fact, a new program called the “Driving PROGRAMS 23
Check-Up” has been developed by the American Figure 3 illustrates the three main levels of driver
Automobile Association Foundation for Traffic rehabilitation programs, which are defined as
Safety (AAAFTS) that focuses on a driving basic, low tech, and high tech.26 The basic program
evaluation of driving skills and knowledge, but is appropriate for older adult drivers with no or
not medical fitness to drive.27 Such a service could minor physical impairments who require only
provide support for some older adults without very basic adaptive equipment in the vehicle.
specific medical conditions who may need help The low-tech program can address the needs of
with driving skills. For example, if an older adult older adult drivers who may need mechanical
has a stroke and can no longer drive, the spouse, or low-tech vehicle modifications or equipment
now assuming the role of primary driver, may be (e.g., hand controls, left foot accelerator, spinning
licensed, but lack experience or confidence having knob for one-handed steering) and/or training in
been in the passenger seat for many previous years. safe use on the road. The high-tech program is
For spouses who have not driven in many years, necessary for older adults who need to drive from
a referral to a driving school for a driver refresher a wheelchair or need high-tech equipment, such as
course may improve confidence and safety. low-effort steering. The programs that have high
tech programs typically provide the full spectrum,
including the basic program services.

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Figure 3 - Spectrum of Driver Rehabilitation Program Services

Spectrum of Driver Rehabilitation Program Services

A description consumers and health care providers can use to distinguish the services provided by
driver rehabilitation programs which best fits a client’s need.
DRIVER REHABILITATION PROGRAMS
Program Type
Determine fitness to drive and / or provide rehabilitative services.
Levels of BASIC LOW TECH HIGH TECH
Program and
Typical Provider Provider is a Driver Rehabilitation Driver Rehabilitation Specialist , Certified Driver
#
Driver Rehabilitation Specialist#, Certified Driver Rehabilitation
Credentials Specialist (DRS)# with professional Rehabilitation Specialist*, Occupational Therapist Specialist*, Occupational Therapist with Specialty Certification in
background in occupational therapy, with Specialty Certification in Driving and Community Driving and Community Mobility+.
other allied health field, driver Mobility+, or in combination with LDI.
Certification in Driver Rehabilitation is recommended as the
education or a professional team of
Certification in Driver Rehabilitation is recommended provider for comprehensive driving evaluation and training with
CDRS or SCDCM with LDI**.
as the provider for comprehensive driving evaluation advanced skills and expertise to complete complex client and
and training. vehicle evaluation and training.
Program Service Offers driver evaluation, training Offers comprehensive driving evaluation, training and Offers a wide variety of adaptive equipment and vehicle options
and education. education, with or without adaptive driving aids that for comprehensive driving evaluation, training and education,
affect the operation of primary or secondary controls, including all services available in Low Tech and Basic programs. At
May include use of adaptive driving
vehicle ingress / egress, and mobility device storage / this level, providers have the ability to alter positioning of primary
aids that do not affect operation of
securement. May include use of adaptive driving aids and secondary controls based on client’s need or ability level.
primary or secondary controls (e.g.,
such as seat cushions or additional mirrors.
seat cushions or additional mirrors). High Tech adaptive equipment for primary and secondary controls
At the Low Tech level, adaptive equipment for primary includes devices that meet the following conditions:
May include transportation
control is typically mechanical. Secondary controls may 1) capable of controlling vehicle functions or driving controls, and
planning (transition and options),
include wireless or remote access.
cessation planning, and recommen- 2) consists of a programmable computerized system that
dations for clients as passengers. May include transportation planning (transition and interfaces / integrates with an electronic system in the vehicle.
options), cessation planning, and recommendations for
clients who plan to ride as passengers only.
Access to Driver’s Requires independent transfer into Addresses transfers, seating and position into OEM^ Access to the vehicle typically requires ramp or lift and may
Position OEM^ driver’s seat in vehicle. driver’s seat. May make recommendations for assistive require adaptation to OEM driver’s seat. Access to driver position
devices to access driver’s seat, improved positioning, may be dependent on use of a transfer seat base, or clients may
wheelchair securement systems, and / or mechanical drive from their wheelchair. Provider evaluates and recommends
wheelchair loading devices. vehicle structural modifications to accommodate products such
as ramps, lifts, wheelchair and scooter hoists, transfer seat bases,
wheelchairs suitable to utilize as a driver seat, and / or wheelchair
securement systems.
Typical Vehicle Uses OEM^ controls. Primary driving control examples: Primary driving control examples (in addition to Low Tech options):
Modification:
A) mechanical gas / brake hand control; A) powered gas / brake systems;
Primary Controls:
Gas, Brake, B) left foot accelerator pedal; B) power park brake integrated with a powered gas / brake system;
Steering
C) pedal extensions; C) variable effort steering systems;
D) park brake lever or electronic park brake; D) reduced diameter steering wheel, horizontal steering, steering
E) steering device (spinner knob, tri-pin, C-cuff). wheel extension, joystick controls;
E) reduced effort brake systems.
Typical Vehicle Uses OEM^ controls. Secondary driving control examples: Electronic systems to access secondary and accessory controls.
Modification:
A) remote horn button;
Secondary Secondary driving control examples (in addition to
Controls B) turn signal modification (remote, crossover lever); Low Tech options):
C) remote wiper controls; A) remote panels, touch pads or switch arrays that interface
D) gear selector modification; with OEM^ electronics;

E) key / ignition adaptions. B) wiring extension for OEM^ electronics;

C) powered transmission shifter.
#DRS - Health professional degree with specialty training in driver evaluation and rehabilitation, *CDRS – Certified Driver Rehabilitation Specialist – Credentialed by ADED (Association for Driver Rehabilitation
Specialists). +SCDCM – Specialty Certified in Driving and Community Mobility by AOTA (American Occupational Therapy Association) ^OEM – Original Equipment installed by Manufacturer.
**LDI-licensed driving instructor.

Driver Rehabilitation Programs: Defining Program Models, Services, and Expertise.

Occupational Therapy In Health Care, 28(2):177–187, 2014

It is important to note that the services of an occupational therapist providing medically necessary services
are covered by third-party payers, Medicare, and Medicaid.

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FUNDING SOURCES FOR DRIVER referral. There are many models of programs, some
ASSESSMENT AND REHABILITATION private practice, some associated with hospitals or
The costs associated with specialized driving universities. All likely have some combination of
services may be a barrier to access and adherence costs that may be insurance eligible and some that
to the recommendation for evaluation. Many are not. It would be misleading to offer global cost
specialized services require associated “out-of- estimates in this document. Periodic inquiry with
pocket” fees, and the comprehensive driving local providers is the most straightforward way to
evaluation is no exception. If driving safety is ensure communication of accurate information. The
in question, the evaluation data to support following questions may guide this inquiry:
continued driving or cessation is essential. Ethically, 1. What are your costs for driver assessment
recommendations must follow a medically indicated and training? Costs vary between programs and
need and not be based on cost. according to the extent of services provided (e.g.,
It is also important to recognize this highly skilled evaluation, training, rehabilitation intervention).
evaluation is not the same as a driving test offered 2. What are typical costs for basic adaptive
through the state licensing authority, which is equipment?
typically a basic entry-level test of knowledge
3. Does your program assist patient exploration of
(rules of the road) and skills of handling a motor
insurance and funding options? Typically, the DRS
vehicle (overlearned and practiced by older adults).
is well informed of funding opportunities and will
Typically, the individual must complete a knowledge
assist clients in this exploration.
test, pass a vision screen, and demonstrate
a specific list of prompted maneuvers on the Two programs that typically support expenses
road. It is not a measure of capacity, judgment, associated with comprehensive driving evaluations,
or executive ability, and it is not geared to the driver rehabilitation, and vehicle modifications
experienced driver. It results only in a pass/fail with are state workers’ compensation and vocational
no recommendation or information to caregivers of rehabilitation programs. These programs offer
what comes next. Similarly, typical driving schools financial support for mobility for persons with a
are geared toward education and learning how to disability in support of return-to-work, meaning
drive safety. The typical driving instructor expertise many older adult drivers will not qualify for either
is teaching and learning, and he or she may offer program. Coverage from Medicare, Medicaid,
an older driver multiple lessons to resolve the and private insurance companies is variable and
safety issue of missing a stop sign, when in fact, depends on local interpretation of policies (i.e.,
the cognitively impaired older adult will likely not government fiscal intermediaries).28 (Please see
benefit from lessons as a novice driver might. the reference for examples of how to appeal
Accordingly, while costs for driving evaluations denials and pursue funding for coverage of driving
vary, informed consumers should consider the full evaluations.) The Veterans Administration (VA)
package, for example, if lessons are included. programs may also cover driving evaluations
and training for spinal cord and mobility-related
As a referral source, understanding and
injuries, as well as offer senior driving safety
communicating a basic understanding of costs
assessments, although not all states have a VA
and options may improve the effectiveness of
driver rehabilitation program. In those instances,

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

the VA program may contract with a local driver Certification in Driving and Community Mobility
rehabilitation program to provide services to (SCDCM) (www.aota.org/Education-Careers/
veterans. Many driver rehabilitation programs Advance-Career/Board-Specialty-Certifications/
choose to offer their services as private pay Driving-Community-Mobility.aspx) is available for
only, because current reimbursement models application from the credentialing body at AOTA.
are inadequate to cover the expenses of this The SCDCM includes a development plan and must
individualized and highly trained specialized service. be renewed, via application, every 5 years. Only
Since rates and extent of insurance reimbursement occupational therapy practitioners may apply for
vary, older adult drivers should be encouraged certification for this advanced level of achievement.
to independently inquire about program rates, The Association for Driver Rehabilitation Specialists
insurance coverage, and payment procedures that (ADED) (formerly Association of Driver Educators
may include the requirement to pay up-front and for the Disabled, still known as ADED) also offers
receive the approved reimbursement at a later time. education and certification to become a DRS.
Also, older adults and caregivers should be Because persons of varied backgrounds may apply
advised to carefully review insurance policies. Of for certification through ADED, the education and
interest, at least one automobile insurance provider experience qualifications to take the certification
offers a plan that reimburses up to $500 for a examination vary. Once attained, ADED requires
comprehensive driving evaluation performed by that the certified driver rehabilitation specialists
a DRS who is also an occupational therapist. This (CDRSs [www.aded.net/?page=215]) renew their
specific policy allows the older adult up to three certification every 3 years by fulfilling a minimum
years recovery to access this benefit. of 30 continuing education hours in the field of
Transportation is a significant factor in decisions for driver rehabilitation. Although many DRSs either
housing and placement in facilities. The personal hold certification or are in the process of obtaining
vehicle driven by self or spouse is the most the necessary education and experience to sit for
preferred mode of transportation. When balanced the examination, in most states certification is not
against the personal and global costs to the older required to practice driver rehabilitation.
adult driver and the community of a crash, or Driver rehabilitation programs are expanding
services needed to support an older adult lacking nationally to include occupational therapy
independent mobility, the comprehensive driving practitioners with advanced knowledge in driving
evaluation may prove to be a cost-saving strategy. rehabilitation who have formed relationships
(for referral) with the smaller number of highly
FINDING A DRIVER REHABILITATION trained specialists. DRSs are located across the
SERVICE
country, although availability is typically in urban
Two national associations offer education and areas or large medical centers. DRSs can be
credentials in driver rehabilitation. The American in private practice or affiliated with hospitals,
Occupational Therapy Association (AOTA) offers a rehabilitation centers, driving schools, VA hospitals,
multitude of education options to develop specialty and state motor vehicle departments. Driving
expertise in driving and community mobility. In rehabilitation services may also be accessed
addition, a portfolio-based professional Specialty through area agencies on aging, universities, and

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area departments of education. Before referring medications, and potential progression of the
older adults to driving rehabilitation services, it is condition.
important to ensure the appropriate level of service n Does the driver rehabilitation program provide
needed is available. The credentials and knowledge a comprehensive driving evaluation that includes
level of the provider, typical services provided, and both clinical and on-road assessments? A DRS
expected outcome should match the needs of the who provides both components of the evaluation
older adult driver and caregivers. A background (or a program whose team of specialists perform
in driver education alone is likely insufficient for both components) is ideal. Referral to two
appropriate assessment of medically impaired separate specialists or centers is inconvenient for
drivers and correct interpretation of the assessment. the older adult and the clinical team member and
To find a provider in the local area, calling the often presents a greater challenge in insurance
occupational therapy departments in local hospitals reimbursement. In addition, some programs
or rehabilitation centers is a good place to start. use a driving simulator program, which should
The AOTA website is a source to locate a DRS not be used to replace the on-road component.
by state (https://www.aota.org/olderdriver). The Simulators have the advantages of reliability and
ADED’s online directory is another good source of safety, but they are not standardized and validity
information (https://www.aded.net/search/custom. is limited when compared with the performance-
asp?id=1984) to locate DRSs and CDRSs. The local based road test. In addition, in older adults they
chapters of subspecialty organizations such as may induce motion sickness, which can limit the
the Alzheimer’s Association may keep up-to-date findings.
driving evaluation program information on their n Does the program provide rehabilitation and
websites. Many local chapters of the Alzheimer’s training? A driver rehabilitation program should
Association (https://www.alz.org/help-support/ ideally provide both evaluation and rehabilitation.
caregiving/safety/dementia-driving) also provide If the older adult driver will likely need any
lists of area driving evaluation programs. adaptive devices or vehicle modifications, he or
When selecting a DRS or driving rehabilitation she and their caregivers should go to a “low tech”
program, the older adult driver and/or caregivers or “high tech” program (see Appendix C) that has
may wish to inquire: the appropriate equipment to evaluate and train
n How many years of experience does the DRS (or the driver in their use.
program) have and what types of clients do they n How much can the older adult driver expect to
serve? In many cases, experience may be a more pay out-of-pocket for assessment, rehabilitation,
important indicator of quality than certification and adaptive equipment?
alone. Many well-qualified DRSs are not certified n Who will receive a report of the assessment
(and certification is typically not required). outcome? Typically, reports are sent to the older
n For older adults with medical conditions, it is adult driver and to the referring clinical team
important to ascertain if the DRS has a medical member and/or referring agency (e.g., workers’
background. The complexity of conditions such compensation or office of retirement services).
as dementia, stroke, or Parkinson disease requires Some DRSs also send reports to caregivers, at the
a DRS that has been educated in the conditions, request of the caregiver and with the older adult’s

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consent. Whether or not the DRS reports to the recommendation for driver assessment is elective
state licensing agency is variable and should be or essential to ongoing driving. If the latter, steps
clearly stated before the evaluation is initiated. for stopping driving until assessment is done must
In states with mandatory reporting laws, the DRS be clearly communicated to the older adult driver
and/or physician may send a report to the state and caregivers and, if necessary, also to the state
licensing agency; even if reporting is not legally licensing authority. Older adults who refuse on the
required, some will still send a report in the basis of cost should be reminded that operating a
interest of public safety and ethical responsibility. motor vehicle is expensive and that the assessment
In cases when the recommendation is to cease is critical for safety and important when considered
driving, reporting to the state licensing agency against the cost of a motor vehicle crash. It is the
will typically result in the state review board clinician’s ethical duty to report to the licensing
or medical board suspending the license or authorities if there are clear indications that
requesting more information, although each varies the older adult is demonstrating unsafe driving
in the process and time frame. practices, resulting in risk to themselves and the
n If the older adult receives recommendations public.
to cease driving, does the DRS provide any If comprehensive driving evaluation through a DRS
counseling or aid in transportation planning? Note is not available, there are several options:
that DRS counseling does not preclude the need n Advocacy efforts can be undertaken to inform
for follow-up by the clinical team. Many times, the local rehabilitation providers that the clinical team
older adult and caregivers may be too distressed is seeking local driving rehabilitation services for
at the time of evaluation and recommendations older adults. Rehabilitation providers must know
to deal with additional information. Mobility of local interest to recognize the need for program
counseling and transportation planning are crucial growth.
for reinforcing the message to cease driving by
n As discussed, occupational therapists are
providing resources to support continued mobility
“generalists” who can provide an occupational
in the community, as well as demonstrating the
therapy evaluation of IADLs. (These services are
health care provider’s compassion and support.
typically provided and reimbursed by Medicare
WHEN DRIVER ASSESSMENT IS NOT AN and Medicaid as occupational therapy services).
OPTION Because driving is an IADL, these assessments can
Unfortunately, driver evaluation and rehabilitation be used to determine driving risk and potential for
services may not always be readily available in the risk. Occupational therapists in general practice
local area. Even if a DRS is available, the older adult may also be able to perform specific assessments
may refuse further assessment or be unable to that provide results correlated to driving risk as
afford it. However, some patients and caregivers in well as provide mobility counseling. Referral to
DRS shortage areas may be willing to travel to have these types of health professionals may actually
this type of evaluation, particularly if the chances are be a more widely available option in many
good that the evaluation may result in prolonging communities.
driving life expectancy and safety. n Private driving schools and driving education
It is important to distinguish whether the programs may be available in the local area.

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However, they may not have expertise in in writing. This may place the clinical team member
evaluating older adults with medical impairments. in a difficult position. Many states require physicians
n Further evaluation by another health to fill out forms that require medical information
professional such as a geriatrician, neurologist, and vision testing results and to provide an opinion
psychiatrist, or neuropsychologist can be on whether the driver should undergo visual and/or
considered for an older adult who has a chronic on-road testing.
condition such as Alzheimer disease or an Regardless if the older adult has no medical
episodic acute illness (e.g., seizure disorder). contraindications to continued driving, he or she
n If changes in driving behavior are likely to should be offered education and handouts such as
improve the older adult’s driving safety (e.g., the Ten Tips for Aging Well and Safe Driving Tips
avoiding driving at night, rush hour, adverse (available in this guide). All older adults should be
weather conditions, etc.), the clinical team encouraged to develop a transportation plan, and
member can make recommendations. However, to become familiar with and able to successfully
officially, state policies vary in the area of access alternative forms of transportation. Planning
restrictions. Strict adherence to these policies ahead is invaluable to support aging in place while
can be made a condition for licensing through bridging short- or long-term disruptions in the most
the state licensing agency or medical review common and familiar form of transportation—the
board. State policies should be checked before personal vehicle.
making these recommendations. It also has to
be acknowledged that the research literature
on the benefits of license restriction is not clear.
In general, when possible, it is generally better
to lean toward driving autonomy with license
restriction, but if there are concerns that the older
adult would not honor the restrictions then driving
cessation may be the best option.
If the older adult’s driving safety is an urgent
concern, the clinician may wish to report to the
state licensing agency, which will have steps to
follow that may include a state driving assessment.
Depending on the particular state’s reporting laws,
physicians may be legally responsible for reporting
“unsafe” drivers to the state licensing agency. (For
a discussion of the legal and ethical issues, see
Chapter 7; for a list of state licensing agencies and
other resources on state laws, see Chapter 8.) The
older adult should be made aware of the referral/
report to the state licensing agency, which should
be documented and also offered to the older adult

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Research Agenda for Advancing Safe Mobility. Journal of Applied models, services and expertise. Occupational Therapy in Health Care,
Gerontology. https://doi.org/10.1177/0733464817739154. 28, 177-187. https://doi.org/10.3109/07380577.2014.903582.
14. Dickerson, A.E., Stinchcombe, A., & Bédard, M. (2017). Transferability 27. Dickerson, A. E., Schold Davis, E., Stutts, J., & Wilkins, J. (2018).
of driving simulation findings to the real world. In: S. Classen (Ed.), Best Development and Pilot Testing of the Driving Check-Up: Expanding the
Evidence and Best Practices in Driving Simulation: A Guide for Health Continuum of Services Available to Assist Older Drivers. Washington,
Care Professionals. Bethesda, MD: AOTA Press. pp. 281-294. D.C.: AAA Foundation for Traffic Safety. Retrieved from https://
15. Stern, E. B., Akinwuntan, A. E., & Hirsch, P. (2017). Simulator sickness: aaafoundation.org/wp-content/uploads/2018/05/AAAFTS-Driving-
Strategies for mitigation and prevention. In S. Classen (Ed.), Best Check-Up-Final-Report-text-and-appendices-FINAL.pdf.
Evidence and Best Practices in Driving Simulation: A Guide for Health 28. Stressel, D., & Dickerson, A. E. (2014). Documentation and
Care Professionals. Bethesda, MD: AOTA Press. pp. 107-120. reimbursable service for driver rehabilitation. Occupational Therapy in
Health Care, 28, 209-222. https://doi.org/10.3109/07380577.2014.90
4960.

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CHAPTER 6 A
 DVISING THE OLDER ADULT ABOUT TRANSITIONING FROM
DRIVING

KEY POINTS
n Driving decline happens conclusions and discuss n Ideally, clinicians will know
slowly, so older adults and alternative transportation referral sources (gerontological
family members may have options; this should be care managers, social
already adapted and adjusted documented in the older workers, driving rehabilitation
to minimize driving risks. adult’s health record. specialists, and local Agencies
n Health care providers should n If an older adult who is on Aging) in the community
proactively/annually screen frail unsafe to drive continues that can provide accessible/
older adults for driving safety driving, caregiver responsibility affordable mobility counseling
to establish a pattern over and intervention (when and information on local
time. available) is important to transportation alternatives,
document. A “do not drive” with the goal to make
n Health professionals transportation opportunities
are encouraged to have prescription may be provided
to the older driver and, if available for all.
a transportation planning
discussion before an older appropriate, the caregiver. n All clinicians must
adult is facing imminent loss of Clinicians should also be “emphasize the need for
the privilege to drive. aware of their state mandatory counseling to be personalized.
reporting laws and process Older drivers vary in their
n When an older adult is to report unsafe drivers openness to discussing driving
unsafe to drive, he or she to the licensing authority, and their preferences for when
and their caregivers should if permissible under state and with whom to have such
review the assessment and guidelines. conversations.”1

You continue to provide care for Mr. Phillips’ “We’ve talked about this before, and I figured
chronic conditions and follow up on his driving it was coming sooner or later.” He believes that
safety. Mr. Phillips has gradually decreased rides from family, friends, and the senior citizen
his driving over the years. Three years later, shuttle in his community will be adequate for his
Mr. Phillips has a right middle cerebral artery transportation needs, and he plans to give his
stroke and deficits of left-sided weakness and car to his granddaughter.
hemispatial inattention. His health has declined
Mrs. Bales was able to reduce her narcotic pain
to the extent that you now believe it is no
medication use with increased physical therapy
longer safe for him to drive, and you advise
and topical anti-inflammatory medication. She
him that it is time to stop driving completely.
also stopped her alcohol use, helping her to
You also feel that because of the fixed nature
continue driving for another 2 years. However,
of his deficits (longer than 6 months since
her early macular degeneration began to
the event), driver rehabilitation is unlikely to
progress rapidly and is now considered severe.
improve his driving safety. Mr. Phillips replies,

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F
or most of us, driving is a symbol of legal responsibility to protect the safety of the
independence and a source of self-esteem. older adult, as well as that of the public, through
When we retire from driving, we lose not only assessing driving-related functions, exploring
a form of transportation but also all the emotional medical and rehabilitation options to improve
and social benefits derived from driving. In primary driving safety, and when all other options have
preventive care, the transition to cessation of been exhausted, providing recommendations for
driving may be discussed as part of Medicare restriction or cessation of driving. Within the clinical
Preventative Services in the Medicare Wellness team, primary clinicians are often considered key for
Visit. The Medicare Learning Network (detailed driver licensing and assessment referral. In tertiary
on https://www.cms.gov/Medicare/Prevention/ preventive care, when it is clear to the clinical
PrevntionGenInfo/medicare-preventive-services/ team that an older adult driver must stop driving,
MPS-QuickReferenceChart-1.html [accessed the team must manage such challenging cases,
April 2019]) provides educational products and including encouraging the older adult driver to
information to proactively address health conditions involve caregivers in creating a transportation plan
that may adversely affect driving ability. and obtaining the older adult driver’s permission
Advance planning for driving cessation ideally will when involving his or her support system.
be reviewed along with other standard instrumental
USEFUL STEPS IN COUNSELING OLDER
activities of daily living in primary prevention. In ADULTS TO STOP DRIVING
secondary prevention, referral to the clinical team
can assist with anticipation of and preparation for Begin with the Older Adult’s Perspective
driving cessation,2 rather than responding abruptly
An initial assessment of the older adult’s perception
in an acute need. It is strongly recommended that
of his or her driving ability often directly influences
older adults explore and utilize a variety of local
the process in which a person redefines not only
alternative transportation options well in advance of
personal mobility but also public risk. Reviewing
need so that if/when the time comes that they do
the self-perceived driving skills of the older adult is
need to rely on other transportation options, they
critical in any discussion regarding driving cessation.
have experience and realistic expectations already
Clinicians and caregivers must acknowledge that
in place.
their goals may be very different from those of the
For various reasons, clinical team members may older adult. In addition, within this later stage of
be reluctant to discuss driving cessation with older life, “individuals vary in their functional abilities,
adults. Clinicians may fear delivering bad news or lifestyle, personal resources, and attitudes.”3 Driving
be concerned that the older adult will lose mobility cessation stress often directly creates an identity
and all its benefits. Clinicians may also avoid change, challenging how one thinks of himself or
discussions of driving altogether, because they herself, not as a driver, but as an “old person.”4
believe that an individual will not heed their advice Older adults’ self-assessments suggest they may
or become angry. Clinicians may be concerned over-estimate personal driving competences.
about losing an individual to another practice. Longstanding character appraisal may bias older
These concerns are all valid. However, clinical team adults toward objectively acknowledging their
members have an ethical and, in some states, a safety risk.5 The older adult’s individual insight,
self-determination, confidence, autonomy, and

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relatedness to social activity require understanding community agencies such as Area Agencies on
by the clinical team. Aging to provide additional services.

Utilize Clinical Practice Tool: Assessment of Utilize a Clinical Team

Readiness for Mobility Transition (ARMT)
Clinical teams require skill sets, assessment
Consider the ARMT, for use by social service, instruments, and an appreciation of age-related
health, and transportation professionals when driving retirement challenges. Because driving
assessing older clients and intervening to promote cessation involves so many aspects of the older
individualized planning. The ARMT is based on adult’s coping style and physical and mental health,
multiphase, qualitative-quantitative research the availability of social support and a clinical team
effort to identify and measure key individual sensitive to age-related mobility change is critical to
differences that define the construct of readiness6 address multiple needs and direct an intervention
to discontinue driving. In addition, the ARMT may plan.10
assist in the identification of health changes in the
older adult and individualize the driving retirement Develop Clinical Team Communication
discussion7 (detailed on www.umsl.edu/mtci/PDFs/ Clinical teams concur that concise communication is
ARMT%20Manual%208-11.pdf [accessed April both fundamental and one of the most challenging
2019]). aspects of good care during a transition process.
Cultural heritage must be acknowledged and
Assess Family/Caregiver Readiness for Mobility
respected in decision-making, because a lack
Transition
of understanding may prevent the older adult
Whenever available, there is no substitute for critical from requesting clarification. Older adults with
caregiver support in developing plans for driving compromised health literacy may agree with the
cessation. It is important early on to determine clinician in an effort to maintain their dignity,
whether the older adult has any caregivers who can even when they do not fully understand medical
support this transition. Of note, if the primary care terminology.11
provider recommends an older adult retire from
driving, the older adult often takes this advice.8 Explain the Importance of Driving Cessation
For a planned transition from driving by the clinical If the older adult driver has undergone the CADReS
team to be successful, caregiver buy-in to a unified toolbox assessments (see Chapters 3 and 4) or
position and support is critical. It is very difficult to assessment by a driver rehabilitation specialist,
successfully counsel older adults to stop driving if results in simple language should be provided to
their caregivers wish them to continue operating a the older adult driver and his or her caregivers
motor vehicle or disagree among themselves. to share and discuss. Results must be clearly
Remember that an involved caregiver, if present, explained, including the intended needs of the
is the one constant and consistent member of older adult and what the findings indicate about
the “team.” Education of caregivers may increase the older adult driver’s level of function and why
informed decision-making and prevent plan-of-care this function is important for driving. The potential
errors.9 When no caregiver support is available, it is risks of driving should be stated, ending with the
very important to engage local resources through recommendation that the older adult stop driving.

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This might be a good time to discuss the older and caregiver during this transition with the goal
adult driver’s thoughts or feelings, especially if he or to think of a new framework for independence and
she were to cause a vehicle crash. If the older adult needs at this stage of life.
should not drive, the clinical team might discuss
issues related to injury, public safety, and/or financial Consider Dignified Approaches
liability. This discussion should be put in writing with Caregivers who know the older adult may identify
copies given to the older adult driver. If the older outside factors to retire from driving, such as
driver lacks decision-making capacity, a copy must creating a written pro and con list allowing the
be given to a family member or caregiver. older adult to see and recognize the facts. Also,
putting the focus on the older adult helping another
“Mrs. Bales, the results of your eye exam show family member (child, grandchild) who needs a car
that your vision isn’t as good as it used to be. more than he or she does, may help. In addition,
Good vision is important for driving because comparing the annual car-related cost (insurance,
you need to be able to see the road, other cars, car maintenance) with alternative modes of
pedestrians, bicyclists, and traffic signs. With transportation may be a more dignified reason to
your vision becoming severely impaired, I’m stop owning a car.
concerned you’ll be in a car crash. Because your
visual deficits from your macular degeneration Proactive Transportation Planning
cannot be corrected to a level safe for driving, It’s important to encourage older adult drivers
for your own safety and the safety of others, it’s to begin to think about what to expect when
time for you to retire from driving. In addition, their driving abilities begin to decline and to let
there are legal requirements for vision that, them know that many people make the decision
unfortunately, you no longer meet.” to restrict or stop driving when safety becomes
a concern. Older adults are encouraged to take
Older adult drivers may become upset or angry
control of their future by creating a transportation
at the clinical team’s recommendation to curtail
plan and discussing with their family or caregivers
driving. These feelings must be acknowledged,
if possible. If the individual does not have the
and although clinicians should be sensitive to the
cognitive capability for these tasks, see the section
practical and emotional implications of driving
on those who lack decision-making capacity
cessation, it is necessary to remain firm with the
later in this chapter. As with all late life planning,
recommendation. Engaging in disputes or long
preparation before the event of need, creating a
explanations should be avoided. Instead, the focus
driving cessation plan with transitional strategies, is
must be on making certain that the older adult
necessary.
understands the recommendation and that it was
made for his or her safety. If the older adult driver is Discuss Transportation Options
mentally competent and willing to allow a caregiver
Once driving cessation has been recommended,
to be present at the visit, this may be helpful when
possible transportation alternatives need to be
communicating this sensitive information. All
explored and discussed with the older adult. “A
discussions should be documented in the health
conditional concern is the general lack of awareness
record. It is critical for the clinical team to reinforce,
about alternative transportation options such as van
reinterpret, and follow up with the older adult driver

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services”12 often operated by community agencies to safely use common transportation alternatives,
to make transportation affordable. such as the bus. The importance of planning for
Providing the older adult with resources to explore social activities, which contribute to quality of life,
options (e.g., handouts in Appendix B) will help should be stressed. Helpful resources addressing
empower him or her to formulate a personal plan transportation include Area Agency on Aging and/
for transportation. Special mention is made of or the Alzheimer’s Association. For information on
The Hartford’s (The Hartford Center for Mature local resources such as taxis, ride-hailing services,
Market Excellence) educational guidebooks: We public transportation services, and senior-specific
Need to Talk: Family Conversations with Older transportation services, contact The Eldercare
Drivers (https://s0.hfdstatic.com/sites/the_hartford/ Locator (1-800-677-1116, www.eldercare.gov/
files/we-need-to-talk.pdf), At the Crossroads: [accessed April 2019]; be prepared to provide
Family Conversations about Alzheimer’s Disease, the relevant city and state) which can provide
Dementia & Driving (https://s0.hfdstatic.com/sites/ connections to senior services nationwide. This
the_hartford/files/cmme-crossroads.pdf ), and You might be a good time to refer to clinical teams,
and Your Car: A Guide to Driving Wellness (http:// including a social worker, occupational therapist,
hartfordauto.thehartford.com/UI/Downloads/You_ nurse, or a gerontologic care manager. The team
and_Your_Car.pdf)[all accessed April 2019]).13 Using may be aware of alternative modes of transportation
alternative transportation options, such as buses, and/or may deal with the older adult’s feelings of
trains, cabs, ride-hailing services, or even walking, social isolation or depression.
offers older adults independence from having to Older adults should be encouraged to involve
rely on others. caregivers and supportive friends and to form a
A discussion of driving alternatives can begin by social network in creating a transportation plan. The
asking if the older adult has made plans to stop older adult’s permission should always be obtained
driving or how he or she currently finds rides when when involving others, who would be encouraged
driving is not an option. Alternative transportation to offer rides and formulate a weekly schedule for
methods (Table 6.1) should be explored, as running errands. However, the older adult must
well as any barriers the older adult foresees be included when caregivers are also included in
(e.g., financial constraints, limited service and the discussion. Help in arranging for delivery of
destinations, required physical skills for accessibility, prescriptions, newspapers, groceries, and other
rural community, living out of the mainstream). services may also be considered (see Table 6.2).
Discussing the economic impact of owning and
Reinforce Driving Cessation
maintaining a vehicle may be an important detail
for the older adult. The funds currently used toward Although the message to cease driving is essential
owning a vehicle will be available for alternative for ensuring the older adult’s safety, this approach
transportation options. also places a significant demand on the adult to
change his or her current behavior. Therefore, the
The older adult may need assistance to develop a
clinical team will need to ensure the older adult
transportation plan that identifies his or her most
understands the reasons (legal, health, and safety)
feasible transportation options, because certain
for the driving cessation recommendation. In many
cognitive and physical skills are often necessary

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cases, older adults may become argumentative or n The clinical team must understand each
emotional during the office visit. They may not fully state’s reporting requirements and explain
comprehend the recommendations or remember this requirement to the older adult driver and
all the information provided, partly due to the caregivers (see Chapters 7 and 8 for more details).
emotions of tension and fear when anyone receives State regulations, in the case of mandatory
negative feedback. reporting laws, dictate that older adult drivers
The following strategies may reinforce patient and possibly by proxy, their caregivers) must
education: inform the local state licensing agency of medical
conditions that could affect the older adult’s safe
n Make open-ended statements, such as “Please
operation of a vehicle. The older adult should
share with me your concerns regarding the
be informed that the state licensing agency will
assessment and recommendations.” Alternatively,
follow up and advised about what to expect as
“What worries you the most about not driving?”
part of this evaluation (i.e., a review of the driving
Reassure the older adult that you and the clinical
record, a medical statement, potential on-road
team are available if he or she has questions or
testing).
needs further assistance.
n In states with voluntary laws, a referral to the
n Use a teach-back technique by requesting the
licensing agency could still be appropriate, and
older adult to repeat why he or she must not
older adults may be informed that unsafe/non-
drive. Reinforce that this recommendation is for
compliant actions will be reported if they drive
his or her personal safety and the safety of others
against medical advice (detailed in Chapter 7,
on the road and may optimally reduce the amount
Ethical and Legal Issues).
of stress and energy to drive.
n Help facilitate caregiver assistance in
n The older adult driver may benefit from visual
encouraging driving cessation, and if necessary,
reinforcement of a prescription with the words
encourage the older adult to self-report his or her
“Do Not Drive.” Ensuring that the older adult
impairment to the state licensing agency. It may
understands why he or she is receiving this
be helpful to enlist other trusted allies, such as
prescription may help avoid feelings of anxiety
clergy, friends, or the family attorney.
or anger. See Table 6.3 for further reinforcement
tips. This can also be helpful for the family or care Follow-Up with the Older Adult
providers so that they can be seen as supporters
At the older adult’s follow-up appointment, for
of the older adult rather than as the one telling
completeness, assess:
them they cannot drive, especially if there are
memory issues. n The older adult’s ability to comply with the driving
cessation recommendation,
n Send the older adult a letter that recommends
driving cessation (see Table 6.6 for a template). n Transportation resources the older adult identified
Place a copy of this letter in the health record and has or has not used, evaluating the viability of
as both documentation and another visual tool the chosen options,
for reinforcement. The letter should be written n Signs of isolation or depression.
in simple language to ensure the older adult The assessment begins by asking the older adult
understands the clinical team’s recommendation. how he or she got to the appointment that day.

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This will help determine whether the older adult has a valuable service to communicate delicately with
been able to plan for and schedule transportation the family caregivers the essential need to maintain
to and from necessary appointments. Ensure that a supportive connection, especially during this
the older adult has secured reliable and sufficient period with the retired driver and anticipate feelings
transportation resources to meet his or her needs. of grief from driving cessation.14
Utilize the clinical team; refer to a social worker or In all levels of care, clinicians must be alert to signs
gerontologic care manager. of depression, neglect, and social isolation (see
Table 6.4 and Table 6.5). It is important to continue
Clinician: I’m pleased to see you for your follow-
to monitor older adults for any signs of worsening
up appointment today. How were you able to
mental or physical health and to ask how they are
get to the office?
managing without driving. Caregivers must be
Mrs. Bales: Oh, my son dropped me off. educated on signs of depression and asked if they
Clinician: I see. Has he been driving you lately? have any concerns. Clinicians are encouraged to
consider using formal assessments for depression
Mrs. Bales: Yes, ever since I stopped driving, he
such as the Geriatric Depression Scale (http://
and his wife have been taking me where I need
www.npcrc.org/files/news/geriatric_depression_
to go. He’s going to pick me up in 15 minutes.
scale_short_form.pdf) or the PHQ-9 (Patient Health
Clinician: How has that been working for you? Questionnaire) (https://www.phqscreeners.com/
Mrs. Bales: It’s worked quite well. select-screener/36).
Clinician: I have a prescription for you to refill The older adult’s functional or cognitive
your medicines after our appointment. Will your impairments should continue to be assessed and
son be able to take you to the pharmacy? treated. If the older adult improves to the extent
Mrs. Bales: Yes, that won’t be a problem. that he or she is safe to drive again, the individual
should be notified and given the resource sheet on
Clinician: It’s wonderful that your son and
Tips for Safe Driving (see Appendix B).
daughter-in-law are a reliable source of rides for
you. What do you do when they are unable to SITUATIONS THAT REQUIRE ADDITIONAL
drive you where you need to go? COUNSELING
Mrs. Bales: I am stuck at home. Additional counseling may be needed to encourage
Clinician: I understand how that can be driving retirement or to help older adults cope with
frustrating. Here is a list of some programs in this loss. Potential situations that may arise with
our area, which are ride services, like a taxi, and individuals who have difficulty coping or adhering to
your son can help you choose which one might the recommendation to stop driving are described
work the best for you so you can call for a ride below.
anytime you want.
The Resistant Older Adult Driver
Anguish and rumination regarding driving cessation If the older adult becomes belligerent or refuses
may persist for months, resulting in a prolonged to stop driving, it is important to understand
negative impact on the relationship between the why. Knowing the reason will help to address the
older adult and family caregivers. Clinicians provide

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individual’s concerns. n Assist the older adult driver to consider the

Be sure to listen and use supportive statements positives of this decision—an opportunity to assert
when addressing the older adult’s concerns. Let the control over a limitation. Often, discussion of
individual know you are an advocate for his or her relinquishing driving privileges tends to focus on
health and safety. the negative aspects of driving cessation, such as
“losing independence” or “giving up freedom.”
Remember that driving cessation can have severe
Help the older adult driver view this as a step in
emotional and practical implications, and older
health promotion and safety for themselves and
adults may have a difficult time adjusting. It is also
others. Use phrases such as “It’s time to retire
important to remember that driving is more than
from driving.” and point out that older adults
a mode of transportation for baby boomers.15,16
can still stay connected by requesting rides from
This segment of the population grew up with the
caregivers and using community services. It may
automobile as their method of social networking,15,16
be helpful to point out that the older driver has
so giving up their car needs to be approached the
quite likely been giving rides to others throughout
same as other losses. It is often about more than
his or her driving career, and others may now be
getting to where they need and want to go.
allowed to return the favor. Another positive is
Asking the older adult driver to define when that expenses will be lower without the financial
a person would be unfit to drive may help the responsibility of maintaining a vehicle. Help older
individual better recognize impairment in his or adult drivers calculate the expenses (licensure,
her own driving capabilities, as well as provide registration, insurance, maintenance, parking, etc.)
an opportunity to assess his or her judgment and they will no longer have to pay for compared with
insight. In addition, it might open up discussion to the cost of alternative transportation. This exercise
reach some common ground. may help them see the monetary value in driving
Many older adult drivers are able to identify peers cessation.
whose driving they consider unsafe, yet may not n Refer the older adult driver to a social
have the insight to recognize their own unsafe worker or clinical team member. Older adult
driving habits. It can be helpful to ask older adults if drivers may need additional help in securing
they have friends with whom they are afraid to drive resources and transitioning to a life without
and why. Older adult drivers should be encouraged driving. Social workers often provide supportive
to obtain a second opinion if they feel additional counseling to older adults and caregivers,
consultation would be helpful. assess the individual’s psychosocial needs,
In addition: assist in locating and coordinating community
services and transportation, and enable older
n Help the older adult driver identify support
adults to maintain independence and safety
systems. Ask him or her to list family members,
while preserving quality of life. The National
faith communities, neighbors, etc., who are able
Association of Social Workers Register of Clinical
and willing to help with transportation. This may
Social Workers is a valuable resource for finding
help the older adult driver become aware of a
local social workers who have met national,
supportive network and feel more at ease when
verified, professional standards for education,
searching for alternative transportation.
experience, and supervision. Information may

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be ordered and the online register accessed at if available. Caregivers play a crucial role in
www.helpstartshere.org/find-asocial-worker. Local encouraging the older adult to stop driving and
hospitals are another resource for social workers, to help the individual find alternatives. Clinicians
and referral sources include the Area Agency on should inform caregivers that the clinical team
Aging or the Alzheimer’s Association. would support and assist their efforts in any way
n Some areas offer public transportation training possible.
for seniors. If this is offered in the older adult’s In rare instances, it may be necessary to appoint
area, a recommendation to participate may be a legal guardian for the older adult. In turn, the
helpful. guardian may forfeit the older adult’s car and
license on behalf of the individual’s safety. These
The Older Adult Driver with Symptoms actions should be taken only as a last resort. From a
of Depression practical standpoint, hiding, donating, dismantling,
As noted, “decreased life satisfaction, and or selling the car may also be useful in these difficult
less productive engagement in life can result situations.
from DRC”17 (driving reduction and cessation).
Depression may occur from a combination of factors The Older Adult Driver Who Shows Signs of
such as diminished health, social isolation, and Self-Neglect, Neglect, or Abuse
feelings of loss. An older adult driver suspected of Older adults may be unable to secure resources for
being depressed and resulting in bereavement (see themselves and may be isolated, lacking sufficient
Table 6.4) should be fully assessed to determine support from family, friends, or an appointed
the most appropriate treatment. Older adults and caregiver. If the older adult does not have the
caregivers should be educated about symptoms capacity to care for his or herself, or caregivers are
of depression and available treatment options. unable to provide adequate care, signs of neglect
Referring the older adult to individual or group or self-neglect (see Table 6.5) may be evident.
therapy, and/or to social/recreational activities If neglect or self-neglect are suspected, Adult
may be considered. Pharmacologic treatment or Protective Services (APS) should be involved.
referral to a mental health professional may also Neglect is the failure of a caregiver to fulfill his or
be appropriate. It is important to acknowledge her caregiving responsibilities, whether because
that the older adult has suffered a loss due to of willful neglect or as a result of disability, stress,
driving cessation and recognize that this may be an ignorance, lack of maturity, or lack of resources.
especially difficult time for him or her. Self-neglect is the inability to provide for one’s own
essential needs. APS will investigate for neglect,
The Older Adult Driver Who Lacks Decision-Mak-
self-neglect, or abuse of the older adult. APS can
ing Capacity
secure services such as case planning, monitoring,
When the older adult driver has significant cognitive and evaluation, and can arrange for medical, social,
impairment and/or lacks insight or decision-making economic, legal, housing, law enforcement, and
capacity (e.g., in certain cases of dementia, stroke, other emergency or supportive services. Contact
etc.), it is imperative to obtain the help of the information for each state office can be obtained by
caregiver, surrogate decision-maker, or guardian, calling the Eldercare Locator at 800-677-1116.

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Table 6.1. Transportation Alternatives

n Walking

n Train/subway

n Bus

n Taxi/ride-hailing services

n Family and friends

n Community transportation services

n Hospital shuttles

n Medi-car

n Delivery services

n Volunteer drivers (e.g., church, synagogue, temple, mosque, community centers)

n Private for-profit senior care services

n Rides in Sight (www.ridesinsight.org, call toll-free 855-607-4337)

Rides in Sight is a free transportation referral service that assists individuals in finding a transportation
program that fits their specific needs in the older adult’s area. They can be found online or by phone during
business hours.

Table 6.2. Family/Caregiver Assistance

 ncourage family members and caregivers to promote the health and safety of the older adult by
n E
endorsing clinician recommendations and assisting in securing needed transportation.
n Include caregivers in the mobility counseling process.

n Provide resources to caregivers.

n Provide copies of the How to Assist the Older Driver resource sheet (Appendix B).

n Look for signs of caregiver burnout.

n Keep the communication door open to caregivers.

n In the case of cognitive impairment when it is believed the older adult driver does not have decision-
making capacity (e.g., lack of insight), communication with a family member or caregiver to reinforce
recommendations is imperative.
n Recognize that if family members or caregivers depend on the older adult driver for transportation, the
situation may require more time, counseling, and support to meet everyone’s needs.
n Be attentive to the changing needs of the older adult and caregiver.

n Offer to have a family member “stop by” on a set schedule for a set time period with his or her vehicle and
be available to assist with any transportation needs the older adult may have. This will eliminate the need
for the older adult to ask for a ride to the bank or market and allow them to plan ahead.

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Websites (all accessed April 2019) adults, individuals with disabilities, and caregivers.

AAA Long Road Senior Cohort Study National Association of Area Agencies on Aging
(https://aaafoundation.org/resources/) (www.n4a.org/about-n4a)
Online free resources to help older adults assess personal Area Agencies on Aging are a leading aging issues
driving readiness, and resources to make informed resource providing specific regional services.
choices.
National Association of Social Workers
AAA Senior Driving (https://seniordriving.aaa.com/) (http://www.helpstartshere.org)
This website, a AAA product, is intended to provide users Locate a social worker by ZIP code.
with general information to help them better understand
National Council on Aging NCOA
the traffic safety implications of certain health conditions
(https://www.ncoa.org/)
and human behaviors as we get older.
Review NCOA assistance on healthy aging, financial
Alzheimer’s Association security and more for professionals, older adults,
(www.alz.org/care/alzheimers-dementia-and-driving.asp) caregivers, and supporters.
The Alzheimer’s Association provides links to driving
National Highway Traffic Safety Administration
counseling support for caregivers.
(https://www.nhtsa.gov/road-safety/older-drivers)
American Occupational Therapy Association NHTSA’s priorities are to reduce the number of deaths and
(https://www.aota.org/Practice/Productive-Aging/ injuries by preventing traffic-related crashes or mitigating
Driving.aspx) risks of serious injuries associated with traffic-related
Locate an occupational therapist able to conduct driving crashes. This includes addressing behaviors of drivers,
assessment and locations by ZIP code. pedestrians, and cyclists in relation to one another and
addressing vehicle safety issues. NHTSA’s Older Drivers
Centers for Disease Control and Prevention
site offers downloadable materials and short video clips
(CDC) MyMobility Plan (https://www.cdc.gov/
that clinicians can offer their patients and families to help
motorvehiclesafety/older_adult_drivers/mymobility/index.
them understand how aging can affect driving and what
html)
an older driver or caregiver can do to continue driving
MyMobility Plan provides general guidance for older safely with age, such as adapting a vehicle to meet
adults seeking to maintain both individual and community specific needs. See also, “Talking With Older Drivers
mobility. About Safe Driving,” intended to provide users with
Family Caregiver Alliance (www.caregiver.org) general information to help them better understand the
This organization supports and sustains the important traffic safety implications of certain health conditions and
work of families nationwide caring for adult loved ones human behaviors as we get older.
with chronic, disabling health conditions. National Volunteer Transportation Center
Health in Aging Foundation (www.NationalVolunteerTransportationCenter.org)
(www.HealthinAging.org) The National Volunteer Transportation Center was created
This Foundation was established by the American to support existing and emerging volunteer transportation
Geriatrics Society to bring the knowledge of geriatrics programs and services across the country.
healthcare professionals to the public, with a wide range Rides in Sight (https://www.ridesinsight.org/)
of resources. A national non-profit transportation system supported by
National Aging and Disability Transportation Independent Transportation Network America dedicated
Center to helping find transportation alternatives. This service
(www.seniortransportation.net) is membership-based; people 60 and older and visually
Works to increase transportation availability for older impaired adults are eligible to join.

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Table 6.3. Tips to Reinforce Driving Cessation

n Givethe older adult and caregiver a written prescription that states: “Do Not Drive, For Your Safety
and the Safety of Others.” This acts as a reminder for the older adult and emphasizes the strength of
your message.
n Remind the older adult that this recommendation is for his or her safety and for the safety of other
drivers.
n Askthe older adult driver how he or she might feel if he or she were to get in a crash and injure
himself, herself, or someone else.
n Pointout the economic advantages of not having a car, which will eliminate many expenses, including
gas, maintenance (oil changes, tires, and tune-ups), insurance, registration/license fees, financing
expenses, and depreciation of the car’s value.
n Have a plan in place that involves caregiver support for alternative transportation.

Table 6.4 Questions to Assess for Major Depressive Disorder (adapted from DSM-5)18
These questions are concerning most of the day or nearly every day and are not related to another
medical illness.
n Has your mood been sad, empty, or hopeless?
n Have you lost enjoyment in all or most activities?
n Have you noticed any weight changes?
n Have you noticed any changes in sleeping habits or concentration?
n Have you noticed a lack of energy or slower movement?
n Have you noticed feelings of worthlessness or recurrent ideas of death?

Table 6.5 Signs of Neglect, Self-Neglect, or Abuse in Older Adults

n An injury that has not been properly treated
n Symptoms of dehydration and/or malnourishment
n Weight loss
n Soiled clothing
n Recurrent falls with or without injuries
n Evidence of inadequate or inappropriate administration of medications
n Spoiled or outdated food in the refrigerator
n Loss of income from difficulty with finances

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Table 6.6 Sample Letter

January 23, 2019

Mr. Clayton Phillips
123 Lincoln Lane
Sunnydale, XX 55555

Dear Mr. Phillips:

I am writing to follow-up on your clinic visit of January 5, 2019. You will recall we talked about your
driving safety. I tested your vision (eyes), strength, movement, and thinking skills, and reviewed your
health problems and medicines. I recommended you stop driving because of your poor vision, muscle
weakness, and slowed reaction time.
I know that driving is important to you, and I know it is hard to give up. However, your safety is more
important. To help you get around, your son and your friends have offered to help you. You may also
use the public transportation system in your neighborhood. Alternatively, please consider Rides in
Sight (www.ridesinsight.org). Rides in Sight will assist you with your individual specific needs in your
neighborhood. You may search online or call toll free (1-855-607-4337); a person will answer during
business hours. The handout How to Assist the Older Driver (enclosed) has some other ideas we talked
about. I am also sending a copy of these materials to your son so that 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.
In a state that has mandatory reporting, consider adding:
As we discussed, the state of (state name) requires me to notify the state licensing agency of people
who have medical conditions that might affect driving safety. Because I am required by law to do this, I
have given your name to the _ (state name) licensing agency. The licensing agency will send you a letter
in a few weeks to discuss your driver’s license.
In a state that has voluntary reporting, consider adding:
It is very important that you do not drive, because you are putting yourself and the public at risk. If you
continue to drive, I will need to submit your name to the state licensing agency for an evaluation and
possible revocation of your license.
Please call my office if you have any questions. I look forward to seeing you next month.
Sincerely,
Physician
Enc: How to Assist the Older Driver
cc: Son’s name

Note: The sample letter in Table 6.6 has been written at an average 9th grade level. It should be
easily understood by 14- to 15-year-olds according to Flesch-Kincaid Readability www.webpagefx.
com/tools/read-able/flesch-kincaid.html (accessed April 2019).

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REFERENCES
1. Betz, M. E, Scott, K., Jones, J., & DiGuiseppi, C. (2015). Older adults’ 13. The Hartford Financial Services Group, Inc. We Need to Talk: Family
preferences for communication with healthcare providers about driving A Conversations with Older Drivers.(accessed April 2019) Retrieved from
LongROAD Study. Washington, D.C.: AAA Foundation for Traffic Safety. www.thehartford.com/mature-market-excellence/family-conversations-
Retrieved from https://aaafoundation.org/wp-content/uploads/2017/12/ with-older-drivers; At the Crossroads: Family Conversations about
OlderAdultsPreferencesForCommunicationReport.pdf. Alzheimer’s Disease, Dementia & Driving. Available at https://
s0.hfdstatic.com/sites/the_hartford/files/crossroads-kit-intro.pdf; and
2. Betz, M. E., Jones, V. C., & Lowenstein, S. R. (2014). Physicians and
You and Your Car: A Guide to Driving Wellness. (http://hartfordauto.
advance planning for “driving retirement”. American Journal of
thehartford.com/UI/Downloads/You_and_Your_Car.pdf).
Medicine, 127, 689-690. https://doi.org/10.1016/j.amjmed.2014.03.025.
14. Liddle, J., Gustafsson, L., Mitchell, G., & Pachana, N. A. (2017). A
3. Dickerson, A. E., Molnar, L. J., Bedard M., Eby, D. W., Berg-Weger, M.,
difficult journey: reflections on driving and driving cessation from a
Moon, C., Grigg, J., Horowitz, A., Meuser, T., Myers A., O’Connor, M., &
team of clinical researchers. The Gerontologist. 57(1), 82-88. https://
Silverstein, N. M. (2017). Transportation and aging: an updated research
doi.org/10.1093/geront/gnw079.
agenda to advance safe mobility among older adults transitioning
from driving to non-driving. Gerontologist,59(2), 215-221. https://doi. 15. Dickerson, A. E. (2016). Driving and Community Mobility as an
org/10.1093/geront/gnx120. Instrumental Activity of Daily Living. In: Gillen, G. (Ed.) Stroke
Rehabilitation, 4th edition. St. Louis, MO: Elsevier Publishing, pp. 237-
4. Pachana, N.A., Jetten, J., Gustafsson, L., & Liddle, J. (2017). To be or
264.
not to be (an older driver): social identity theory and driving cessation
in later life. Ageing & Society, 37, 1597-1608. https://doi.org/10.1017/ 16. Dickerson, A. E., Stinchcombe, A., & Bédard, M. (2017). Chapter 23:
S0144686X16000507. Transferability of driving simulation findings to the real world. In: S.
Classen (Ed.), Best Evidence and Best Practices in Driving Simulation:
5. Gabaude, C., Paire-Ficout, L., & Lafont, S. (2016, November).
A Guide for Health Care Professionals. Bethesda, MD: AOTA Press, pp.
Determinants of driving errors in older adults. The Gerontologist, 56,
281-294.
Issue Suppl_3. 571. https://doi.org/10.1093/geront/gnw162.2294.
17. Vivoda, J. M., Heeringa, S. G., Schulz, A. J., Grengs, J., & Connell, C.
6. Meuser, T. M., Berg-Weger, M., Chibnall, J. T., Harmon, A. C., &
M. (2017). The influence of the transportation environment on driving
Stowe, J. D. (2011). Assessment of readiness for mobility transition
reduction and cessation. The Gerontologist, 57(5),824-832. https://doi.
(ARMT): a tool for mobility transition counseling with older
org/10.1093/geront/gnw088.
adults. Journal of Applied Gerontology, 32, 484-507. https://doi.
org/10.1177/0733464811425914. 18. American Psychiatric Association. (2013). Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition. Washington, D.C.: American
7. Kandasamy, D., Harmon, A. C., Meuser, T. M., Carr, D. B., & Betz, M.
Psychiatric Association.
E. (2018). Predictors of readiness for mobility transition in older drivers.
Journal of Gerontological Social Work, 61, 193-202. https://doi.org/10.1
080/01634372.2018.1433260.
8. Morgan, E. (2018, February). Driving dilemmas: a guide to driving
assessment in primary care. Clinical Geriatric Medicine, 34(1), 107-115.
https://doi.org/10.1016/j.cger.2017.09.006.
9. Brummel-Smith, K., Munn, J. C., & Danforth, D. A. (2014).
Interprofessional team care. In R. J. Ham et al. (eds). Ham’s Primary Care
Geriatrics. 6th Edition. Philadelphia: Elsevier, Inc.
10. Berg-Weger, M., Meuser, T. M., & Stowe, J. (2013). Addressing
individual differences in mobility transition counseling with older adults.
Journal of Gerontological Social Work, 56, 201-218. https://doi.org/10.
1080/01634372.2013.764374.
11. Moore, I. (2014). Assessing the geriatric patient: planning for transitions
of care. Consultant Pharmacist, 29(6), 369-374. https://doi.org/10.4140/
TCP.n.2014.369.
12. Zhang, Q., Northridge, M. E., Jin, Z., & Metcalf, S. S. (2018). Modeling
accessibility of screening and treatment facilities for older adults using
transportation networks. Applied Geography, 93, 64-75. https://doi.
org/10.1016/j.apgeog.2018.02.013.

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C H A P T E R 7 E THICAL AND LEGAL ISSUES

KEY POINTS
n Laws, regulations, and n Some states (CA, DE, NJ, n Patient permission should
policies vary not only by state NV, OR, PA) have mandatory be obtained before contacting
but also by local jurisdiction reporting requirements that caregivers, and this should be
and are subject to change. may give rise to liability for documented in the patient’s
Healthcare professionals failure to report. health record. If the patient
should seek legal advice on n The ethical responsibility to maintains decisional capacity
specific issues or questions.1,2 maintain patient confidentiality and denies permission, his or
n It is important to know as well as the ethical her wishes must be respected.
and comply with state responsibility to public safety
requirements to avoid being is not limited to physicians; all
subject to a third-party lawsuit. healthcare professionals have
the same obligation.

T
his chapter provides a general overview
Mrs. Allen, a 78-year-old woman, is
to assist clinicians to understand the
accompanied by her daughter, who reports
process, including their ethical and legal
that her mother lives alone, has become
responsibilities, for reporting unsafe drivers to
increasing forgetful, repeats herself within
minutes, and has difficulty dressing herself, their state licensing agency. Although some of
performing personal hygiene tasks, and the issues addressed are inherently ethical and/
completing household chores. She is or legal, this chapter is not to be construed as
particularly concerned about her mother’s daily providing legal advice. The views, discussion,
trips to the grocery store two miles away. Mrs. conclusions, and legal analysis are those of the
Allen has become lost while on these trips and, authors and do not represent the opinions,
according to the store manager, has handled policies, or official positions of the National
money incorrectly. Dents and scratches have Highway Traffic Safety Administration or the
appeared on the car without explanation. Mrs. American Geriatrics Society and do not replace
Allen’s daughter has asked her mother to stop local legal advice and review of state laws and
driving and tried to take the car keys, but Mrs. local statutes. It is important for physicians and
Allen responds with anger and resistance.
other healthcare providers to seek legal advice
On previous visits, you have recommended
in their state on specific issues or questions
that she consider alternatives to driving. The
that may arise with an individual patient.
daughter would like to know how to manage
her mother’s long-term safety and health, and Older adults receive services in multiple settings
especially how to address the driving issue. from all types of professionals, including all
members of the clinical team (medicine, nursing,
pharmacy, social work, occupational therapy,

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psychology, etc.). Most existing legal guidance for

older adult drivers refers specifically to physicians, Clinician: Mrs. Allen, when do you think it’s an
although all clinical professionals have similar ethical appropriate time for a person to stop driving?
duties and obligations. The following discussion Mrs. Allen: I suppose when they drive unsafely
therefore specifically cites physicians in most or are a threat to others on the road.
instances, but the principles discussed should be
Clinician: That is an excellent observation, and I
adopted by the entire clinical team.
would agree with you.

Clinician: Mrs. Allen, I understand you drove Mrs. Allen: Well, a friend of mine doesn’t
yourself to the appointment today. This worries drive very well. He drives all over the road
me. At our last visit, I recommended you retire and runs red lights. I won’t get in the car with
from driving. Please share the reason you drove him anymore because I worry about what may
here today. happen.

Mrs. Allen: Well, I don’t understand why you’re Clinician: That is indeed a scary situation for
so concerned. I’ve never gotten into a car your friend and others on the road, too. It’s
crash. My driving is fine and, frankly, I don’t great that you’re aware of the potential danger
think you have any right to tell me not to drive. and know how to ensure your own safety. I’m
wondering if there’s someone you trust who
Clinician: It sounds like you are frustrated, and
would tell you when they thought it was unsafe
I can’t imagine how difficult it must be for you
for you to continue driving?
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 The case studies in this chapter serve to illustrate
healthcare provider, that is my primary concern. the range of opinions in attempting to fairly define
I want to help make this easier for you. Your the scope of the clinician’s responsibility to report
Rapid Pace Walk (15 seconds) and MoCA test age impaired drivers. In addition, they consider
results (score 18/30) show that your responses society’s efforts to provide a safe environment for its
are not as sharp as they need to be for you citizens.
to drive safely. Let’s talk about some of your
concerns regarding retiring from driving. On further evaluation, you diagnose Mrs. Allen
with Alzheimer disease. It is readily apparent
Laws, regulations, and policies vary not only by state that her condition has progressed to the extent
but also by local jurisdiction. They are also subject that she can no longer drive safely and that
to change, and the state licensing agency should rehabilitation is not likely to improve her driving.
be contacted for the most up-to-date information. You tell Mrs. Allen that she must stop driving for
For a state-by-state list of licensing agency contact her own safety and that of others on the road.
information and additional resources for locating You also explain that the state reporting laws
licensing requirements and renewal criteria, instruct physicians to notify the licensing agency
reporting procedures, etc, see Chapter 8. of medically unsafe drivers. Initially, Mrs. Allen
does not understand but when you specifically
tell her that she can no longer

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safety. Clinicians should advise and counsel patients

drive herself to the grocery store every day, about medical conditions and possible adverse
she becomes agitated and abusive, screaming, effects from medication that may impair the ability
“I hate you!” and “I’m going to sue you!” to drive safely and document this discussion in
Her daughter understands your decision to the medical record. Some states have mandatory
report Mrs. Allen to the state licensing agency reporting requirements that may give rise to both
but is now concerned that her mother will civil and criminal liability for failure to report.7 For
encounter problems if she attempts to drive example, wording in the Pennsylvania law has led
without a license. Mrs. Allen’s daughter asks if the Pennsylvania state licensing agency to conclude
it is absolutely necessary for you to report her that physicians who do not report “could be held
mother. What do you say? responsible as a proximate cause of an accident
resulting in death, injury or property loss caused
Many physicians are uncertain of their legal by your patient; the Pennsylvania statute further
responsibility, if any, to report unsafe drivers to states that providers who do not comply with their
their state licensing agency.3,4 A survey of geriatric legal requirement to report may be convicted of
physicians in the United states, discovered 31.8% a summary criminal offense.”8 Case law illustrates
were ignorant of state guidelines regarding that failure to advise patients about such medical
reporting at-risk drivers.5 The situation is further conditions and adverse effects of medication can
complicated by the risks of damaging the be considered negligent behavior, making the
clinician-patient relationship, violating patient physician liable for monetary damages.9
confidentiality, and potentially losing patients.4,6 As The Public: In addition to caring for their patients’
a result, clinicians are often faced with a dilemma: health, physicians may, in certain circumstances and
should they report the unsafe driver, or should jurisdictions, have some responsibility for protecting
they forego reporting and risk being liable for any the safety of the public.10,11 This is termed third-
potential patient or third-party injuries for failing party liability. In certain states, physicians have
to report? Furthermore, how should clinicians been found liable for third-party injuries because
engage caregivers to lessen the burden of a driving they failed to advise their patients about medical
restriction or cessation? conditions, adverse effects of medication,
or medical devices that may impair driving
ETHICAL DUTIES
performance.12–14
Current legal and ethical debates highlight duties
Generally, American civil law does not impose
of the physician that are relevant to the issue of
liability on parties for failing to aid or rescue other
driving. These include the duties to protect patient
parties. According to The Restatement (Second) of
health as well as maintain patient confidentiality.
Torts § 314 (1965): “The fact that the actor realizes
or should realize that action on his part is necessary
Duty to Protect
for another’s aid or protection does not of itself
The Patient: Protecting the patient’s physical and
impose upon him a duty to take such action.”15
mental health is considered the clinician’s primary
However, physicians have had an ethical mandate
responsibility. This includes not only treatment and
to protect the public from dangerous patients for
prevention of illness but also caring for the patient’s

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decades. In the case of Tarasoff v. Regents,16 the who has become an unsafe driver. In those states, it
California Supreme Court recognized the right of is important to document the following:25
a third party to sue if a health professional did not n An assessment regarding the ability of the
warn of an imminent threat. The ruling applies only patient to drive a motor vehicle.
in California but has been cited across the nation.
n An assessment of the specific danger posed by
The Tarasoff doctrine states that the most important
the patient’s driving to other individuals on the
consideration is the existence of a foreseeable
highway.
threat. So if a physician believes or predicts that
a person in treatment is likely to inflict serious n Attempts made to contact patient’s family
bodily harm on a third party who can be reasonably members26 or guardian, including the content of
identified, then he or she has a duty to warn or the conversation and the means used to make
protect that potential victim.17 contact.
Other Healthcare Professionals: The ethical
Maintain Patient Confidentiality
responsibility to maintain patient confidentiality
Patient confidentiality is the right of an individual to is not limited to physicians; all health care
have personal, identifiable medical information kept professionals have the same obligation.27,28
private. These protections are found in the federal Patient confidentiality is crucial within the health
Health Insurance Portability and Accountability Act care professional–patient relationship, because
of 1996 (HIPAA).18 All healthcare professionals have it encourages the free exchange of information
a legal duty to protect private patient information allowing the patient to describe symptoms for
from disclosure to anyone, including the patient’s diagnosis and treatment.19 Without belief that their
family, attorney, or the government, without care is confidential, patients may not trust their
authorization from the patient.19-21 health care professional and, thus, be less likely
HIPAA encourages the free exchange of information to disclose information for effective treatment.19
between the healthcare professional and the However, just as with physicians, this responsibility,
patient, allowing the patient to describe symptoms is not absolute.20,29 A good example of health care
for diagnosis and treatment. Individuals may be professional standards for the treatment of older
less likely to seek treatment, disclose information adult patients can be found on the website of
for effective treatment,22 or trust the healthcare the American Society of Consultant Pharmacists
professional unless confidentiality is ensured.19 (https://cdn.ymaws.com/www.ascp.com/
resource/collection/28D69F2D-18D9-4EF8-A086-
However, nondisclosure requirements are not
675AB7E4ECD8/Quality_Standards_and_Practice_
absolute. There may be public policy reasons
Principles_for_Senior_Care_Pharmacists.pdf) 20
to breach confidentiality, such as removing
unsafe drivers from the road.4,23 Thus, patient CONCERNS ABOUT REPORTING
confidentiality may not necessarily protect the
A Canadian study explored physicians’ attitudes on
physician from a third-party legal action in the
medical fitness to drive and found that although
impaired driver situation.23,24
most medical professionals would report unfit
Some states do not provide immunity for physicians drivers, they believed such action could adversely
who warn a government agency about an individual affect the confidentiality expectations within the

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physician-patient relationship.24,30 Physicians have information. In these states, physicians who disclose
raised concerns about mandatory reporting, stating medical information without patient authorization
it can violate privacy, compromise the ability may be liable for breach of confidentiality. However,
to counsel patients, and negatively impact the failure to disclose may make the physician liable to
physician-patient relationship.24,31 Some physicians third parties who are injured by the patient.13 This
have suggested that mandatory reporting has the presents a “take it or leave it” Hobson’s choice,*
potential to discourage patients from seeking health but ultimately safety of the patient and the public
care.3,32 should come first.
In the six states that have mandatory reporting
BALANCING ETHICAL AND LEGAL
requirements (California, Delaware, Nevada, New RESPONSIBILITIES
Jersey, Oregon, and Pennsylvania), studies show
Balancing competing ethical and legal duties can
physicians are more likely to report.33 Unless
be problematic. The following strategies may be
required by law to report, clinicians may choose not
helpful.
to do so.

Counsel Patients and Caregivers

Immunity and Confidentiality
Patients should be advised of medical conditions,
NHTSA’s Highway Safety Program Guideline No.13
medications, medical devices, and procedures that
- Older Driver Safety35 recommends that states
may affect driving performance. (For a reference
enact policies or regulations that protect clinicians.
table of such medical conditions and medications,
The AAA Foundation for Traffic Safety report Driver
with recommendations for each, see Chapter
Licensing Policies and Practices provides a list of
9.) If the patient gives permission, his or her
states that currently have laws in this area which
caregivers should be involved in the counseling
medical providers can use to look up their own state
process whenever appropriate. Caregivers
regulations.36
included in the process are more likely to assist
Adherence to State Reporting Laws the patient with the changes a loss of license will
bring. Losing one’s driver’s license has significant
Each state has its own reporting laws. For a
psychological consequences, because the ability
state-by-state listing of licensing agency contact
to drive is inexorably intertwined with the sense of
information and other resources for licensing
independence.
requirements, see Chapter 8. Note that information
may change over time, and the state licensing Driving cessation has other major consequences
agency should always be contacted for the most up- besides loss of autonomy. The older adult’s ability to
to-date information. conduct the business of daily living is impaired, as
is his or her ability to participate in social activities
In states without laws mandating physicians to
or volunteering. Therefore, social isolation is likely.
report patients to the state licensing agency,
Caregivers are also negatively impacted, because
physicians should have written patient releases
they are expected to fill in many of the gaps that
that comply with HIPAA before disclosing medical

*Thomas Hobson (circa 1544–1630) kept a stable and required every customer to take either the horse nearest the stable door or take no horse at
all.37 Thus, a “Hobson’s Choice” is given to one asked to choose between two undesirable alternatives.

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will inevitably arise as a result of the older adult’s that the patient may be an unsafe driver should be
driving cessation. These risks need to be recognized provided.
and weighed versus the concerns of public safety.
Reduce the Impact of Breaching Patient
If the older adult does not have decision-making
Confidentiality
capacity (e.g., due to Alzheimer disease), this
information should be given to a surrogate In adhering to state reporting laws, clinicians may
decision-maker. need to breach patient confidentiality, as is true
for several other medical conditions commonly
Recommend Driving Cessation reported to state and local health departments.
As discussed in previous chapters, clinicians should However, several measures can be taken to reduce
recommend driving cessation for patients believed the impact on the clinician-patient relationship.
to be unsafe drivers who have a condition(s) likely Inform the Patient of Notice to the State
to affect driving safety but unlikely to improve with Licensing Agency: Before reporting a patient to
available medical treatment or with an adaptive the state licensing agency, clinicians should inform
device or technique. As always, clinical judgment the patient of their intent and explain that it is the
should be based on the older adult’s driving abilities ethical, and in some cases, legal responsibility of
and not on age per se. This recommendation should the clinician to make the report. Describing the kind
be documented in the patient’s health record, and of follow-up that can be expected from the state
the clinician’s office should have a system to check licensing agency is also advised. The patient should
on compliance with recommendations. be assured that out of respect for his or her privacy,
only the minimum information required will be
Know and Comply with State Reporting Laws disclosed and that all other information will remain
Clinicians must know and comply with their state’s confidential. When submitting a report to the state
reporting laws (see Chapter 8). Clinicians who fail licensing agency, only the minimum information
to follow these laws may be liable for patient and necessary (or required by the reporting guidelines)
third-party injuries and could face civil or criminal should be provided to establish that the patient
charges as well. may be unsafe to drive.

In states that have a mandatory medical reporting Even in states that offer anonymous reporting or
law, the state licensing agency’s official form should reporter confidentiality, being open and honest
be used to report the required medical conditions. with patients is a good idea. It may help to remind
In states that have a voluntary medical reporting patients that the physician does not determine
law, the state licensing agency’s official form can be whether they are licensed to drive and that this
used or other similar forms. Some states provide decision is ultimately made by the state.
civil immunity if professionals report in good faith. Providing patients with as much information as
Patient consent, if any, should be documented. possible, perhaps including a copy of the state
If the state licensing agency’s guidelines do not licensing agency report, can involve them in the
indicate what patient information must be reported, process and give them a greater sense of control.
only the minimum information necessary to show In addition, patient permission should be obtained

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before contacting caregivers, and this should be assessment and/or rehabilitation.

documented in the patient’s health record. If the n The clinician’s recommendation on whether
patient maintains decisional capacity and denies the patient should continue driving or
permission, their wishes must be respected. cease driving. In the case of a cease driving
Document Diligently: All efforts to assess and recommendation, a summary of interventions
maintain the patient’s safety and that of the public (e.g., “sent letter to patient to reinforce
should be documented in the patient’s health recommendation,” “discussed transportation
record. In the event of a patient or third-party options and gave copy of ‘Patient Resource
crash injury, good documentation may protect the Sheet’,” “contacted family members with
clinician from civil liability. patient’s permission,” “reported patient to state
Clinicians should protect themselves legally licensing agency with patient’s knowledge”)
by documenting their efforts, discussions, should be included. Copies of any written
recommendations, and any referrals for further correspondence should also be included in the
testing in the patient’s health record.38 In other patient’s health record.
words, all the steps performed in the Plan for Older n Follow-up for degree of success in using
Drivers’ Safety (PODS) (see Chapter 1) should be alternative transportation options and any signs
documented, including: of social isolation and depression, including any
n Any direct observations of the patient’s further interventions, such as referral to a social
functional status or red flags as described in worker, geriatric care manager, or mental health
PODS. Driving history that leads the clinician to professional.
believe that the patient may be at risk of unsafe
ADDITIONAL LEGAL AND ETHICAL
driving should also be documented. CONCERNS
n Any counseling specific to driving (e.g., Other particularly challenging situations may arise.
documenting that the patient is aware of the The following examples provide some possible
warning signs of hypoglycemia and its effects on actions that may be used as a guide.
driving performance).
n Formal assessment of the patient’s driving- Situation 1: The patient threatens to sue if he or
related functions (e.g., documenting that the she is reported to the state licensing agency.
patient has undergone the Clinical Assessment n A patient’s threat to sue should not deter the
of Driving Related Skills (CADReS); include the clinician from complying with state reporting laws.
CADReS scoring sheet in the patient’s health If a patient threatens to sue, clinicians can take
record). several steps to protect themselves in the event of
n Any medical interventions and referrals that a lawsuit:
have been made to improve the patient’s - Know if your state has passed legislation
function, as well as any repeat testing to specifically protecting healthcare professionals
measure improvement. against liability for reporting unsafe drivers in
n A copy of the driver rehabilitation specialist good faith (see Chapter 8).28
(DRS) report if the patient has undergone driver - Understand that even in the absence of such

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legislation, physicians generally run little risk Situation 3: The patient’s license has been sus-
of liability for following mandatory reporting pended by the state licensing agency for unsafe
statutes in good faith. Consult your attorney or driving, but the clinician is aware that he or she
malpractice insurance carrier to determine your continues to drive.
degree of risk. This patient is violating the law, and several
- Make certain the reasons for believing that questions are raised: Is the clinician responsible
the patient is an unsafe driver have been clearly for upholding the law at the expense of breaching
documented. patient confidentiality? Because the license has
been revoked by the state licensing agency, is the
n Be aware that clinician-patient privilege does
driving safety of the patient now the responsibility
not preclude the clinician from reporting the
of the state, the clinician, or both?
patient to the state licensing agency. Physician-
patient privilege, which is defined as the patient’s Several steps can be taken in this situation:
right to prevent disclosure by the physician of n Ask the patient why he or she continues to
any communication between the physician and drive. Address the specific causes brought up by
patient, does not apply in cases of mandatory the patient (see Chapter 6 for recommendations).
reporting. Patients can be reminded that clinicians With the patient’s permission, caregivers should
do not determine licensing. Ultimately, this is be involved in finding solutions such as alternative
the responsibility of the state, and thus the state methods of transportation.
makes the final decision on determining whether
n Ask the patient if he or she understands that
the patient can continue to drive.
continuing to drive is breaking the law. Reiterate
concerns about the patient’s safety and ask how
Situation 2: The patient is an unsafe driver in a
he or she would feel about causing a crash and
state without state reporting laws.
potentially being injured or injuring someone else.
In this situation, the clinician’s priority is to ensure
Discuss the emotional burden a car crash would
that the unsafe driver does not drive. If this can be
cause the patient, his or her family, and all others
accomplished without having the patient’s license
involved.
revoked, then there may be no need to report
n Discuss the financial and legal consequences
the patient to the state licensing agency. Before
of being involved in a crash without a license or
reporting a patient, clinicians may address the risk
auto insurance. Many clinicians remind patients
of liability for breaching patient confidentiality by
and families/caregivers of the possibility of their
following the steps listed under Situation 1.
financial liability for any injuries caused by driving.
However, if the patient continues to refuse to
n If the patient is cognitively impaired and lacks
stop driving, then clinicians must consider which
insight into this problem, the issue must be
is more likely to cause the greatest amount of
discussed with the individual who holds decision-
harm: breaching the patient’s confidentiality versus
making authority for the patient, if the patient has
allowing the patient to potentially injure himself or
a designated decision-maker. If not, the patient
herself or third parties in a motor vehicle crash.
and caregiver(s) should pursue the process of
appointing one. These parties should understand

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their responsibility to prevent the patient from clinician reports by requiring the patient to be
driving. retested, inform the patient that just as it is the
n If the patient continues to drive and the state clinician’s responsibility to report the patient to the
has a mandatory reporting law, clinicians must agency, it is the patient’s responsibility to prove
adhere to the law by reporting patients who his or her driving safety to the agency. Emphasize
are unsafe drivers (even if the patient has been that the state licensing agency makes the final
reported previously). If the state does not have decision, and that only the state can legally
a mandatory reporting law, the clinician should revoke a driver’s license. Remind the patient that
base the decision to report as in Situation 2 (see everything medically possible has been done to
above). The state licensing agency, as the agency help him or her pass the driver test.
that grants and revokes the driver’s license, will n As always, maintain professional behavior by
follow up as it deems appropriate. remaining matter-of-fact and not expressing
hostility toward the patient, even if he or she
Situation 4: The patient threatens to find a new ultimately makes the decision to seek a new
clinician if reported to the state licensing agency. clinician.
Although unfortunate, this situation should not
prevent clinicians from caring for the patient’s health PATIENT RESOURCES
and safety. In addition, physicians must adhere to The following online patient/caregiver resources are
state reporting laws, regardless of such threats. available from the National Highway Traffic Safety
Several strategies may help diffuse this situation: Administration (NHTSA). Clinicians may wish to
download these materials and are free to put their
n Reiterate the process and information used to
personalized information/logo on the materials.
support the recommendation that the patient stop
driving. Driving Safely While Aging Gracefully,39 is guidance
available on the National Highway Traffic Safety
n Reiterate concern for the safety of the patient,
Administration Older Driver website and can help
any passengers, and others on the road.
older adults assess whether they should still be
n Remind the patient that providing him or her driving.
with the best possible health care includes safety
Getting Around: Other Ways to Get Around40 is a
measures of all types. State that driving safety
brochure from AAA designed to help families cope
is as much a part of patient care as encouraging
with an older adult who should not be driving.
patients to keep smoke detectors in the house
Clinicians may wish to keep a supply of these
and have regular physical check-ups.
documents on hand. Additional resources are
n Encourage patients to seek a second opinion, discussed in Chapter 6 and listed in Appendix B.
if appropriate. A DRS may evaluate the patient if
this has not already been done, or the patient may GLOSSARY OF TERMS 42–45
consult another clinician. Before consulting the reference list in Chapter 8,
n If the state licensing agency follows up on it will be helpful to be familiar with the following
terms and concepts (Table 7.1).

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Table 7.1 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 states will maintain the
confidentiality of the reporter, unless otherwise required to disclose
by a court order.41

Driver rehabilitation programs These programs, run by DRSs, help identify at-risk drivers and
improve driver safety through adaptive devices and compensatory
techniques. Drivers typically receive a clinical evaluation, on-road
assessment, and, if necessary, vehicle modifications and training.
(For more information on driver assessment and rehabilitation, see
Chapter 5.)

Duty to protect In certain jurisdictions, physicians have a legal duty to warn the
public of danger their patients may cause, especially in the case
of identifiable third parties.6 With respect to driving, mandatory
reporting laws and physician reporting laws provide physicians with
guidance on their duty to protect.

Good faith Honesty and respect in all professional interactions42

Immunity for reporting Many states exempt physicians from liability for civil damages
brought by the patient if the physician previously reported the
patient to the state licensing agency.

Medically impaired driver A driver who is suffering from cognitive and/or functional
impairments likely to affect the ability to safely operate a motor
vehicle.

Mandatory medical reporting laws In some states, physicians are required to report patients who have
specific medical conditions (e.g., epilepsy, dementia) to their state
licensing agency. These states provide specific guidelines and
forms that can be obtained through the state licensing agency.

Medical Advisory Boards (MABs) MABs generally consist of local or consultant physicians who
work in conjunction with the state licensing agency 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.

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Table 7.1 Glossary of Terms/cont.

Patient confidentiality The right of an individual to have personal, identifiable medical

information kept private.

Physician reporting laws Some states require physicians to report “unsafe” drivers to the
state licensing agency, with varying guidelines for defining “unsafe.”
The physician may need to provide the patient’s diagnosis and any
evidence of a functional impairment that can affect driving (e.g.,
results of neurologic testing) to prove that the patient is an unsafe
driver.43

Physician liability Refers to the legal duty of the physician to report his or her patient’s
status as an at-risk driver to the state licensing agency. Failure to
report (negligence) can result in the physician being held liable
(responsible) for civil damages caused by the patient’s car crash.44

Renewal procedures L icense renewal procedures vary by state. Some states have age-
based renewal procedures, i.e., at a given age, the state may reduce
the time interval between license renewal, restrict the ability to
obtain license renewal by mail, require specific vision ability and
knowledge of traffic laws and signs, and/or require on-road testing.
Very few states require a medical report for license renewal.45

Restricted driver’s license Some states offer a 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 adaptive
devices, and shortening the renewal interval. The efficacy of these
types of restrictions has not been studied.

Third party The generic legal term for any individual who does not have a direct
connection with the clinician but who might be affected by him or
her, e.g., anyone injured other than the patient.

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REFERENCES
1. Senior driving. AAA.com state laws, https://seniordriving.aaa.com/ 047, 126 N.M. 404, 970 P.2d 590, 38 N.M. B. Bull. 2, 38 N.M. B. Bull. 11
states/. 2 (1998) (This Court did not extend the duty articulated in Wilschinsky
to prescription cases under the case fact pattern.) See also Brown v.
2.Quick Facts Regarding Cognitive Impairment, and Age Related License
Kellogg, 2015-NMCA-006, 340 P.3d 1274 (N.M. Ct. App. 2014).
Restrictions. List of Each State’s (Including District of Columbia) Specific
Age Based Policies in Alphabetical Order. Retrieved from http://adsd. 10.Tarasoff v. Regents of University of California, 17 Cal. 3d 425; 551
nv.gov/uploadedFiles/adsdnvgov/content/Boards/TaskForceAlzheimers/ P.2d 334; 131 Cal. Rptr. 14 (Cal. 1976 Cal.); 83 A.L.R.3d 1166, 1976
State%20Regulations%20Dementia%20and%20Driving.pdf. (rehearing to the California Supreme Court upheld on the duty to
warn and protect). In Tarasoff, the California Supreme Court held that,
3.Kelly, R., Warke, T., & Steele, I. (1999). Medical restrictions to driving:
under certain circumstances, a therapist had a duty to warn others
the awareness of patients and doctors. Postgraduate Medical Journal,
that a patient under the therapist’s care was likely to cause personal
75(887), 537-539.
injury to a third party. There the court said, “Although . . . under the
4.Gergerich, E., M. (2016). Reporting policy regarding drivers with common law, as a general rule, one person owed no duty to control
dementia. Gerontologist, 56(2):345-356. https://doi.org/10.1093/ the conduct of another, nor to warn those endangered by such
geront/gnv143. conduct, the courts have carved out an exception to this rule in cases
5.Miller, D., & Morley J. (1993). Attitudes of physicians toward elderly in which the defendant stands in some special relationship to either
drivers and driving policy. Journal of the American Geriatrics Society, the person whose conduct needs to be controlled or in a relationship
41(7), 722-724. to the foreseeable victim of that conduct.” (P. 435.) Applying that
exception to the facts of Tarasoff, the court held that where a therapist
6.Carmody, J., Granger, J., Lewis, K., Traynor, V. & Iverson, D. (2013). knows that his patient is likely to injure another and where the identity
What factors delay driving retirement by individuals with dementia?: of the likely victim is known or readily discoverable by the therapist,
the doctors’ perspectives. Journal of Australasian College Road Safety, he must use reasonable care to prevent his patient from causing the
24(1), 10-16. Retrieved from http://ro.uow.edu.au/cgi/viewcontent. intended injury. Such care includes, at the least, informing the proper
cgi?article=1355&context=smhpapers. authorities and warning the likely victim. However, the court did not
7. OR. REV. STAT.§ 807.710 (2015). hold that such disclosure was required where the danger presented
was that of self-inflicted harm or suicide or where the danger consisted
8. Title 75 PA. CODE § 1518(b) The Vehicle Code (stating physicians are of a likelihood of property damage. Instead, the court recognized the
immune from any civil or criminal liability if they report patients 15 importance of the confidential relationship which ordinarily obtains
years old or older who have been diagnosed as having a condition that between a therapist and his patient, holding that “. . . the therapist’s
could impair their ability to safely operate a motor vehicle; but, if the obligations to his patient require that he not disclose a confidence
physician does not report could, then, possibly be held responsible as unless such disclosure is necessary to avert danger to others . . . .”
a proximate cause of an accident resulting in death, injury, or property (Tarasoff, supra, p. 441; italics added). The holding in Tarasoff was
loss caused by the physician’s patient. Also, physicians who do not questioned in Mason v. IHS Cedars Treatment Ctr. of Desoto Tex.,
comply with their legal requirement to report may be convicted of a Inc. (Tex. App. Dallas Aug. 15, 2001); criticized in Gregory v. Kilbride,
summary criminal offense). 150 N.C. App. 601, 565 S.E.2d 685 (N.C. App. 2002) and Tedrick
9.Gooden v. Tips, 651 S.W.2d 364, 1983 Tex. App., 43 A.L.R.4th 139 v. Cmty. Res. Ctr., Inc., 235 Ill. 2d 155, 920 N.E.2d 220 (Ill. 2009);
(Tex. App. Tyler 1983) (case stating that physicians have a duty to warn and superseded in part by Nebraska State statue in Munstermann
patients that medications may impair driving but that physicians do v. Alegent Health - Immanuel Med. Ctr., 271 Neb. 834, 716 N.W.2d
not have a duty to control a patient’s behavior). However, the Supreme 73, (Neb.2006). It should be noted that the Tarasoff ruling per se,
Court of Texas significantly narrowed physicians’ duties to third parties. upon which the principles of “Duty to Warn” and “Duty to Protect”
In Praesel v. Johnson, 967 S.W.2d 391, 396 (Tex. 1998), the court noted are based, originally applied only in the State of California and now
that it had “generally limited the scope of the duty owed by physicians applies only in certain jurisdictions. The U.S. Supreme Court has not
in providing medical care to their patients.” The court “declined heard a case involving these principles. Many states have adopted
to impose on physicians a duty to third parties to warn an epileptic statutes to help clarify steps that are considered reasonable when a
patient not to drive.” Somewhat similarly that court “weighed the risk, physician is pre-sentenced with someone making a threat of harm to
foreseeability, and likelihood of injury against the social utility of the a third party. Tasman, A., Kay, J., Lieberman, J. A., & Fletcher, J. (eds).
actor’s conduct, the magnitude of the burden of guarding against the Psychiatry, 1st ed. Philadelphia: W.B. Saunders Company; 1997, p.
injury, and the consequences of placing the burden on the defendant,” 1815.
and also considered “whether one party would generally have superior 11.Brisbane v. Outside in Sch. of Experiential Educ., Inc., 799 A.2d 89 (Pa.
knowledge of the risk or a right to control the actor who caused the Super. Ct. 2002) (defining factors in a Pennsylvania case to determine
harm.” 967 S.W.2d at 397-98. For a general discussion on this topic, the existence of a duty: (1) the relationship between the parties, (2) the
see 43 A.L.R. 4th 153; 35 U. Mem. L.Rev. 173; See Comment: Driving social utility of the actor’s conduct, (3) the nature of the risk imposed
on the center line: Missouri physician’s potential liability to third persons and foreseeability of the harm incurred, (4) the consequences of
for failing to warn of medication side effects (46 St. Louis L.J. 873); imposing a duty upon the actor, (5) the overall public interest in the
Wilschinsky v. Medina, 1989- NMSC-047, 108 N.M. 511, 775 P.2d 713, proposed solution). Pennsylvania did not expand the duty of a parent
(N.M. 1989). (New Mexico case stating that the physician owed a duty to encompass supervision of adult children, see Kazlauskas v. Verrochio
of care to an individual harmed by the physician’s patient, that the (M.D. Pa. Oct. 27, 2014). Case questioned by Bellah v. Greenson, 81
patient’s duty specifically extended to persons the patient injured by Cal. App. 3d 614, 146 Cal. Rpt., 535, 1978, 17 A.L.R. 4th 1118 (Cal.
driving a car from the doctor’s office after being injected with drugs App. 1st Dist. 1978). Explained by Felty v. Lawton, 1977 OK 109, 578
that were known to affect judgment and driving ability; the medical P.2d 757 (Okla. 1977). For a general discussion on this topic, see A.L.R.
standards for administering drugs had to define the physician’s duties of 3d 1201; 46 Ca. Jur., Negligence Sections 10 and 212.
care). Limited by Lester by & Through Mavrogenis v. Hall, 1998-NMSC-

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12. Gooden v. Tips, supra at FN 5; Kaiser v. Suburban Transp. System, 65 19. De Bord, J., Burke, W., & Dudzinski, D. (2013). Ethics in Medicine.
Wn.2d 461, 398 P.2d 14 (Wash.1965) (Washington case stating that Seattle: University of Washington School of Medicine. Retrieved from
a physician could be held liable due to the fact that a patient took https://depts.washington.edu/bioethx/topics/confiden.html.
medication completely unaware that it would have any adverse effect
20. American Society of Consultant Pharmacists (2011). Quality
on him because the physician failed to warn his patient, whom he
Standards and Practice Principles for Senior Care Pharmacists .
knew to be a bus driver, of the dangerous side effects of drowsiness
Retrieved from http://c.ymcdn.com/sites/www.ascp.com/resource/
or lassitude that may be caused by taking this particular medication).
collection/28D69F2D-18D9-4EF8-A086-675AB7E4ECD8/Quality_
Superseded on other grounds by statute State v. Fisher (Wash. Ct.
Standards_and_Practice_Principles_for_Senior_Care_Pharmacists.pdf.
App. May 29, 2012).
21. American Nurses Association (2001). American Nurses Association.
13. Calwell v. Hassan, 260 Kan. 769, 925 P.2d 422 (Kan. 1996) (Kansas
Code of ethics for nurses with interpretive statements. 2nd Ed.
case stating that the doctor had no duty to protect bicyclists - a
(2015). Retrieved from https://www.nursingworld.org/practice-policy/
third party from his patient’s actions because the patient who
nursing-excellence/ethics/.
had a sleep disorder was aware of the problem and admitted to
knowing that she should have stopped driving). Adams v. Bd. of 22. Nass, S., Levit, L., & Gostin, L. (2009). Institute of Medicine
Sedgwick County Comm’rs, 289 Kan. 577, 214 P.3d 1173 (Kan. (US) Committee on Health Research and the Privacy of Health
2009); Wilson v. McDaniel, 327 P.3d 1052, 2014 Kan. App. Unpub. Information: The HIPAA Privacy Rule. Beyond the HIPAA Privacy Rule:
(Kan. Ct. App. 2014) (cited in dissenting opinion). Duvall v.Goldin, Enhancing Privacy, Improving Health Through Research. Washington
139 Mich. App. 342, 362 N.W.2d 275, (Mich. App. 1984) (Michigan (DC): National Academies Press (US).
case stating the physician was liable to third persons injured as it 23. Berger, J., Rosner, F., Kark, P., & Bennett, A., for the Committee on
was foreseeable that a doctor’s failure to diagnose or properly treat Bioethical Issues of the Medical Society of the State of New York.
an epileptic condition could have created a risk of harm to a third (2000). Reporting by Physicians of Impaired Drivers and Potentially
party and that as a result of the patient’s medical condition, caused Impaired Drivers. Journal of General Internal Medicine, 15(9), 667-
an automobile accident involving the third persons). Dawe v. Dr. 672. https://dx.doi.org/10.1046%2Fj.1525-1497.2000.04309.x.
Reuven Bar-Levav & Assocs., P.C., 485 Mich. 20, 780 N.W.2d 272
(Mich. 2010). Distinguished in Singleton v.United States Dep’t of 24. Avraham, R., & Meyer, J. (2016). The Optimal Scope of Physicians’
Veterans Affairs, 2013 U.S. Dist. (E.D. Mich. Aug. 15, 2013). Myers v. Duty to Protect Patients’ Privacy, 100 Minn. L. Rev. Headnotes 30.
Quesenberry, 144 Cal. App. 3d 888, 193 Cal. Rptr. 733 (Cal. App. 4th 25. Lambert, K., & Wetheimer, M. (2018). What Is My Duty to Warn?
Dist. 1983) (California case stating that if a physician knows or should American Psychiatric Association. Retrieved from https://psychnews.
know a patient’s condition will impair the patient’s mental faculties psychiatryonline.org/doi/full/10.1176/appi.pn.2016.1b1.
and motor coordination, a comparable warning is appropriate).
Distinguished in Greenberg v. Superior Court, 172 Cal. App. 4th 26. Richman, D. (2016). Dealing with Patients Who Have Compromised
1339, 92 Cal. Rptr. 3d 96 (Cal. App. 4th Dist.2009) Schuster v. Driving Ability. Retrieved from www.nyacp.org/files/District%20
Altenberg, 144 Wis. 2d 223, 424 N.W.2d 159 (Wis. 1988) (Wisconsin Meetings/Compromised%20Driving%20Ability_final.pdf.
case stating that if it was ultimately proven that it could have been 27. Justice, J. (1997). Patient confidentiality and pharmacy practice.
foreseeable to a psychiatrist, exercising due care, that by failing to Consultant Pharmacist, 12(11).
warn a third person or failing to take action to institute detention or
28. Erickson, J., & Millar, S. (2005, May 31). Caring for Patients While
commitment proceedings someone would be harmed, negligence
Respecting Their Privacy: Renewing Our Commitment. The Online
could be established). Distinguished by Milwaukee Deputy Sheriff’s
Journal of Issues in Nursing, 10(2). Manuscript 1. Retrieved from
Association v. City of Wauwatosa, 2010 WI App 95, 327 Wis. 2d 206,
www.nursingworld.org/MainMenuCategories/ANAMarketplace/
787 N.W.2d438 (Wisc. App.2010) and Hornback v.Archdiocese of
ANAPeriodicals/OJIN/TableofContents/Volume102005/No2May05/
Milwaukee, 2008 WI 98, 313 Wis. 2d 294, 752 N.W.2d 862(Wisc.
tpc27_116017.html.
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29.Tasman, A., Kay, J., Lieberman, J. A., & Fletcher, J. (1997). Psychiatry,
14. Joy v. Eastern Maine Medical Center, 581 A.2d 418 (Me. 1990)
1st ed. p. 1808. Philadelphia: W. B. Saunders Company. See also
(appeal after remand affirmed) (Maine case stating that when the
Quality Standards and Practice Principles for Senior Care Pharmacists
doctor knew, or reasonably should have known that his patient’s
Quality Standard 3, Section 8.
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 30. Shawn, C., Marshall, M., & Gilbert, N. (1999). Saskatchewan
to warn his patient of that fact). Distinguished by Flanders v. Cooper, physicians’ attitudes and knowledge regarding assessment of
1998 ME 28, 706 A.2d 589 (Me. 1998). medical fitness to drive. Canadian Medical Association Journal,
160(12), 1701–1704.
15.The Restatement (Second) of Torts § 314 (1965).
31. Meuser, T. M., Carr, D. B., Ulfarsson, G. F., Berge-Weger, M.,
16. Johnson, R., Persad, G., & Sisti, D. (2014, December). The Tarasoff
Niewoehner, P., Kim, J. K., & Osberg, S. (2008). Medical Fitness
Rule: The Implications of Interstate Variation and Gaps in Professional
to Drive and a Voluntary Reporting Law. Washington, DC: AAA
Training, J Am Acad Psychiatry and the Law Online, 42(4), 469-477.
Foundation for Traffic Safety. Retrieved from https://aaafoundation.
Retrieved from http://jaapl.org/content/42/4/469.long.
org/wp-content/uploads/2018/02/MedicalFitnesstoDriveReport.pdf.
17. University of California v. Katherine Rosen Opinion No. S230568.
32. West, K., Bledsoe, L., Jenkins, J., & Nora, L. M. (2001-2002). The
(2018) Retrieved from https://caselaw.findlaw.com/ca-supreme-
Mandatory Reporting of Adult Victims of Violence: Perspectives from
court/1892230.html.
the Field. 90 Kentucky Law Journal, 1071.
18. Health Insurance Portability and Accountability Act of 1996 (HIPAA),
33. Older Californian Traffic Safety Task Force, Health Services
Public Law 104-191. 45 C.F.R.§ 164.512(a)—Uses and Disclosures
Workgroup and Policy and Legislation Workgroup, p.2. (The six
Required by Law (2000). Federal Register Vol. 65, No. 250, Thursday,
states are California, Delaware, Nevada, New Jersey, Oregon, and
December 28, 2000, Rules and Regulations, p 82811.
Pennsylvania.)

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34. Lococo, K. (2003). Summary of Medical Advisory Board Practices in

the United States. (Task Report Prepared Under NHTSA Contract No.
DTNH22-02-P-05111). Quakertown, PA: TransAnalytics LLC.
35. Uniform Guidelines for State Highway Safety Programs. Highway
Safety Program Guideline No. 13. Older Driver Safety. (2014).
Washington, D.C.: National Highway Traffic Safety Administration.
Retrieved from https://www.nhtsa.gov/nhtsa/whatsup/tea21/
tea21programs/pages/812007D-HSPG13-OlderDriverSafety.pdf.
36. AAA Foundation for Traffic Safety. (2016). Driver License Policies
and Practices. Retrieved from http://lpp.seniordrivers.org/index.
cfm?selection=reportingdrs1.
37. What is the origin of the phrase “Hobson’s Choice?”https://www.
theguardian.com/notesandqueries/query/0,5753,-23563,00.html.
38. Carr, D. (2000). The older adult driver. American Family Physician,
61(1), 141–148. Retrieved from https://www.aafp.org/afp/2000/0101/
p141.html.
39. National Highway Traffic Safety Administration. (n.d.) Driving Safely
While Aging Gracefully. Washington, DC: Author. Retrieved from
https://one.nhtsa.gov/people/injury/olddrive/driving%20safely%20
aging%20web/index.html.
40. Getting Around: Other Ways to Get Around. Washington, DC:
AAA Foundation for Traffic Safety. (2018). Retrieved from https://
seniordriving.aaa.com/maintain-mobility-independence/other-ways-
get-around/.
41. Sterns, L., Aizenberg, R., & Anapole, R. (2001, August). Family and
Friends Who are Concerned About an Older Driver Need Resources
(Report No. DOT HS 809 307). Washington, DC: National Highway
Traffic Safety Administration. Retrieved from https://icsw.nhtsa.gov/
people/outreach/traftech/TT257.htm.
42. American Association for Thoracic Surgery. (2008). Code of Ethics.
Retrieved from http://aats.org/aatsimis/AATS/Association/By-Laws_
and_Policies/Code_of_Ethics/CODE_OF_ETHICS.aspx.
43. 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.
44. Capen, K. (1994). New court ruling on fitness-to-drive issues will
likely carry “considerable weight” across country. Canadian Medical
Association Journal, 151(5), 667. Retrieved from https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC1337209/pdf/cmaj00053-0173.pdf.
45. Tripodis, V. L. (1997). Licensing policies for older drivers: balancing
public safety with individual mobility. Boston College Law Review, 38
B.C.L. Rev. 1051. Retrieved from http://lawdigitalcommons.bc.edu/
cgi/viewcontent.cgi?article=2083&context=bclr.

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C H A P T E R 8 S TATE LICENSING AND REPORTING LAWS

KEY POINTS
n Each state has its own licensing and license renewal criteria.
n Licensing and license renewal information is subject to change, and statutes for specific states
should be checked for up-to-date changes in laws or requirements.

E
ach state has its own licensing and license A database of state license renewal cycles, vision
renewal criteria for drivers of private motor requirements, and procedures can be found at:
vehicles. In addition, certain states require n Insurance Institute for Highway Safety
health care professionals to report unsafe drivers (www.iihs.org/iihs/topics/laws/olderdrivers)
or drivers with specific medical conditions to the
n Insurance Information Institute
driver licensing agency. State law restrictions for
(www.iii.org/)
older drivers vary according to age requirements
of additional drivers, length of renewal cycle,
This information is subject to change, and statues
vision requirements, license restrictions, level of
for specific states should be checked for up-to-date
mandatory reporting by health care professionals,
changes in laws or requirements. This is especially
civil immunity, anonymity protection, and process
important when creating a clinic policy or deciding
for evaluation by medical advisory boards. The
on an individualized approach to reporting. Legal
effectiveness of driving restrictions in reducing
counsel is recommended to advise on decision-
vehicle crashes or fatalities involving older adults
making in this area.
also varies from state to state.

Licensing agency contact information by state STATE LICENSING AGENCIES

is listed below, along with additional resources (CURRENT AS OF APRIL 2019)
for locating license renewal criteria, reporting
Alabama
procedures, and medical advisory board
Alabama Law Enforcement Agency Department of Public
information. These materials are intended to guide
Safety
healthcare professionals in understanding their legal
PO Box 1471
responsibilities and managing the driving safety Montgomery, AL 36102-1471
of their patients. The information provided should 334-242-4400
neither be construed as legal advice nor used to https://www.alea.gov/dps
resolve legal problems. If legal advice is required,
a licensed attorney (in the relevant state) should be
consulted.

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Alaska Colorado
Alaska Department of Administration Division Colorado Department of Revenue Division
of Motor Vehicles of Motor Vehicles
1300 W. Benson Boulevard 1881 Pierce Street
Anchorage, AK 99503-3696 Lakewood, CO 80214
855-269-5551 303-205-5600
http://doa.alaska.gov/dmv/ https://www.colorado.gov/dmv
http://doa.alaska.gov/dmv/akol/medical_impair.
htm?_ga=2.190336107.1963593011.1530539137- Connecticut
339207583.1530539137 Connecticut Department of Motor Vehicles
60 State Street
Arizona Wethersfield, CT 06161-2510
Arizona Department of Transportation 860-263-5700
Motor Vehicle Division http://www.ct.gov/dmv/site/default.asp
PO Box 2100, Mail Drop 555M
Phoenix, AZ 85001-2100 Delaware
800-251-5866 Delaware Division of Motor Vehicles
https://www.azdot.gov/motor-vehicles Driver License Administration Medical Section
https://www.azdot.gov/motor-vehicles/driver-services/ PO Box 698
MedicalReview Dover, DE 19903
302-744-2507
Arkansas https://www.dmv.de.gov/
Arkansas Department of Finance and Administration https://www.dmv.de.gov/services/driver_services/senior/
Arkansas Driver Control index.shtml
1900 W. 7th St., Rm 1070
Little Rock, AR 72201 District of Columbia
501-682-1631 District of Columbia Department of Motor Vehicles
https://www.dfa.arkansas.gov/driver-services/ Medical Review Office
https://www.dfa.arkansas.gov/driver-services/driver- 955 L’Enfant Plaza, SW
control/ Washington, DC 20024
202-737-4404
California https://dmv.dc.gov/
California Department of Motor Vehicles Licensing https://dmv.dc.gov/service/dmv-medical-requirements
Operations Division
2570 24th Street, MS J152 Florida
Sacramento, CA 95818-2698 Florida Highway Safety and Motor Vehicles
916-657-6550 Medical Review Office
https://www.dmv.ca.gov/portal/dmv 850-617-3814
https://www.dmv.ca.gov/portal/ https://www.flhsmv.gov/
dmv/?1dmy&urile=wcm:path:/dmv_content_en/dmv/dl/ https://www.flhsmv.gov/driver-licenses-id-cards/florida-
driversafety/dsmedcontraffic granddriver/medical-reporting-medical-review-process/

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Georgia Indiana
Georgia Department of Driver Services, Attn: Medical Indiana Bureau of Motor Vehicles
Unit Indiana Government Center North
PO Box 80447 100 North Senate Avenue
Conyers, GA 30013 Indianapolis, IN 46204
678-413-8400 888-692-6841
https://dds.georgia.gov/ https://www.in.gov/bmv/

Hawaii Iowa
Hawaii’s Medical Advisory Board Iowa Department of Transportation Motor Vehicles
Aliiaimoku Building Division
869 Punchbowl Street 800 Lincoln Way
Honolulu, HI 96813 Ames, IA 50010
808-692-7656 or 808-692-7655 515-239-1101 or 515-244-8725
http://www.honolulu.gov/license https://www.iowadot.gov/mvd/
http://hidot.hawaii.gov/administration/bac/mab/
Kansas
Idaho Kansas Department of Revenue Division of Vehicles
Idaho Transportation Department Driver’s Licensing
Division of Motor Vehicles - Driver Services P.O. Box 2188
3311 W. State Street Topeka, KS 66601-2188
PO Box 7129 785-296-3671 or 785-296-3963
Boise, ID 83707-1129 https://www.ksrevenue.org/dovindex.html
208-334-8000 https://www.ksrevenue.org/dovmedvision.html
https://itd.idaho.gov/itddmv/
Kentucky
Illinois Kentucky Transportation Cabinet
Illinois Office of the Secretary of State Department of Vehicle Regulation
Driver Services Department Attn: Medical Review Board
2701 S. Dirksen Parkway 200 Mero Street
Springfield, IL 62723 Frankfort, KY 40622
217-782-6212 https://drive.ky.gov/
Driver Services Department–Metro https://drive.ky.gov/driver-licensing/Pages/Kentucky-
17 N. State Street, Suite 1100 Medical-Review-Board-Program.aspx
Chicago, IL 60602
312-793-1010 Louisiana
http://www.cyberdriveillinois.com/departments/drivers/ Louisiana Office of Motor Vehicles
home.html PO Box 64886
http://www.cyberdriveillinois.com/departments/drivers/ Baton Rouge, LA 70896
drivers_license/medical_vision.html 225-925-6146
http://www.expresslane.org

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Maine Minnesota
Maine Bureau of Motor Vehicles Minnesota Department of Public Safety Driver
Attn: Medical Advisory Board and Vehicle Services
29 State House Station Attn: Medical Unit
Augusta, ME 04333-0029 445 Minnesota Street, Suite 170
209-624-9000 ext 52124 St Paul, MN 55101-5170
https://www.maine.gov/sos/bmv/ 651-296-2025
https://www.maine.gov/sos/bmv/licenses/medical.html https://dps.mn.gov/divisions/dvs/Pages/default.aspx
https://dps.mn.gov/divisions/dvs/Pages/dvs-content-
Maryland detail.aspx?pageID=670
Maryland Motor Vehicle Administration
6601 Ritchie Highway NE Mississippi
Glen Burnie, MD 21062 Mississippi Department of Public Safety Driver
410-768-7000 or 800-492-4575 Improvement PO Box 948
http://www.mva.maryland.gov/ Jackson, MS 39205
http://www.mva.maryland.gov/about-mva/ 601-987-1515 or 601-987-1212
info/26200/26200-03T.htm https://www.driverservicebureau.dps.ms.gov/

Massachusetts Missouri
Massachusetts Registry of Motor Vehicles Missouri Driver License Bureau
Medical Affairs Branch P.O. Box 200
PO Box 199100 Jefferson City, MO 65105-0200
Boston, MA 02119-9100 573-526-2407
857-368-8000 or 800-858-3926 https://dor.mo.gov/drivers/
https://www.mass.gov/orgs/massachusetts-registry-of- https://dor.mo.gov/faq/drivers/unsafe.php
motor-vehicles
https://www.mass.gov/medical-standards-related-to- Montana
driving Motor Vehicle Division
Attn. Medical Unit
Michigan P.O. Box 201430
Michigan Department of State Helena, MT 59620-1430
Driver Assessment and License Appeal Unit 406-444-3933
P.O. Box 30810 https://dojmt.gov/driving/driverservices/
Lansing, MI 48909-9832
517-335-7051 Nebraska
https://www.michigan.gov/sos Nebraska Department of Motor Vehicles
https://www.michigan.gov/ Driver Licensing Division
agingdriver/0,6066,7-341-72511---,00.html PO Box 94726
Lincoln, NE 68509-4726
402-471-3861
https://dmv.nebraska.gov/
https://dot.nebraska.gov/safety/driving/age/

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Nevada North Carolina

Nevada Department of Motor Vehicles Management North Carolina Division of Motor Vehicles Medical
Services and Programs Division Evaluation & Review
555 Wright Way 3112 Mail Service Center
Carson City, NV 89711 Raleigh, NC 27697-3112
(702) 486-4368 (919) 861-3809
http://www.dmvnv.com https://www.ncdot.gov/DMV/
https://www.ncdot.gov/dmv/license-id/license-
New Hampshire suspension/medical-review-program/Pages/default.aspx
New Hampshire Department of Safety Division
of Motor Vehicles North Dakota
10 Hazen Drive North Dakota Department of Transportation
Concord, NH 03305 Drivers License Division
603-227-4000 Attn: Chief Examiner
https://www.nh.gov/safety/divisions/dmv/ 608 East Boulevard Avenue
Bismarck, ND 58505-0750
New Jersey 701-328-4353
New Jersey Motor Vehicle Commission http://www.dot.nd.gov/
P.O. Box 173 http://www.dot.nd.gov/divisions/driverslicense/
Trenton, NJ 08666-0173 whatcanido.htm
609-292-7500 x5032
https://www.nj.gov/mvc/ Ohio
https://www.nj.gov/mvc/drivertopics/medreview.htm Ohio Bureau of Motor Vehicles
Driver License Special Case Section/Medical Unit
New Mexico PO Box 16784
Drivers Services Bureau Columbus, OH 43216-6784
Motor Vehicle Division 614-752-7500
P.O. Box 1028 http://www.bmv.ohio.gov
Santa Fe, NM 87504-1028 http://bmv.ohio.gov/dl-restriction-medical.aspx
888-683-4636
http://www.mvd.newmexico.gov/ Oklahoma
Department of Public Safety
New York Driver Compliance Division - Medical Desk
New York Department of Motor Vehicles PO Box 11415
Medical Review Unit Oklahoma City, OK 73136-0415
6 Empire State Plaza, Room 337 405-425-2083
Albany, NY 12228 https://www.ok.gov/dps/
518-474-0774, Option #3
https://dmv.ny.gov/
http://dmv.ny.gov/driver-license/dmvs-medical-review-
program

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Oregon South Dakota

Oregon Department of Motor Vehicles Driver Safety Unit South Dakota Department of Public Safety Driver
1905 Lana Avenue NE Licensing
Salem OR 97314 118 West Capitol Avenue
503-945-5083 Pierre, SD 57501
https://www.oregon.gov/ODOT/DMV 605-773-6883
https://www.oregon.gov/ODOT/DMV/pages/at-risk_ https://dps.sd.gov/driver-licensing
program_index.aspx https://dps.sd.gov/driver-licensing/south-dakota-
licensing-information/aging-drivers
Pennsylvania
Pennsylvania Department of Transportation Bureau of Tennessee
Driver Licensing Tennessee Department of Safety & Homeland Security
Driver Qualifications Section Driver License Division
PO Box 68682 1150 Foster Ave
Harrisburg, PA 17106-8682 Nashville, TN 37249-1000
717-787-9662 615-741-3954
http://www.dmv.pa.gov/ https://www.tn.gov/driver-services.html
http://www.dmv.pa.gov/Driver-Services/Mature-Drivers/
Pages/default.aspx Texas
Texas Department of Public Safety Driver License Division
Rhode Island Enforcement and Compliance Service
Rhode Island Department of Revenue Division of Motor P.O. Box 4087
Vehicles Austin, TX 78773-0320
Adjudication Office 512-424-2600
600 New London Avenue http://www.dps.texas.gov/DriverLicense/
Cranston, RI 02920 http://www.dps.texas.gov/DriverLicense/
401-462-0800 MedicalRevocation.htm
http://www.dmv.ri.gov/
http://www.dmv.ri.gov/adjudication/medical/index.php Utah
Utah Department of Public Safety Driver License Division
South Carolina PO Box 144501
South Carolina Department of Motor Vehicles Salt Lake City, UT 84129
PO Box 1498 801-957-8690
Blythewood, SC 29016 https://dld.utah.gov/
803-896-5000 https://dld.utah.gov/other-resources/medical-standards/
http://scdmvonline.com/
Vermont
Vermont Department of Motor Vehicles
120 State Street
Montpelier, Vermont 05603-0001
802-828-2000
http://dmv.vermont.gov/
http://dmv.vermont.gov/licenses/renew/mature-drivers

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Virginia Wyoming
Virginia Department of Motor Vehicles Medical Review Wyoming Department of Transportation Driver Services
Services Program
PO Box 27412 Driver Services - Driver Review Section
Richmond, VA 23269 5300 Bishop Blvd.
804-497-7100 Cheyenne, WY 82009-3340
https://www.dmv.virginia.gov 307-777-4800
https://www.dmv.virginia.gov/drivers/#medical/index.asp http://www.dot.state.wy.us/driverservices

Washington
ADDITIONAL RESOURCES
Washington State Department of Licensing Driver
Records
AAA/CAA Digest of Motor Laws
PO Box 9030
http://drivinglaws.aaa.com/
Olympia, WA 98507-9030
360-902-3900 Driver Licensing Policies and Practices
https://www.dol.wa.gov/ http://lpp.seniordrivers.org/
https://www.dol.wa.gov/driverslicense/reportunsafe.html
Insurance Institute for Highway Safety
http://www.iihs.org/iihs/topics/t/older-drivers/
West Virginia
topicoverview
West Virginia Department of Transportation Division of
Motor Vehicles Insurance Information Institute
Medical Review Unit https://www.iii.org/
PO Box 17030
Charleston, WV 25317
304-558-3900
https://transportation.wv.gov/dmv/
https://transportation.wv.gov/DMV/Drivers/Pages/
Medical-Review-Unit.aspx

Wisconsin
Wisconsin Department of Transportation
Medical Review & Fitness Unit
PO Box 7918
Madison WI 53707-7918
608-266-2327
http://wisconsindot.gov/Pages/online-srvcs/online.aspx
http://wisconsindot.gov/Pages/dmv/license-drvs/mdcl-
cncrns/med-concerns.aspx

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CHAPTER 9 M
 EDICAL CONDITIONS, FUNCTIONAL DEFICITS, AND
MEDICATIONS THAT MAY AFFECT DRIVING SAFETY

KEY POINTS
n Many medical conditions, progression. n Advise the older adult
functional deficits, and/or n If the functional deficit about the risks to his or her
medications may potentially is due to an identifiable driving safety, consider referral
impair driving. offending agent (e.g., for assessment of driving
n Treat the underlying medical medication with potentially performance, recommend
condition and/or functional driver-impairing [PDI] effects), driving restrictions or driving
deficit to improve the remove the offending agent or cessation as needed, and
condition/impairment or limit reduce the dose, if possible. document the discussion in
the health record.

T
his chapter contains reference tables of risk.* However, increasing evidence suggests that
medical conditions, functional deficits, and interventions for some medical conditions (e.g.,
medications that may impair driving skills, treating obstructive sleep apnea, performing
with associated consensus recommendations. cataract surgery, discontinuing a benzodiazepine)
Whenever scientific evidence supports the and functional deficits (e.g., improving information
recommendations, it is included. These processing speed, physical ability), combined with
recommendations apply only to drivers of private classroom and on-road training may lower crash risk
motor vehicles and should not be applied to or enhance/maintain driving performance. As such,
commercial drivers. Although many of the listed these recommendations are provided as a means
medical conditions are more prevalent in the older to help raise awareness of which drivers might be at
population, the recommendations apply to all increased risk, suggest options for intervention, and
drivers with medical impairments, regardless of guide the decision-making process. When evidence
age. is not available, the recommendations are based
The medical conditions were chosen for their on consensus recommendations and best clinical
relevance to clinical practice and/or because there judgment. They are not intended to substitute for
is some evidence-based literature indicating an the individual clinician’s judgment.
association with driving impairment. Interested
clinicians are referred to reviews that provide details HOW TO USE THIS CHAPTER
regarding individual conditions or deficits, as well as Clinicians may consult this chapter for questions on
guidelines from other countries, including Australia, specific medical conditions, functional deficits (e.g.,
Canada, Ireland, and the United Kingdom.1-8 deficits in vision, cognition, or motor function), and/
Although these recommendations are based on or medications that may have an effect on driving
scientific evidence whenever possible, their use safety. If an older adult presents with any of these
per se has not yet been proved to reduce crash issues, clinicians may base further assessment and

*Note: Although scientific evidence links certain medical conditions and levels of functional impairment with crash risk, more research
is needed to establish that driving restrictions based on these medical conditions and levels of functional impairment significantly
reduce crash risk.

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interventions for driving safety on the guidelines extensive medical evaluation and treatment,
presented here. such individuals should be strongly urged to seek
alternative forms of transportation, including
General Recommendations taxis, rides from family and friends, and medical
n Treat the underlying medical condition and/ transportation services.
or functional deficit to improve the condition/ In the hospital and the emergency department,
impairment or limit progression. driving should be routinely addressed before the
n If the functional deficit is due to an identifiable older adult’s discharge whenever appropriate,
offending agent (e.g., medication with PDI effects), especially in the presence of new functional deficits
remove the offending agent or reduce the dose, if or when prescribing new medications. Even for
possible. the older adult whose symptoms or treatment
clearly precludes driving, it should not be assumed
n If the functional deficit can be addressed through
that the person is aware that he or she should
compensation or modification (e.g., hand controls,
not drive. The clinician should counsel the older
left foot accelerator), refer for a comprehensive
adult regarding driving, discuss a future plan (e.g.,
driving evaluation.
resumption of driving on resolution of symptoms,
n Advise the older adult about the risks to his or driver rehabilitation on stabilization of symptoms,
her driving safety, consider referral for assessment reassessment by the primary clinician or relevant
of driving performance, recommend driving specialist before driving resumption), and document
restrictions or driving cessation as needed, and the discussion in the health record.
document the discussion in the health record.
An older adult’s driving purposes may range from
n For acute or episodic illnesses (e.g., seizure being responsible for taking grandchildren to day
disorder and/or diabetes with hypoglycemia), care to driving for a vocation (e.g., a salesperson
clinical judgment and subspecialist input is who drives throughout a region). Such differences
recommended, in addition to following specific may influence the extent of the interventions or
state statutes. advice in regard to an evaluation. For example,
more restriction or a performance-based road test
If further evaluation is required and desirable, or may be more aggressively pursued for an older
the conditions and/or functional deficits are not adult who frequently drives long distances over
medically correctable, the older adult should be unfamiliar roads versus for one who drives short,
referred to a driver rehabilitation specialist (DRS) for familiar routes.
a driving evaluation (including on-road assessment).
The DRS may prescribe adaptive equipment and REFERENCE TABLES OF MEDICAL
training on how to use it (see Chapter 5). CONDITIONS, FUNCTIONAL DEFICITS,
AND MEDICATIONS THAT MAY AFFECT
Clinicians should advise older adults against driving DRIVING SAFETY
if they report symptoms that are irreversible, for
Various medical conditions and/or functional
which no safe compensatory techniques/equipment
deficits are covered in the following sections (with
are available, and are incompatible with safe driving
corresponding tables). Conditions treated with
(e.g., visual changes, syncope or presyncope,
medications with PDI effects are listed at the end
vertigo, etc.). If these symptoms continue despite

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of the discussion for that condition and cross- noted to reduce crash risk.15 Older adults with
referenced to Section 13 (on medications) for more persistent vision deficits may potentially reduce
information. their effect on driving safety by restricting travel
Section 1: Vision and Hearing Loss to low-risk areas and conditions, such as familiar
surroundings, low-speed areas, non-rush hour
Section 2: Cardiovascular Disorders
traffic, daytime, and good weather conditions. This
Section 3: Cerebrovascular Disorders has been noted for certain eye diseases, such as
Section 4: Neurologic Disorders glaucoma.16 Bioptic driving is allowed in 44 states,
although requirements vary.17 Bioptic driving is
Section 5: Psychiatric Disorders
a method of driving in which a small telescopic
Section 6: Metabolic Disorders system is used to improve a person’s far vision for
Section 7: Musculoskeletal Disorders some visually impaired individuals and might be
Section 8: Peripheral Vascular Disorders considered for some drivers. The recommendations
below are subject to each state’s licensing
Section 9: Renal Disorders
requirements. For resources to locate Internet
Section 10: Respiratory and Sleep Disorders listings for current individual state laws, see
Section 11: Effects of Anesthesia and Surgery Chapter 8.

Section 12: Cancer

Sensory Deprivation
Section 13: Medications
1. Visual acuity
a. Cataracts
SECTION 1: VISION AND HEARING LOSS
b. Retinopathy (diabetic or hypertensive)
Vision is the primary sense used in driving (versus c. Keratoconus
hearing and proprioception) and is responsible d. Macular degeneration
for 95% of driving-related sensory inputs.9 Age- e. Nystagmus
and disease-related changes of the eye and brain f. Telescopic lens
may affect visual acuity, visual fields, night vision,
2. Visual field
contrast sensitivity, and other aspects of vision.
a. Glaucoma
External obstruction of view (e.g., blepharoptosis)
b. Hemianopia/quadrantanopia
should not be overlooked, because it may
c. Monocular vision
significantly limit visual fields. The literature on eye
d. Ptosis or upper lid redundancy
disease suggests that driving impairment is likely
e. Retinitis pigmentosa
mediated by impairment in contrast sensitivity,10
visual fields,11 or visual processing speed. 3. Contrast sensitivity

Whenever possible, vision deficits should be 4. Defective color vision

managed and corrected. Interventions for 5. Poor night vision and glare recovery
common eye diseases such as age-related macular 6. Diplopia
degeneration,12 glaucoma,13 and cataracts14 have
7. Hearing loss
the potential to improve or stabilize the condition,
and in some cases these interventions have been

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Table 9.1 - Sensory Deprivation

Visual acuity Many states require far visual acuity of 20/40 for licensure. State driver licensing agencies
are urged to base their visual acuity requirements on the most current data, as appropriate.
Referral to an ophthalmologist is recommended to optimize refraction and because
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
individual prefers. The older adult should wear any corrective lenses usually worn for
driving.

Older adults with decreased far visual acuity may potentially lessen its effect on driving
safety by restricting driving to low-risk areas and conditions (e.g., familiar surroundings,
non-rush hour traffic, low-speed areas, daytime, and good weather conditions).

For best-corrected far visual acuity less than 20/70, clinicians should recommend an on-road
assessment performed by a DRS (where permitted and available) to evaluate the older
adult’s performance in the actual driving task.

For best-corrected far visual acuity less than 20/100, clinicians should recommend the older
adult not drive unless safe driving ability can be demonstrated in an on-road assessment
performed by a DRS (where permitted and available). See also Telescopic lens, below.

Cataracts No restrictions if standards for visual acuity and visual fields are met, either with or without
cataract removal.
Individuals who require increased illumination or who experience difficulty with glare
recovery should avoid driving at night and under low-light conditions, such as during
adverse weather.

Diabetic or hypertensive No restrictions if standards for visual acuity and visual fields are met.
retinopathy Annual eye examinations are recommended for diabetic individuals.

Keratoconus Individuals with severe keratoconus correctable with hard contact lenses should drive
only when the lenses are in place. If lenses cannot be tolerated, individuals with severe
keratoconus should not drive even if they meet standards for visual acuity, because their
acuity dramatically declines outside their foveal vision, rendering their peripheral vision
useless.

Macular degeneration No restrictions if standards for visual acuity and visual fields are met.
Older adults who experience difficulty with glare recovery should avoid driving at night.
Individuals with the neovascular “wet” form may require frequent assessment because of
the rapid progression of the disease.

Nystagmus No restrictions if standards for visual acuity and visual fields are met.

Telescopic lens A bioptic telescope is an optical telescope mounted on the lens of eyeglasses. During
normal use, the wearer can view the environment through the regular lens.

When extra magnification is needed, a slight downward tilt of the head brings the object of
interest into the view of the telescope.18

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Telescopic lens (cont.) The specialist who prescribes a telescopic lens should ensure that the older adult is
properly trained in its use.

It has not been established whether telescopes enhance the safety of low-vision drivers.
The American Academy of Ophthalmology’s Policy Statement, Vision Requirements for
Driving (approved by Board of Trustees, October 2001) states:

“More than half the states allow drivers to use bioptic telescopes mounted on glasses,
through which they spot traffic 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.”

A road test should be administered only in those states that permit the use of bioptic
telescopes in driving.

Visual field Although an adequate visual field is acknowledged to be important for safe driving, there is
no conclusive evidence to define what is meant by “adequate” nor is there any consistent
standard as to how visual fields are tested. Visual field requirements vary between states,
with many states requiring a visual field of 100 degrees or more in the horizontal plane, and
other states having a lesser requirement or none at all.18

If the primary care clinician has any reason to suspect a visual field defect (e.g., through
personal report, medical history, or confrontation testing), he or she should refer the
older adult to an ophthalmologist or optometrist for further evaluation. Both the primary
care clinician and specialist should be aware of and adhere to their state’s visual field
requirements, if any.

For binocular visual field at or near the state minimum requirement or of questionable
adequacy (as deemed by clinical judgment), a comprehensive driving evaluation (including
on-road assessment) performed by a DRS is strongly recommended. Through driving
rehabilitation, older adults may learn how to compensate for decreased visual fields,
although not hemineglect.

In addition, the DRS may prescribe enlarged side and rearview mirrors as needed and train
the older adult in their use.

Glaucoma No restrictions if standards for visual acuity and visual fields are met. Continued follow-
up with an ophthalmologist and monitoring of visual fields and intraocular pressure are
recommended.

Hemianopia/ Clinicians may choose to refer older adults to a DRS for assessment and rehabilitation.
quadrantanopia With or without rehabilitation, older adults should drive only if they demonstrate safe
driving ability in an on-road assessment performed by a DRS.

Monocular vision Older adults with acquired monocularity may need time to adjust to the lack of depth
perception and reduction in total visual field. This period of adjustment varies among
individuals, but it is reasonable to recommend temporary driving cessation for several
weeks.

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Monocular vision (cont.) After this period, there are no restrictions if standards for visual acuity and visual fields are
met. After individuals start driving again, they should be advised to assess their comfort
level by driving in familiar, traffic-free areas before advancing to areas of heavy traffic.
Again, use of larger mirrors and evaluation and training by a DRS are encouraged.

Ptosis or lid redundancy, Individuals with fixed ptosis or lid redundancy may drive without restrictions if their eyelids
blepharospasm do not obscure the visual axis of either eye and they are able to meet standards for visual
acuity and visual fields without holding their head in an extreme position. Blepharospasms
should be controlled so there is no interference with vision.

Retinitis pigmentosa No restrictions if standards for visual acuity and visual fields are met.
Older adults who require increased illumination or who experience difficulty adapting to
changes in light should not drive at night or under low-light conditions, such as during
storms.

Contrast sensitivity 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,
deficits in contrast sensitivity are much greater in older adults than in their younger
counterparts.2
Among older drivers, binocular measures of contrast sensitivity have been found to be a
valid predictor of crash risk in individuals with cataracts.19 However, there are presently no
standardized cut-off points for contrast sensitivity and safe driving, and it is not routinely
measured in eye examinations.
Older adults can be educated about driving conditions to avoid if they have poor contrast
sensitivity (e.g., dawn, dusk, fog).

Defective color vision No restrictions if standards for visual acuity and visual fields are met.
Deficits in color vision are common (especially in men) and usually mild.
There appears to be no correlation between defective color vision and crash rates.20Some
states require prospective drivers to undergo color vision screening, and many of these
states require screening for commercial drivers only.18
Despite reported difficulties with color vision discrimination while driving (difficulty
distinguishing color of traffic signals, confusing traffic lights with street lights, and difficulty
detecting brake lights), it is unlikely that color vision impairments represent a significant
driving hazard.2 Standardization of traffic signal positions allows color blind individuals to
interpret traffic signals correctly based on position. Clinicians may wish to advise older
adults that the order of signals in the less commonly used horizontal placement of left to
right is red, yellow, green.

Poor night vision If the older adult reports poor visibility at night, clinicians should recommend
ophthalmologic and/or optometric evaluation. If the evaluation does not reveal a treatable
cause for poor night vision, clinicians should recommend that the older adult not drive at
night or under other low-light conditions, such as during storms or at dusk.

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Diplopia Individuals with double vision in the central aspect of vision (20 degrees above and below,
left and right of fixation) should not drive. Those with uncorrected diplopia 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 standards for driving. There
should be a 3-month adjustment period, after which specialists can determine if adequate
adjustment has occurred.6

Hearing loss No restrictions.

Relatively few studies have examined the relationship between hearing impairment and
risk of motor vehicle crash. Of these, none have shown a significant relationship between
hearing impairment and risk of crash.2 However, one study suggested that a combination of
hearing and vision deficits might increase crash risk.21

SECTION 2: CARDIOVASCULAR 4. Time-limited restrictions: cardiac procedures

DISORDERS
a. Percutaneous transluminal coronary
1. Unstable coronary syndrome (unstable angina or angioplasty
myocardial infarction)
b. Pacemaker insertion or revision
2. Cardiac rhythm abnormalities that may cause a
c. Cardiac surgery involving median sternotomy
sudden, unpredictable loss of consciousness
d. Coronary artery bypass graft
a. Atrial flutter/fibrillation with bradycardia or
rapid ventricular response e. Valve repair or replacement

b. Paroxysmal supraventricular tachycardia, f. Heart transplant

including Wolf-Parkinson-White syndrome 5. Internal cardioverter defibrillator (ICD)
c. Prolonged, nonsustained ventricular Although the data are still unclear in regard to
tachycardia a definitive relationship between crash risk and
d. Sustained ventricular tachycardia cardiovascular diseases, one study noted a modest
increase in total crash risk and at-fault risk for older
e. Cardiac arrest
adults with cardiac disease.22 For older adults with
f. High-grade atrioventricular block known cardiac disease, clinicians should strongly
g. Sick sinus syndrome/sinus bradycardia/sinus and repeatedly caution such individuals to seek help
exit block/sinus arrest immediately on experiencing any symptoms that
may indicate an unstable cardiac situation, including
3. Cardiac disease resulting from structural or
prolonged chest discomfort, acute shortness
functional abnormalities
of breath, syncope, presyncope, palpitations,
a. Congestive heart failure with low output lightheadedness, etc. Under no circumstances
syndrome should the older adult drive while experiencing
b. Hypertrophic obstructive cardiomyopathy these symptoms, even to seek help.
c. Valvular disease (especially aortic stenosis)

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Table 9.2 - Cardiovascular Disorders

Unstable coronary syndrome (unstable Older adults should not drive if they experience symptoms at rest or at the
angina or myocardial infarction) wheel.
Individuals may resume driving when they have been stable and
asymptomatic for 1–4 weeks, as determined by a cardiologist, after
treatment of the underlying coronary disease. Driving may usually
resume within 1 week after successful revascularization by percutaneous
transluminal coronary angioplasty and by 4 weeks after coronary artery
bypass grafting (CABG).23
See also recommendations for CABG below (4.c in this section).

Cardiac conditions that may cause A main consideration in determining medical fitness to drive for older
a sudden, unpredictable loss of adults with cardiac conditions is the risk of presyncope or syncope due
consciousness to a slow or rapid rhythm abnormality.24 For older adults with a known
arrhythmia, clinicians should identify and treat the underlying cause of
arrhythmia, if possible, and recommend temporary driving cessation until
symptoms have been controlled.

Atrial flutter/fibrillation with bradycardia No further restrictions once heart rate and symptoms have been
or rapid ventricular response controlled.

Paroxysmal supraventricular tachycardia, No restrictions if the older adult is asymptomatic during documented
including Wolf-Parkinson-White syndrome episodes.
Older adults with a history of symptomatic tachycardia may resume driving
after they have been asymptomatic for 6 months on antiarrhythmic therapy.
Individuals who undergo radiofrequency ablation may resume driving
after 6 months if there is no recurrence of symptoms, or sooner if no
preexcitation or arrhythmias are induced on repeat electrophysiologic
testing.

Prolonged, nonsustained ventricular No restrictions if the older adult is asymptomatic during documented
tachycardia (VT) episodes.
Individuals with symptomatic VT may resume driving after 3 months if
they are on antiarrhythmic therapy (with or without an ICD) guided by
invasive electrophysiologic testing, and VT is noninducible at repeat
electrophysiologic testing. They may resume driving after 6 months without
arrhythmia events if they are on empiric antiarrhythmic therapy (with or
without an ICD), or have an ICD alone without additional antiarrhythmic
therapy.25

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Sustained ventricular tachycardia (VT) Older adults may resume driving after 3 months if they are on antiarrhythmic
therapy (with or without an ICD) guided by invasive electrophysiologic
testing, and VT is noninducible at repeat electrophysiologic testing.
Individuals may resume driving after 6 months without arrhythmia events if
they are on empiric antiarrhythmic therapy (with or without an ICD), or have
an ICD alone without additional antiarrhythmic therapy.25
Long-distance and/or sustained high-speed driving is not recommended.
Older adults with VT should avoid the use of cruise control.25

Post-cardiac arrest See the recommendations for sustained VT (above).

For individuals who experience a seizure in the setting of cardiac arrest,
see the recommendations for seizure disorder in Section 4, Neurologic
Diseases.
If clinically significant cognitive changes persist after the older adult’s
physical recovery, cognitive testing is recommended before the older adult
is permitted to resume driving. In addition, on-road testing performed by a
DRS may be useful in assessing an older adult’s fitness to drive.

High-grade atrioventricular block For symptomatic block managed with pacemaker implantation, see
pacemaker recommendations in this section.
For symptomatic block corrected without a pacemaker (e.g., by withdrawal
of medications that caused the block), older adults may resume driving
after they have been asymptomatic for 4 weeks and ECG documentation
shows resolution of the block.

Sick sinus syndrome/sinus bradycardia/ No restrictions if the older adult is asymptomatic. Regular medical follow-
sinus exit block/sinus arrest up is recommended to monitor progression.
For symptomatic disease managed with pacemaker implantation, see
pacemaker recommendations in this section.
Clinicians should be alert to possible cognitive deficits due to chronic
cerebral ischemia. Clinicians may refer individuals with clinically significant
cognitive changes to a DRS for an evaluation of driver safety, including on-
road assessment.

Cardiac disease resulting from A main consideration in determining medical fitness to drive for older
structural or functional abnormalities adults with abnormalities of cardiac structure or function is the risk of
presyncope or syncope due to low cardiac output, and of cognitive deficits
due to chronic cerebral ischemia.
Older adults who experience presyncope, syncope, extreme fatigue, or
dyspnea at rest or at the wheel should cease driving.
Cognitive testing is recommended for those individuals with a history
of cognitive impairment that may impair the older adult’s driving ability.
Clinicians may refer individuals with clinically apparent cognitive changes to
a DRS for a comprehensive driving evaluation.1

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Congestive heart failure with low Older adults should not drive if they experience symptoms at rest or while
output syndrome operating a motor vehicle.
Clinicians should reassess older adults for driving fitness every 6 months
to 2 years as needed, depending on clinical course and control of
symptoms. Individuals with functional class III congestive heart failure
(marked limitation of activity but no symptoms at rest, working capacity 2
to 4 metabolic equivalents (METS) should be reassessed at least every 6
months.

Hypertrophic obstructive OIder adults who experience syncope or presyncope should not drive
cardiomyopathy until they have been successfully treated.

Valvular disease (especially Older adults who experience syncope or presyncope or unstable angina
aortic stenosis) should not drive until the underlying disease is corrected.

Time-limited restrictions: cardiac Driving restrictions for the following cardiac procedures are based on
procedures the older adult’s recovery from both the procedure itself and the underlying
disease for which the procedure was performed.

Percutaneous transluminal coronary Older adults may resume driving 48 hours to 1 week after successful PTCA
angioplasty (PTCA) and/or stenting procedures, depending on their baseline condition and
course of recovery from the procedure and underlying coronary disease.25,26

Pacemaker insertion or revision Older adults may resume driving 1 week after pacemaker implantation if no
longer experiencing presyncope or syncope:
a. ECG shows normal sensing and capture, and
b. Pacemaker performs within manufacturer’s specifications.26

Cardiac surgery involving median Driving may usually resume 4 weeks after coronary artery bypass grafting
sternotomy (CABG) and/or valve replacement surgery, and within 8 weeks after
heart transplant, depending on resolution of cardiac symptoms and the
individual’s course of recovery. In the absence of complications during or
after surgery, the main limitation to driving is the risk of sternal disruption
after median sternotomy.
If cognitive changes persist after the older adult’s physical recovery,
cognitive testing is recommended before the individual is permitted to
resume driving. In addition, on-road testing performed by a DRS may be
useful in assessing the older adult’s fitness to drive.

Internal cardioverter See the recommendations for non-sustained and sustained ventricular
defibrillator (ICD) tachycardia (2.c and 2.d in this section). If the device is used for primary,
rather than secondary, prevention, driving may resume in 1 week if the
older adult is subsequently symptomatic.27

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SECTION 3: CEREBROVASCULAR this evaluation depends on the severity and extent

DISORDERS of the deficits, many evaluations for cognitive
and motor defects are performed between 3 and
1. Post intracranial surgery
6 months. Once symptoms have stabilized, the
2. Stroke DRS should assess the older adult for fitness-to-
3. Transient ischemic attacks drive through a comprehensive driving evaluation
4. Subarachnoid hemorrhage that includes clinical and on-road components.
After assessment, the DRS may recommend
5. Vascular malformation
compensatory techniques and/or adaptive devices
6. Syncope (e.g., wide rearview mirror, spinner knob for steering
Strokes and other insults to the cerebrovascular wheel, left foot accelerator) and provide training
system may cause a wide variety of symptoms, in their use. Even individuals with mild deficits
including sensory deficits (e.g., numbness or loss should undergo driver evaluation before resuming
of sensation), motor deficits (e.g., weakness), and driving, if possible. Research indicates that a
cognitive impairment (e.g., memory, hemispatial post-stroke determination of driving safety made
inattention). These symptoms range from mild to on a medical basis alone may be inadequate.31
severe and may resolve almost immediately or Several studies note associations with impairment
persist for years. Because each person is affected on road tests with measures of perception, visual
uniquely, the clinician must take into account the selective attention, mental speed, working memory,
individual older adult’s constellation of symptoms, executive function, and complex visual-perception/
severity of symptoms, course of recovery, and attention information.32-34
baseline function when making recommendations For older adults whose symptoms clearly preclude
concerning driving. Studies have indicated that a driving, it should not be assumed that the individual
substantial number of community-dwelling stroke is aware that he or she should not drive. In such
patients continue to drive a car.28 However, most cases, the clinician should counsel the older adult
stroke patients may not receive any type of formal on driving cessation and document the discussion
driving evaluation but simply resume driving.29 in the health record. Recovery from stroke may take
If present, the larger a homonymous visual field up to a year and even though the older adult may
defect, the greater the likelihood of losing one’s not be able to drive within the first 3–6 months, it is
license. Unfortunately, many individuals may not be possible that he or she may improve after a year to
aware of this deficit.30 have the potential to drive.35-37
Driving should always be discussed before the older
adult’s discharge from the hospital or rehabilitation
center and the discussion documented in the health
record.
Older adults with residual neurologic deficits who
wish to resume driving should be referred to a DRS
whenever possible. Although the time frame for

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Table 9.3 - Cerebrovascular Disorders

Post intracranial Older adults should not drive until symptoms of the disease and/or surgery have stabilized or
surgery resolved. See also stroke recommendations below (Section 3.2).

Stroke Older adults with acute, severe motor, sensory, or cognitive deficits should not drive. Depending
on the severity of residual symptoms and the degree of recovery, this restriction may be
permanent or temporary.
On the individual’s discharge from the hospital or rehabilitation center, clinicians may recommend
temporary driving cessation until further neurologic recovery has occurred. Once neurologic
symptoms have stabilized, clinicians should refer appropriate individuals with residual sensory
loss, cognitive impairment, visual field defects, and/or motor deficits to a DRS for driver
assessment and rehabilitation. The DRS may prescribe vehicle adaptive devices and train the
older adult in their use.
Older adults with neglect or inattention should be counseled not to drive until symptoms have
resolved and/or safe driving ability has been demonstrated through assessment by a DRS. All
individuals 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, older adults should still undergo a comprehensive driving evaluation, if
available, because reaction time may continue to be affected and other comorbid conditions
could further increase risk.
Individuals with aphasia who demonstrate safe driving ability may fail in their efforts to renew their
license because of difficulties with the written examination. In these cases, the clinician should
urge the licensing authority to make reasonable accommodations for the older adult’s language
deficit. A DRS may be able to determine whether the deficit is expressive in nature and thus may
allow for interpretation of written (e.g., traffic signs) stimuli. However, traffic signs may still be
interpreted based on color, shape, and symbol recognition.
Older adults with residual cognitive deficits should be assessed and treated as described in
Section 4 on Dementia. Periodic reevaluation of these individuals is recommended, because
some may recover sufficiently over time or with appropriate intervention to permit safe driving.

Transient ischemic Older adults who have experienced a single TIA or recurrent TIAs should not drive until they have
attacks (TIA) undergone medical assessment and appropriate treatment.

Subarachnoid Older adults should not drive until symptoms have stabilized or resolved. Driving may resume
hemorrhage after medical assessment and, if deemed necessary by the clinician, driver evaluation, including
on-road assessment, performed by a DRS.

Vascular If a brain aneurysm or arteriovenous malformation is detected, the older adult should not drive
malformation until he or she has been assessed by a neurosurgeon. The individual may resume driving if the
risk of a bleed is small, an embolization procedure has been successfully completed, and/or
the individual is free of other medical contraindications to driving (e.g., uncontrolled seizures or
significant perceptual or cognitive impairments).

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Syncope 
Although the cause of syncope is often not identified, neurocardiogenic (or reflex mediated),
orthostatic, and cardiac arrhythmia are among the most common causes when one can be
found.38,39 In a case-control study of patients evaluated for syncope, neurally mediated and
cardiac arrhythmia were the most common causes when one could be identified. Long-term
survival and likelihood of recurrence were similar for those who had syncope while driving versus
those who did not.40
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 anticipated likelihood of recurrence. No driving restrictions are
necessary for individuals with infrequent syncope that occurs with warning and with clear
precipitating causes. Older adults 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).41 For individuals who continue to experience unpredictable symptoms
after treatment with medications and pacemaker insertion, driving cessation is recommended.

SECTION 4: NEUROLOGIC DISORDERS Dementia deserves special emphasis, because it

1. Brain tumor presents a significant challenge to driving safety. As
the disease progresses, individuals will ultimately
2. Closed head injury
lose the ability to drive safely. In addition, older
3. Dementia adults with dementia often lack insight into their
4. Migraine and other recurrent headache deficits and, therefore, may be more likely than
syndromes drivers with visual or motor deficits (who tend to
self-restrict their driving to accommodate their
5. Movement disorders
declining abilities) to drive even when it is unsafe.
6. Multiple sclerosis In this case, it becomes the responsibility of family
7. Paraplegia and quadriplegia members and other caregivers to protect the safety
8. Parkinson disease of older adult drivers with dementia by enforcing
driving cessation when this becomes necessary.
9. Peripheral neuropathy
Several reviews on this topic may be of interest
10. Seizure disorder
to clinicians.42-45 Fitness-to-drive studies in older
a. Single unprovoked seizure
adults with dementia indicate that 90% may be
b. Withdrawal or change of anticonvulsant drug
able to pass a road test in the very mild stages
therapy
of the disease (clinical dementia rating of 0.5),
11. Sleep disorders whereas 40% may fail at a mild level of cognitive
a. Narcolepsy impairment (clinical dementia rating of 1.0).46
b. Sleep apnea Furthermore, most older adults with Alzheimer
12. Stroke disease will eventually fail subsequent road tests
when followed longitudinally, indicating that
13. Tourette syndrome
repeat testing at 6–12 months should be strongly
14. Vertigo considered.47However, there is uncertainty about

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prospective risk, at least in the near term. In one the amount of time required to effectively
longitudinal study, some mildly demented drivers diagnose dementia and educate older adults and
not only passed a performance-based road test but caregivers.54 However, some individuals are able to
also had an acceptable crash risk prospectively.48 achieve cognitive stability, at least for a time, with
A recent systematic review found a small body of cholinesterase inhibitors or N-methyl-D-aspartate
literature with inconsistent results for crash risk in (NMDA) receptor antagonists. In addition, older
dementia but more consistent demonstration of adults are now being diagnosed on the “cusp” of
worse driving performance with increasing cognitive the disease in the very early stages. A diagnosis
impairment.49 Although in-office evaluation may not of dementia by itself should not preclude driving
replace an on-road assessment,50 classification rates but should prompt a discussion about meeting
may improve as evidence mounts for measures of transportation needs and eventual driving cessation.
relevant cognitive and other abilities.51-52 In addition, Clinician reluctance to screen for dementia is
a dementia and driving curriculum modeled after unfortunate, because early diagnosis is the first step
an earlier version of this guide has been shown to in promoting the driving safety of these individuals
improve knowledge, attitudes, confidence, and and allowing them to maintain out-of-home mobility
behaviors for health professionals who deal with regardless of driving status. The second step is
older adults with dementia.53 intervention, which includes medications to slow or
Although it is optimal to initiate discussions of stabilize the course of the disease, counseling to
driving safety with older adults and caregivers prepare the older adult and caregivers for eventual
before driving becomes unsafe, dementia may driving cessation, and serial assessment of the
be undetected and undiagnosed until late in the individual’s driving abilities. When assessment
course of the disease. Initially, caregivers and shows that driving may pose a substantial safety risk
clinicians may assume that the older adult’s decline to the older adult, driving cessation is a necessary
in cognitive function is a part of the “normal” aging third step, along with consideration of other
process. Clinicians may also hesitate to screen for transportation options that allow the individual to
and diagnose dementia, because they feel that it is maintain out-of-home mobility. With early planning,
futile and that nothing can be done to improve the older adults and their caregivers can make a more
older adult’s situation or slow disease progression. seamless transition from driving to non-driving
In addition, clinicians may be concerned about status.

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Table 9.4 - Neurologic Disorders

Brain tumor Driving recommendations should be based on the type of tumor, its location and rate of
growth, type of treatment, presence of seizures, and presence of cognitive or perceptual
impairments. Because of the progressive nature of some tumors, serial evaluations of the
individual’s fitness to drive may be needed.
See also the stroke recommendations in Section 3.2.
If the older adult experiences seizure(s), see the seizure disorder recommendations below
(4.10 in this section).

Closed head injury Older adults should not drive until symptoms or signs have stabilized or resolved.
For individuals whose symptoms or signs resolve, driving may resume after medical
assessment and, if deemed necessary by the clinician, a comprehensive driving evaluation
(clinical and on road) performed by a DRS.
Older adults with residual neurologic or cognitive deficits should be managed as described in
Section 3.
If the individual experiences seizure(s), see the seizure disorder recommendations below.

Dementia The following recommendations are adapted from the Canadian Consensus Conference
on Dementia and the Alzheimer’s Association Policy Statement on Driving and Dementia
(approved September 2011):
• A diagnosis of dementia is not, on its own, a sufficient reason to withdraw driving privileges.
A significant number of drivers with dementia are found to be competent to drive in the early
stages of their illness.55 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.
• Clinicians 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 older
adults and their caregivers as early in the process as possible. When appropriate, older adults
should be included in decisions about current or future driving restrictions and cessation; for
older adults whose decision-making capacity is impaired, clinicians and caregivers must decide
in the best interests of the patient.
• Clinicians are recommended to perform a focused medical assessment that includes a
history of any new impaired driving behaviors (e.g., new motor vehicle crashes, moving
violations) from a family member or caregiver and an evaluation of cognitive abilities,
including attention, executive function, information processing speed, judgment, memory, and
visuospatial abilities. Clinicians should be aware that older adults 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 resources for state reporting laws.)
• If concern exists that an older adult 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 a comprehensive driving evaluation (clinical and on

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road) performed by a DRS.

Clinicians should encourage older adults with progressive dementia and their caregivers
to begin planning early in the clinical course for eventual cessation of driving privileges by
exploring alternative transportation options and developing a plan for how to maintain out-of-
home mobility and activity participation.

Migraine and Individuals with recurrent severe headaches should be cautioned against driving when
other recurrent experiencing neurologic manifestations (e.g., visual disturbances or dizziness), when distracted
headache syndromes by pain, and while on any PDI medication. Individuals without a typical aura preceding the
acute attack may be at higher risk.
PDI medications: barbiturates, narcotics, narcotic-like analgesics (see Section 13)

Movement disorders If the clinician elicits complaints of interference with driving tasks or is concerned that
(eg, parkinsonism, the older adult’s symptoms compromise his or her driving safety, referral to a DRS for a
dyskinesias) comprehensive driving evaluation (clinical and on road) is recommended.

Multiple sclerosis Driving recommendations should be based on the type of symptoms and level of symptom
involvement. Clinicians should be alert to deficits that may be subtle (e.g., muscle weakness,
sensory loss, fatigue, cognitive or perceptual deficits, symptoms of optic neuritis) but have a
strong potential to impair driving performance.
A comprehensive driving evaluation (clinical and on road) performed by a DRS may be useful
in determining the ability to drive safely. Additionally, the DRS can recommend modification
to the vehicle (e.g., hand controls, low-effort steering) that can extend the time for continued
driving despite motor symptoms. Serial evaluations may be required as the individual’s
symptoms evolve or progress.

Paraplegia and Referral to a DRS is necessary if the individual wishes to resume driving and/or requires a
quadriplegia vehicle modified to accommodate him or her as a passenger. The DRS can recommend
an appropriate vehicle and prescribe vehicle adaptive devices (e.g., low-resistance power
steering and hand controls) and train the individual in their use. In addition, the DRS can assist
the individual with ability to access the vehicle, including opening and closing car doors,
transfer to the car seat, and independent wheelchair stowage, through vehicle adaptations
and training. With spinal cord injury, referral should be fairly early in the process so caregivers
can have the time needed to secure an appropriate vehicle, because not all vehicles are
adaptable for this level of impairment.56
Driving should be restricted until the individual demonstrates safe driving ability in the
adapted vehicle.

Parkinson disease Older adults with Parkinson disease may be at increased risk of driving difficulties
because of motor, visual, and cognitive dysfunction.57 Clinicians should base their driving
recommendations on the level of motor, visual, and cognitive symptom involvement; the
individual’s response to treatment; and presence and extent of any medication adverse effects.
(See Section 13 for specific recommendations on antiparkinsonian medications.) Serial physical
and cognitive evaluations are recommended every 6–12 months because of the progressive
nature of the disease.

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If the clinician is concerned that dementia, vision, and/or motor impairments may affect the
older adult’s driving skills, a comprehensive driving evaluation (clinical and on road) performed
by a DRS may be useful in determining the individual’s fitness to drive.
The following recommendations were affirmed at the AOTA/NHTSA Expert Summit (March
2012) specific to Parkinson disease:58
 1. Drivers with Parkinson disease who have mild motor disability as measured by low
scores on the Unified Parkinson Disease Rating Scale (UPDRS) Part 3, and no or few risk
factors (antiparkinsonian drugs, >75 years old) may be fit to drive. Individuals who fit this
profile and those who are newly diagnosed with Parkinson disease are recommended to:
• Plan a baseline comprehensive driving evaluation by a medically trained DRS
• Because of the progressive nature of the disease, the individual should also:
- Consider annual comprehensive driving evaluations.
- Start planning for eventual driving cessation.
- Seek consultation to develop a plan for use of alternative transportation options.
- Start conversations with the family about retirement from driving.
 2. For those with severe motor impairment and high disease severity (high UPDRS
Part 3 scores) and multiple risk factors (e.g., decreased information processing speed,
the highest risk score on the Useful Field of View, scoring 180 seconds or more on the
Trails B, impaired contrast sensitivity, and scoring >7 seconds on the Rapid Pace Walk),
recommendations include:
• Cessation of driving
• Reporting to the licensing agency as required/allowed by the jurisdiction
 • Addressing transportation options for the individual and caregiver through
consultation or support services
 3. Research is in progress to provide better guidelines for the middle group (i.e., those
individuals with mild to moderate motor disability and few to several risk factors).
Recommendations for this group include:
• Strongly recommending a comprehensive driving evaluation by a medically
trained DRS to provide opportunities for rehabilitation (e.g., behind-the-wheel
training, compensatory strategies, adaptive devices, driving restrictions, and/or self-
regulation)
 • Providing strategies to address transitioning to non-driving (e.g., start conversations
about driving retirement, caregiver involvement in driving retirement, consultation,
and/or referral for counseling)
 • Developing a mobility plan for driving cessation

Peripheral Lower extremity deficits in sensation and proprioception may be exceedingly dangerous
neuropathy for driving, because the driver may be unable to control the foot pedals. If deficits in sensation
and proprioception are identified, referral to a DRS is recommended. The DRS may prescribe
vehicle adaptive devices (e.g., hand controls in place of the foot pedals) and train the
individual in their use.

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Seizure disorder The recommendations below (in this section only) are adapted from the Consensus Statements
on Driver Licensing in Epilepsy, developed and agreed on in March 1992 by the American
Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America.59
These recommendations are subject to each state’s licensing requirements and reporting laws.
A patient with seizure disorder should not drive until he or she has been seizure-free for 3
months. This recommendation appears consistent with available data.60
This 3-month interval may be lengthened or shortened based on the following favorable and
unfavorable modifiers.
Favorable modifiers:
• 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
Unfavorable modifiers:
• Noncompliance with medication or medical visits and/or lack of credibility
• Alcohol and/or drug abuse in the past 3 months
• Increased number of seizures in the past year
• Impaired driving record
• Structural brain lesion
• Non-correctable brain functional or metabolic condition
• Frequent seizures after seizure-free interval
• Prior crashes due to seizures in the past 5 years
• Single unprovoked seizure
• Vagal nerve stimulator implant for seizure control with extended adjustment period
• Three or more antiepileptic drugs necessary to achieve seizure control

Single unprovoked The patient should not drive until he or she has been seizure-free for 3 months.
seizure This time period may be shortened with clinician approval. Predictors of recurrent
seizures that may preclude shortening of this time period include:
• The seizure was focal in origin.
• Focal or neurologic deficits 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.

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Withdrawal or change The patient should temporarily cease driving during the time of medication withdrawal
of anticonvulsant or change because of the risk of recurrent seizure and PDI effects of the
drug therapy medication.
 If the risk of recurrent seizure during medication withdrawal or change is significant, the patient
should cease driving during this time and for at least 3 months thereafter.
If the patient experiences a seizure after medication withdrawal or change, he or she should not
drive for 1 month after resuming a previously effective medication regimen. Alternatively, the
patient should not drive for 6 months if he or she refuses to resume this medication regimen but
is seizure-free during this period.

Sleep disorders

Narcolepsy The older adult should cease driving once diagnosed but may resume driving after treatment
when he or she no longer suffers excessive daytime drowsiness or cataplexy. Clinicians may
consider using scoring tools such as the Epworth Sleepiness Scale to assess the individual’s level
of daytime drowsiness.61

Sleep apnea See Section 10.

Stroke See Section 3.

Tourette syndrome In evaluating the older adult’s fitness to drive, clinicians should consider any comorbid disorders
(including attention deficit hyperactivity disorder, learning disabilities, and anxiety disorder) in
addition to the individual’s motor tics. (For specific recommendations on these disorders, see
Section 5, Psychiatric Disorders).
If the clinician is concerned that the older adult’s symptoms compromise his or her driving
safety, referral to a DRS for a comprehensive driving evaluation (clinical and on road) is
recommended.

PDI medications: antipsychotics (see Section 13 for more information on medication adverse
effects)

Vertigo Older adults with acute vertigo should not drive until symptoms have fully resolved. Under no
circumstances should the individual drive to seek medical attention.
Older adults with a chronic vertiginous disorder are strongly recommended to undergo on-road
assessment performed by a DRS before resuming driving.

PDI medications: antivertigo agents (anticholinergic)

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SECTION 5: PSYCHIATRIC DISORDERS Older adults in the acute phase of a psychiatric

1. Affective disorders illness need to be aware that driving skills could
be affected. In general, driving is safe when the
a. Depression
condition is stable, although adverse effects from
b. Bipolar disorder medications and compliance with the medication
2. Anxiety disorders regimen may need to be taken into consideration.
(For recommendations on medications and driving,
3. Psychotic illness
see Section 13, Medications.)
a. Acute episodes
Psychiatrists may wish to consult the American
b. Chronic illness Psychiatric Association’s Position Statement on the
4. Personality disorders Role of Psychiatrists in Assessing Driving Ability.62
5. Substance abuse
6. Attention deficit disorder/attention deficit
hyperactivity disorder
7. Tourette syndrome

Table 9.5 - Psychiatric Disorders

Affective disorders Clinicians should advise older adults not to drive during the acute phase of illness.

PDI medications: antidepressants (see Section 13 for information on differences among
antidepressants)

Depression No restrictions if condition is mild and stable. Clinicians should always specifically ask about
suicidal ideation and cognitive and motor symptoms.
Older adults should not drive if they are actively suicidal or experiencing significant
mental or physical slowness, agitation, psychosis, impaired attention, and/or impaired
concentration. Individuals should be counseled not to drive themselves to seek medical
attention.

Bipolar disorder No restrictions if condition is stable.

Older adults should not drive if they are actively suicidal, depressed as in 1.a (above) or in
an acute phase of mania. Individuals should be counseled not to drive themselves to seek
medical attention.

Anxiety disorders Older adults should not drive during episodes of severe anxiety. Otherwise, there are no
restrictions if the condition is stable.
PDI medications: benzodiazepines (see Section 13)

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Psychotic illness Clinicians should advise older adults not to drive during the acute phase(s) of illness.
PDI medications: antipsychotics, benzodiazepines
Acute episodes: Older adults should not drive during acute episodes of psychosis. Individuals
with acute psychosis should be counseled not to drive themselves to seek medical attention.
Chronic illness: No restrictions if the condition is stable.

Personality disorders No restrictions unless the older adult has a history of driving violations and his or her
psychiatric review is unfavorable. This includes, but is not limited to, uncontrolled, erratic,
violent, aggressive, or irresponsible behavior.
Because of the high comorbidity of substance abuse with personality disorders, clinicians are
urged to be alert to substance abuse in these individuals and counsel them accordingly (see
recommendations for substance abuse below).

Substance abuse Driving while intoxicated is illegal and highly dangerous to the driver, passengers, and
other road users. Impaired driving is the most common crime in the United States, and it is
responsible for thousands of traffic deaths each year.
Alcohol is not the only cause of impaired driving. Substances including, but not limited
to, marijuana, cocaine, amphetamines (including amphetamine analogues), opiates, and
benzodiazepines may also impair driving skills. Clinicians should query about prescription and/
or nonprescription medication abuse as potential additional agents.
Clinicians should follow up all positive screens with appropriate interventions, including
brief interventions or referral to support groups, counseling, and substance abuse treatment
centers. Clinicians should strongly urge substance abusers to temporarily cease driving while
they seek treatment, and to refrain from driving while under the influence of intoxicating
substances. A non-judgmental and supportive attitude and frequent follow-up may aid
substance abusers in their efforts to achieve and maintain sobriety.
Clinicians should also familiarize themselves with any state laws or regulations regarding
detaining intoxicated individuals who have driven to the hospital or clinic until they are legally
unimpaired.

Attention deficit A review noted increased risk of driving behaviors and a positive effect of stimulant
disorder/attention medications on driving performance.63 Clinicians should educate older adults about
deficit hyperactivity the increased risk associated with the disease and the potential benefits of treatment.
disorder

Tourette syndrome See Section 4.

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SECTION 6: METABOLIC DISORDERS thyroid disorders) may experience signs and

1. Diabetes mellitus symptoms incompatible with safe driving. Clinicians
should advise these individuals to refrain from
a. Insulin dependent diabetes mellitus (IDDM)
driving (including driving to seek medical attention)
b. Non-insulin dependent diabetes mellitus until the symptoms have abated.
(NIDDM)
Data suggest that older adults with diabetes may
2. Hypothyroidism be at increased risk of impaired driving, but the
3. Hyperthyroidism literature is not consistent in this area. Concern has
been raised that the trend in the medical profession
Older adults in the acute phase of a metabolic has been toward tighter control of blood glucose
disorder (e.g., diabetes, Cushing disease, Addison levels, which could result in hypoglycemia and
disease, hyperfunction of the adrenal medulla, possibly increased crash risk.

Table 9.6 - Metabolic Disorders

Diabetes mellitus

Insulin dependent No restrictions if the older adult demonstrates satisfactory control of his or her diabetes,
diabetes mellitus recognizes the warning symptoms of hypoglycemia, and meets required visual standards.
(IDDM)
The major concern is lack of awareness of hypoglycemia.
Several studies have noted that individuals with type 1 IDDM had impaired driving
performance during episodes of hypoglycemia and were unaware of their low blood glucose
at the time of driving assessment.64,65
It is apparent from these studies that many drivers did not take appropriate action even
when they recognized the symptoms of hypoglycemia. Individuals with diabetes 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 lack of awareness of hypoglycemia (e.g., documented blood glucose below 60 mg/
dL without symptoms).
Older adults should be counseled not to drive during acute hypoglycemic or hyperglycemic
episodes. In addition, older adults are advised to keep candy or glucose tablets within reach
in their car at all times, in the event of a hypoglycemic attack. A 2012 American Diabetes
Association position statement highlights important considerations in identification and
management for individuals with diabetes at potential risk of driving difficulties.66
For peripheral neuropathy, see Section 4.
Older adults who experience recurrent hypoglycemic or hyperglycemic attacks should not
drive until they have been free of significant hypoglycemic or hyperglycemic attacks for 3
months.

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Non-insulin dependent Older adults who are managed by lifestyle changes and/or oral medications have no diabetes
mellitus (NIDDM) restrictions unless they develop relevant conditions (e.g., diabetic retinopathy).
If the clinician prescribes an oral medication that has a significant potential to cause
hypoglycemia, he or she should counsel the individual as for IDDM above. Oral medications
may also increase the likelihood of hypoglycemia, which should be managed as in 1.a in this
section.

Hypothyroidism Older adults who experience symptoms (e.g., cognitive impairment, drowsiness, fatigue) that
may compromise safe driving should be counseled not to drive until their hypothyroidism
has been satisfactorily treated. If residual cognitive deficits are apparent despite treatment, a
comprehensive driving evaluation (clinical and on road) performed by a DRS may be useful in
determining the individual’s ability to drive safely.

Hyperthyroidism Older adults who experience symptoms (e.g., anxiety, tachycardia, palpitations) should
be counseled not to drive until their hyperthyroidism has been satisfactorily treated and
symptoms have resolved.

SECTION 7: M USCULOSKELETAL Pain, decreased motor strength, and compromised

DISORDERS range of motion associated with musculoskeletal
1. Arthritis disorders can affect an individual’s ability to
drive. Clinicians should encourage older adults
2. Foot abnormalities
with musculoskeletal disorders to drive a vehicle
3. Limitation of cervical movement with power steering and automatic transmission.
4. Limitation of thoracic and lumbar spine Such vehicles require the least amount of motor
5. Loss of extremities or loss of use of extremities ability for operation among all standard vehicles.
If the clinician is concerned that the individual’s
6. Muscle disorders
musculoskeletal disorders impair his or her driving
7. Orthopedic procedures/surgeries performance, referral to a DRS for a comprehensive
a. Amputation driving evaluation (clinical and on road) is also
recommended. In addition to assessing the
b. Anterior cruciate ligament reconstruction
older adult’s driving skills, the DRS can prescribe
c. L imb fractures and treatment involving compensatory techniques and adaptive devices and
splints and casts train the individual in their use.
d. Rotator cuff repair (open or arthroscopic) Older adults with musculoskeletal disorders
e. Shoulder reconstruction typically have problems with using the seat belt and
f. Total hip replacement ignition key, adjusting mirrors and seats, steering,
transferring in and out of the car, driving in reverse,
g. Total knee arthroplasty
and using controls such as the foot pedals.67 Driving

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impairment has been correlated with the inability restrictions.77 Improvements in relevant physical
to reach above the shoulder.68 Older adults with abilities and driving performance have been noted
physical frailty or disabilities may be at increased with a physical conditioning program.78
risk of a crash69,70 and are more likely to be injured.71 Older drivers are at increased risk of death and
Presence of foot abnormalities, walking less than serious injury in motor vehicle crashes, in part
one block a day, and impaired left knee flexion have because of age-related fragility.79-81 Therefore,
been associated with adverse driving events.71 In clinicians should advise older adults to avoid
one study, older participants involved in a crash driving in potentially risky situations, such as making
were more likely to have difficulty walking one- unprotected left turns, and driving in unfamiliar
quarter mile than controls; increased crash risk for areas or on suburban highways.82
drivers with a history of falls was also noted.72 A
In sum, clinicians can play a role in diagnosing,
recent systematic review and meta-analysis found
managing, and referring older adults with
an association between fall history and crash risk.73
musculoskeletal disorders, thereby helping to
An examination of medically impaired drivers maintain driving privileges and improve traffic
in Utah found an increased crash risk for drivers safety.
with musculoskeletal disorders but not for those
Rehabilitative therapies such as physical or
with muscle or motor weakness.74 In a Canadian
occupational therapy and/or a consistent regimen
longitudinal study, self-reported arthritis/rheumatism
of physical activity may improve the older adult’s
and back pain were associated with motor vehicle
ability to drive and overall level of physical fitness.
injuries.75
Whenever possible, the use of narcotics,
Conversely, individuals with a specific diagnosis of
barbiturates, and muscle relaxants should be
osteoarthritis were no more at risk of a crash than
avoided or minimized in those individuals with
controls in one study.76 Also reassuring was a study
musculoskeletal disorders who wish to continue
noting no increase in crash risk of drivers with cars
driving. See Section 13 for recommendations on
that had been adapted for their musculoskeletal
specific classes of medications.

Table 9.7 - Musculoskeletal Disorders

Arthritis If symptoms of arthritis compromise the older adult’s driving safety, referral to a physical or
occupational therapist for rehabilitative therapy and/or to a DRS for a comprehensive driving
evaluation (clinical and on road) is recommended. The DRS may prescribe vehicle adaptive
devices and train the individual in their use.
See below for specific recommendations on limitation of cervical movement or limitation of
the thoracic or lumbar spine.

Foot abnormalities Foot abnormalities (e.g., bunions, hammer toes, long toenails, calluses) that affect the
older adult’s dorsiflexion, plantar flexion, and/or contact with vehicle foot pedals should be
addressed and treated, if possible. Consideration should be given to referral to a podiatrist.
Older adults may also be referred to a DRS, who can prescribe vehicle adaptive devices and
train the individual in their use.

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Limitation of cervical Some loss of head and neck movement is acceptable if the older adult has sufficient
movement combined rotation and peripheral vision to accomplish driving tasks (e.g., turning, crossing
intersections, parking, backing up) safely. The clinician may also refer the older adult to a
physical or occupational therapist for rehabilitative therapy, and/or to a DRS, who can
prescribe wide-angled mirrors and train the individual in their use.

Limitation of thoracic Older adults with marked deformity, who wear braces or body casts, or who have painfully
or lumbar spine restricted motion in their thoracic or lumbar regions should be referred to a DRS. The DRS
can prescribe vehicle adaptive devices such as raised seats and wide-angled mirrors and train
the individual in their use. The DRS can also prescribe seat belt adaptations as needed to
improve the older adult’s safety and comfort and to ensure that the individual is seated at
least 10 inches from the vehicle air bags.
Older adults 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 may require large
doses of narcotics for control of pain, which also can increase risk.

For paraplegia or quadriplegia, see Section 4.

Loss of extremities For older adults who have lost (or lost the use) of one or more extremities, referral to a DRS
or loss of use is highly recommended. The DRS can prescribe vehicle adaptive devices and/or adaptations
of extremities to limb prostheses, and train the individual in their use. For example, those who have loss of
the right lower extremity may be able to use a left foot accelerator.
For those with an absent, amputated or non-functioning hand, a spinner knob may be
recommended.
The use of artificial limbs on vehicle foot pedals is unsafe because of the lack of sensory
feedback (i.e., pressure and proprioception). For these individuals, specialized hand controls
in place of pedals are required.
Driving should be restricted until the older adult demonstrates safe driving ability (with the
use of adaptive devices, as needed).

Muscle disorders If the clinician is concerned that the older adult’s symptoms compromise his or her driving
safety, referral to a DRS for a comprehensive driving evaluation (clinical and on road) is
recommended. If needed, the DRS may prescribe vehicle adaptive devices and train the
individual in their use.

Orthopedic procedures/surgeries

Amputation See Loss of extremities (above).

Anterior cruciate Individuals should not drive for 4 weeks after right ACL reconstruction. If the older ligament
(ACL) reconstruction adult drives a vehicle with manual transmission, he or she should not drive for 4 weeks after
right or left ACL reconstruction.83

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Limb fractures and No restrictions if the fracture or splint/cast does not interfere with driving tasks.
treatment involving
splints and casts If the fracture or splint/cast interferes with driving tasks for any reason, such as the lack of
sensory feedback (i.e., pressure and proprioception), the older adult may resume driving after
the fracture heals or the splint/cast is removed, after demonstration of the necessary strength
and range of motion.

Rotator cuff repair Individuals should not drive for 4–6 weeks after rotator cuff repair. If the older adult’s vehicle
(open or arthroscopic) does not have power steering, the waiting period may be much longer.
Clinicians should counsel individuals 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.

Shoulder Individuals should not drive for 4–6 weeks after shoulder reconstruction. If the older adult’s
reconstruction vehicle does not have power steering, the waiting period may be much longer.
Clinicians should counsel individuals 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.

Total hip replacement Individuals should not drive for at least 4 weeks after right total hip replacement.
If the older adult drives a vehicle with manual transmission, he or she should not drive for at
least 4 weeks after right or left total hip replacement.
Clinicians should counsel older adults 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
flexion greater than 90 degrees. Clinicians should also counsel individuals that reaction time
may not return to baseline until 8 weeks after the surgery, and that they should exercise extra
caution while driving during this period.84 A recent study found that reaction time recovered in
2–4 weeks and postulated that new techniques may have contributed to the improvement.85

Total knee Individuals should not drive for 3–4 weeks after right TKA. If the older adult drives a vehicle
arthroplasty (TKA) with manual transmission, he or she should not drive for 3–4 weeks after right or left TKA.
The clinician should also counsel individuals that reaction time may not fully return to baseline
until 8 weeks after the surgery and that extra caution should be exercised while driving during
this period.86–91

SECTION 8: PERIPHERAL VASCULAR DISORDERS

1. Aortic aneurysm
2. Deep vein thrombosis
3. Peripheral arterial aneurysm

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Table 9.8 - Peripheral Vascular Disorders

Aortic aneurysm No restrictions to driving unless other disqualifying conditions are present. Individuals 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.

Deep vein Older adults with acute DVT may resume driving when their international normalized ratio
thrombosis (DVT) (INR) is therapeutic (or the risk of embolism is otherwise appropriately treated), and they
can demonstrate adequate ankle dorsiflexion.
Clinicians should advise individuals with a history of DVT to take frequent “mobilization
breaks” when driving long distances.

Peripheral arterial No restrictions unless other disqualifying conditions are present. Older adults whose
aneurysm 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.

SECTION 9: RENAL DISORDERS

1. Chronic renal failure

2. Time-limited restrictions: renal transplant

Table 9.9 - Renal Disorders

Chronic renal failure No restrictions unless the older adult experiences symptoms incompatible with safe driving
(e.g., cognitive impairment, impaired psychomotor function, seizures, extreme fatigue from
anemia). If the clinician is concerned that the individual’s symptoms compromise his or her
driving safety, referral to a DRS for a comprehensive driving evaluation (clinical and on road) is
recommended.
Many older adults with renal failure requiring hemodialysis can drive without restriction.
However, management of renal failure requires that the older adult be compliant with
substantial nutrition and fluid restrictions, frequent medical evaluations, and regular
hemodialysis treatments. Individuals with a history of noncompliance should be advised
against driving. Furthermore, certain medications used to treat adverse effects of hemodialysis
may be substantially impairing (e.g., diphenhydramine for dialysis-associated pruritus), and
dialysis itself may result in hypotension, confusion, or agitation in many people. These effects
may require that older adults avoid driving in the immediate post-dialysis period.

Renal transplant Older adults may resume driving 4 weeks after successful renal transplant on the
recommendation of the physician.

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SECTION 10: RESPIRATORY AND SLEEP DISORDERS

1. Asthma
2. Chronic obstructive pulmonary disease (COPD)
3. Sleep apnea

“Drowsy driving” or driving with fatigue or sleepiness is a common cause of 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 sleep.92 Sleep disorder crash risk may be increased further by
medication use, such as narcotics or antihistamines.93 Individuals with sleep apnea have been noted to have
as high as a 7-fold increased crash risk compared with controls depending on the study.94 Individuals with
these disorders may also be at increased risk of injurious crashes.95 This topic has been extensively reviewed
elsewhere.1 Obstructive sleep apnea is one of the few medical conditions for which treatment has been
shown to return crash risk to baseline levels.96 In addition, recent studies indicate a high prevalence of sleep
disorders or daytime sleepiness in older adults97 and in individuals with diabetes.98 However, in the case of
older adults, the effect on driving safety is unclear.99

Table 9.10 - Respiratory and Sleep Disorders

Asthma No restrictions.
Older adults should be counseled not to drive during acute asthma attacks, or while suffering
transient adverse effects (if any) from asthma medications.

Chronic obstructive No restrictions if symptoms are well controlled, and the older adult does not experience any
pulmonary disease significant adverse effects from the condition or medication.
(COPD)
The older adult should not drive if he or she suffers dyspnea at rest or at the wheel (even with
the use of supplemental oxygen), excessive fatigue, or significant cognitive impairment. If
the older adult requires supplemental oxygen to maintain a hemoglobin saturation of ≥90%,
he or she should be counseled to use the oxygen at all times while driving. Because of the
often tenuous oxygenation status of these individuals, they should also be counseled to avoid
driving when they have other respiratory symptoms that may indicate concomitant illness or
exacerbation of COPD (e.g., new cough, increased sputum production, change in sputum
color, fever).
The following recommendations were affirmed at the AOTA/NHTSA Expert Summit (March
2012) specific to COPD:56
• When an individual has COPD, a referral for a driving evaluation is indicated if any
of the following conditions are present: (1) cognitive decline is evident with either
psychometric testing or while performing other ADLs (e.g., impaired attention,

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fatigue, hypersomnolence); (2) concern is raised about driving safety through direct
observation, family concern, or driving incidents; (3) the individual has difficulty
maintaining oxygen saturation of at least 90% at rest; (4) when the individual
experiences dyspnea at rest or while behind the wheel; and (5) when the individual’s
motor vehicle needs modification for loading a powered mobility device (wheelchair or
scooter) or oxygen containers need to be secured in the vehicle.
• When an individual has COPD, the DRS should monitor oxygen saturation while
driving to measure the effects of driving tasks on oxygen levels in the blood. This
information can be used to verify the need to drive with oxygen to improve cognition,
as well as heart and other organ functioning. Pulse oximetry is also an effective tool to
demonstrate the effects that energy conservation (vehicle features, arm position, etc.)
and breathing techniques have while driving.
• When an individual has COPD, the DRS can provide guidance on overall driving skills
and safety, including driving limits and compensatory techniques, as well as assistance
with loading devices for power mobility devices, and oxygen storage.
• Community mobility should be addressed with every occupational therapy patient as
part of the initial evaluation and most importantly as part of discharge planning.
Because COPD is often progressive, periodic reevaluation for symptoms and oxygenation
status is recommended.
If the clinician is concerned that the older adult’s symptoms compromise his or her driving
safety, referral to a DRS for a comprehensive driving evaluation (clinical and on road) is
recommended. The individual’s oxygen saturation may be measured during the course of the
on-road assessment to provide additional information for management.

Sleep apnea Older adults with excessive daytime sleepiness, loud snoring (particularly if accompanied
by witnessed apneic events), large neck circumference (≥16 inches in women, ≥17 inches in
men), increased body mass index (>35 kg/m2), and/or hypertension that requires two or more
medications should be considered at risk of obstructive sleep apnea, and formal sleep study
evaluation should be considered, especially in any individual who reports having fallen asleep
while driving a vehicle. A person diagnosed with sleep apnea (apnea/hypopnea index ≥5)
who has fallen asleep while driving, or a person with severe obstructive sleep apnea (apnea/
hypopnea index of ≥30) should be counseled to refrain from driving until he or she is receiving
effective treatment (via a positive airway pressure device) after a formal sleep study to confirm
the diagnosis. If these individuals undergo other treatments (surgery, oral appliances), they
should be advised to have a post-treatment sleep study to confirm effectiveness. Clinicians
should counsel older adults prescribed positive airway pressure devices that they should not
drive if they do not use the device unless a formal sleep study confirms resolution of their
obstructive sleep apnea (e.g., after substantial weight loss).

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SECTION 11: EFFECTS OF ANESTHESIA the older adult’s driving performance, referral to a
AND SURGERY DRS for a comprehensive driving evaluation (clinical
and on road) is highly recommended.
1. Abdominal, back, and chest surgery
Clinicians should counsel older adults who undergo
2. Anesthesia surgery—both inpatient and outpatient—not
a. General to drive themselves home after the procedure.
b. Local Although they may feel capable of driving, their
driving skills may be affected by pain, physical
c. Epidural
restrictions, anesthesia, cognitive impairment, and/
d. Spinal or analgesics. (For specific recommendations on
3. Neurosurgery musculoskeletal restrictions and narcotic analgesics,
see Sections 7 and 13, respectively.)
4. Orthopedic surgery
In counseling older adults about their return to
Clinicians should be alert to peri- and postoperative driving after a surgical procedure, clinicians may
risk factors that may affect the older adult’s find it useful to ask whether the individual’s car has
cognitive function after surgery, or restrictions power steering and automatic transmission. Advice
on limb movement or joint range of motion that can then be tailored accordingly.
place the individual at risk of impaired driving As older adults resume driving, they should be
performance. Risk factors include: counseled to assess their comfort level in familiar,
n Preexisting cognitive impairment traffic-free areas before driving in heavy traffic.
n Duration of surgery Those who feel uncomfortable driving in certain
n Age (>60 years old) situations should avoid these situations until their
n Altered mental status after surgery confidence level has returned.
n Presence of multiple comorbidities
Older adults should never resume driving before
n Emergency surgery
they feel ready to do so and have received approval
If the clinician is concerned that residual visual, from the clinician.
cognitive, or motor deficits after surgery may impair

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Table 9.11 - Effects of Anesthesia and Surgery

Abdominal, back, Older adults may resume driving after demonstrating the needed strength and range of
chest and surgery motion.
See Section 2 for recommendations for surgeries involving median sternotomy.

Anesthesia Because anesthetic agents and adjunctive compounds (such as benzodiazepines) may be
administered in combination, older adults should not resume driving until the motor and
cognitive effects from all anesthetic agents have subsided.

General Both the surgeon and anesthesiologist should advise older adults 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.

Local If the anesthetized region is necessary for driving tasks, the older adult should not drive until he
or she has recovered full strength and sensation (barring pain).

Epidural Older adults may resume driving after recovering full strength and sensation (barring pain) in the
affected areas.

Spinal Older adults may resume driving after recovering full strength and sensation (barring pain) in the
affected areas.

Neurosurgery See recommendations for post-intracranial surgery in Section 3.

Orthopedic See recommendations for orthopedic procedures/surgeries in Section 7.

surgery

SECTION 12: CANCER

Table 9.12 - Cancer

Cancer Older adults who experience significant 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 adverse effects of cancer treatment (e.g., antiemetics
for nausea) may impair driving performance. Clinicians should counsel older adults accordingly.
(See Section 13 for recommendations for specific medications.)

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SECTION 13: MEDICATIONS taken into account both the medical condition and
the medications used to treat the condition, the
1. Anticholinergics impact of the medical condition on crash risk is
2. Anticonvulsants much stronger than that of the medication.100 Thus,
this section discusses PDI medications based on
3. Antidepressants
information from observational studies examining
4. Antiemetics risk of crashes; from experimental studies assessing
5. Antihistamines driving performance, as tested in different actual
driving tests or driving simulator tests; and/or from
6. Antiparkinsonian agents
the known adverse effect profile of the medication.
7. Antipsychotics
Some PDI medications are included based on
8. Benzodiazepines and nonbenzodiazepine adverse-effect profile alone, because research
hypnotics evidence is not available delineating risk of traffic
9. Muscle relaxants crashes.

10. Narcotic analgesics The most common PDI medications include the
anticholinergics, anticonvulsants, antidepressants,
As described in the previous sections of this antiemetics, antihistamines, antipsychotics,
chapter, medications may promote safe driving in barbiturates, benzodiazepines/hypnotics, muscle
older adults through adequate management of relaxants, and narcotic analgesics.101-103 Of these
medical conditions and better physical functioning. medication classes, sedative/hypnotics (e.g.,
However, many commonly used prescription and benzodiazepines, zolpidem) have been subject to
over-the-counter medications may impair driving the most scrutiny, and studies have consistently
by adversely affecting the cognitive, visual, and/or found higher risk of traffic crashes associated with
motor abilities needed for safe driving. In general, their use in older adults.102-105 Increased risk of traffic
any drug with a prominent effect on the central crashes is especially prominent when medications
nervous system (CNS) has the potential to impair an are newly initiated.104-106
individual’s ability to operate a motor vehicle. The Older adults often take multiple medications
level of impairment varies from person to person concurrently, with approximately 36% using five or
and between different medications within the same more prescription medications.107 Furthermore, older
therapeutic class. adults often take multiple CNS-active medications,
Expert panels convened by NHTSA to develop a list with 25% taking two or more classes.108 Crash
of safe and unsafe drugs with regard to driving were risk is likely to increase with use of multiple PDI
not able to develop a conclusive list and were only medications109 or concomitant use with alcohol. Table
able to comment on the potential impact of various 9.13 summarizes the common PDI medications and
medications.100 This difficulty stems from inconsistent the specific adverse effects (cognitive, visual, and
research findings, lack of a standardized protocol motor abilities) that may contribute to impaired
for assessing the potential for medications to impair driving. Adverse effects on cognition include
driving, and the difficulty in distinguishing the impact fatigue, sedation/sleepiness, light-headedness,
of the medical condition from the impact of the dizziness, or global cognitive impairment (e.g.,
medication itself that is used to treat the medical impaired judgment, attention, psychomotor
condition on driving safety.100 For studies that have speed). Medications that cause tremor, dyskinesias,

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or extrapyramidal symptoms may impair motor This list of medications is not exhaustive. Other
ability needed for driving. A history of falls has medication classes, such as oral hypoglycemics and
been associated with an increased crash risk, antihypertensives, may cause dizziness or impaired
and medications with CNS effects are known risk cognition if the individual is hypoglycemic or blood
factors for falls. Medications that cause drowsiness, pressure is too low, respectively. Furthermore,
euphoria, and/or anterograde amnesia may also any medication adverse effect (e.g., nausea) that
diminish insight, and older adults may experience reduces the ability to concentrate could potentially
impairment without being aware of it (e.g., impair driving.
benzodiazepines, narcotics, antihistamines).110-113

Table 9.13 - Potentially Driver-Impairing (PDI) Medications

Medication Class PDI Symptom

Anticholinergics Sedation, blurred vision, impaired cognition

Anticonvulsants Sedation, impaired cognition
Antidepressants
Tricyclics (tertiary more Sedation, blurred vision, impaired cognition, tremor, heart palpitations
impairing then secondary)
Selective serotonin Impaired concentration, lightheadedness, tremor
reuptake inhibitors (SSRIs)
Others
Duloxetine Sedation
Mirtazapine Sedation
Bupropion Insomnia (leading to next day somnolence)
Antihistamines (first Sedation, blurred vision, impaired cognition
generation and cetirizine)
Antiparkinson agents All classes may cause sedation.
Dopamine agonists, Medication-specific adverse events: sleep-attacks (most likely with dopamine
levodopa, Anticholinergics agonists), dyskinesias (most likely with levodopa)
Antipsychotics Sedation, blurred vision, impaired cognition, extrapyramidal symptoms, (to varying
extent among agents)
Benzodiazepines/sedatives Sedation, clumsiness, dizziness, impaired vision, impaired cognition
Muscle relaxants Sedation, blurred vision, impaired cognition
Opioid analgesics Sedation, lightheadedness, impaired vision

Other agents
Antihypertensives Dizziness (low blood pressure)
CNS effects (guanfacine, reserpine, methyldopa, clonidine)
Hypoglycemics Symptoms of hypoglycemia (shakiness, impaired concentration, lightheadedness)
Indomethacin CNS effects
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Clinicians should be aware of the PDI risk and experimental studies conducted in younger
attempt to use the safest class of medication when individuals, marijuana is associated with negative
possible. It is difficult to know whether increased risk effects on driving ability, including an increase
of impaired driving is associated with the drug (e.g., in lane weaving, poor reaction time, and altered
antidepressant), the disease itself (e.g., depression, attention to the road.116-118
which may independently impair attention, Although not well studied, the potential exists for
judgment), or a drug-drug interaction.102 Because medications that are strong inhibitors of CYP3A4
of age-related changes in pharmacokinetics (e.g., and CYP2C9 enzymes in the liver to result in higher
reduced renal function) and pharmacodynamics, concentrations of marijuana components in the
older adults may begin to have adverse effects to blood. Moderate-strength evidence from a recent
medications that they have tolerated well for many meta-analysis of 21 multinational observational
years, which may make it difficult to ascertain the studies suggests that acute cannabis intoxication is
cause of new PDI symptoms. associated with a moderate increase in collision risk
(odds ratio, 1.35 [CI, 1.15 to 1.61]).119
ALCOHOL INTERACTION WITH
MEDICATIONS
GENERAL PRESCRIBING PRINCIPLES
As little as one serving of alcohol (1.25 oz. 80-proof
It may not be possible to avoid use of PDI
liquor, 12 oz. beer, 5 oz. wine) has the potential to
medications in older adults; however, several
impair driving ability in many individuals. Because
general prescribing principles can be considered to
of age-related changes in body composition (e.g.,
minimize risk.
increased body fat and decreased lean muscle
mass), the same weight-adjusted amount of alcohol 1. Whenever possible, clinicians should select non-
(hydrophilic) is likely to result in higher blood impairing medications.
levels of alcohol and functional impairment in 2. When prescribing new medications, clinicians
advanced age. In many cases, older adults may be should always consider the individual’s existing
impaired without being aware of it. Furthermore, regimen of prescription and nonprescription
alcohol can potentiate the CNS effects of PDI medications and consider risk of additive PDI
medications to produce profound and dangerous medications. Combinations of drugs may affect
levels of impairment. Clinicians should always drug metabolism and excretion, and produce
warn older adults against drinking and driving, and additive or synergistic interactions to impair driving
against combining alcohol and their CNS-active ability.
medications. 3. Clinicians should add new medications at the
lowest dosage possible, counsel the older adult
MARIJUANA USE to be alert to any impairing effects, and adjust
Prevalence of marijuana use is low in older adults, the dosages as needed to achieve therapeutic
at 1.3-2%.114,115 However, with the increased effects while minimizing driving impairment. For
acceptance of medicinal cannabis and legalization individuals on multiple PDI medications, it is wise to
of marijuana for recreational use, it is likely this start with low doses of each and gradually increase
prevalence of marijuana use will increase. In the dosage of each one at a time to minimize
substantial undesirable effects.

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4. Older adults should be regularly assessed for PDI what to expect and can self-monitor for adverse
symptoms during follow-up visits. events that may affect driving.
5. If medication therapy is initiated while the older 2. Advise the older adult and caregivers to take the
adult is hospitalized, the impact of adverse effects first few doses in a safe environment to determine
on driving performance should be discussed before the presence and extent of any adverse effects.
discharge. Individuals should be advised not to drive during
6. These precautions and discussions should be the initial phase of PDI dosage adjustment(s) if
documented in the health record. they experience drowsiness, lightheadedness, or
other undesirable effects that may impair driving
7. If there is a question of cognitive or motor
performance.
impairment, whether or not due to medications,
the clinician should consider referral to a DRS for 3. Inform the older adult and caregivers that some
a driver evaluation (potentially including on-road medications that cause drowsiness, euphoria, and/
assessment). or anterograde amnesia may also diminish insight
(benzodiazepines, antihistamines, narcotics), and
COUNSELING CONSIDERATIONS that the individual may experience impairment
The following counseling points are important to without being aware of it.
consider when a new PDI medication is started, 4. Discourage the use of alcohol while driving and
or the dosage of an existing PDI medication is inform the older adult and caregivers about the
increased. potential for exacerbation of the PDI effects of
1. Inform the older adult and caregivers about the certain medications with concomitant alcohol use.
specific effects of the medication, so that they know

Table 9.14 - Medications

Refer to Table 9.13 for a full list of the PDI symptoms for each of the medication classes discussed below.

Anticholinergics Many prescription and over-the-counter medications have anticholinergic effects (see
reference for a full list).120 These include several medication classes such as antidepressants
(e.g., tricyclic antidepressants and paroxetine), medications for overactive bladder
(e.g., oxybutynin, tolterodine, trospium, darifenacin), first-generation antihistamines
used for allergies, insomnia, and/or vertigo (e.g., chlorpheniramine, dimenhydrinate,
diphenhydramine, doxylamine), skeletal muscle relaxants (e.g., cyclobenzaprine),
gastrointestinal antispasmodics (e.g., belladonna alkaloids, atropine, hyoscyamine), certain
antipsychotics (e.g., chlorpromazine, clozapine, olanzapine), and antiparkinsonian agents
(e.g., trihexyphenidyl). In most cases, therapeutic alternatives to anticholinergic medications
are available.
Subtle deficits in attention, memory, and reasoning may occur with therapeutic dosages of
anticholinergic drugs without signs of overt toxicity. Delirium can also occur in older adults.

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Table 9.14 - Medications/cont.

Anticonvulsants Older adults should temporarily cease driving during the time of medication initiation,
withdrawal, or dosage change because of the risk of recurrent seizure and/or potential
medication effects that may impair driving performance. If there is significant risk of recurrent
seizure during medication withdrawal or change, the older adult should not drive during this
time and for at least 3 months thereafter.
Many anticonvulsants (e.g., valproic acid, carbamazepine, gabapentin, lamotrigine, topiramate)
are also used as mood stabilizers for treatment of bipolar disorder, for agitation in dementia,
as sedating agents for anxiety, and to treat pain syndromes. These agents may be used as an
adjunct to antidepressants, antipsychotics, and/or anxiolytics.
By themselves, anticonvulsants may be mildly impairing, but when combined with other PDI
medications, the effects on psychomotor performance may be enhanced. Furthermore, some
anticonvulsants are primarily eliminated by the kidneys and increased CNS adverse effects may
be observed with renal impairment. Thus, dose reductions are recommended when estimated
creatinine clearance is <60 mL/min for pregabalin and gabapentin and <80 mL/min for
levetiracetam.120

Antidepressants In general, increased crash risk has been associated with many classes of antidepressants, even
though the magnitude and extent of PDI adverse events vary between them. In general, the
selective serotonin reuptake inhibitors (SSRIs) are first-line agents for depression and anxiety
disorders because of their good tolerability, including a lower risk of CNS depressant adverse
effects. Tricyclic antidepressants with high anticholinergic effects are not advised for those who
wish to continue driving. Mirtazapine, a more sedating antidepressant, is typically taken only
at night to avoid excessive daytime sedation. Duloxetine, a serotonin-norepinephrine reuptake
inhibitor used for depression, chronic pain, fibromyalgia, and anxiety disorders, may also cause
sedation and other CNS effects.

Selective serotonin- SSRIs are commonly prescribed agents to treat depression and anxiety. Paroxetine is unique
reuptake inhibitors in that it has anticholinergic effects, so may be more likely than the other SSRIs (e.g., sertraline,
(SSRIs) citalopram) to impair driving. Although adverse effects tend to be mild and well tolerated,
clinicians should counsel older adults to be alert to the potential of SSRIs to affect driving
performance. Special mention is made of the serotonin syndrome, wherein mental status
changes, autonomic hyperactivity, and neuromuscular adverse effects are observed due to
excessive amounts of the drug, taking multiple drugs that increase serotonin, or a drug-drug
interaction.

Tricyclic Better tolerated agents have replaced TCAs for depression; however, they are still used
antidepressants (TCAs) to manage sleep, menopausal symptoms, neuropathic pain, incontinence, and migraines. The
tertiary tricyclic antidepressants (amitriptyline, doxepin, imipramine) have strong anticholinergic
effects and may impair driving. If a TCA is needed, nortriptyline and desipramine have lower
anticholinergic effects and are preferred but are still not recommended for use in older
adults.120
See Anticholinergics in this section.

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Antiemetics Numerous classes of drugs (some of which include anticholinergics, antihistamines,

antipsychotics, cannabinoids, and benzodiazepines) are used for their antiemetic effect.
For more information, see Anticholinergics, Antihistamines, and Benzodiazepines in this
section.

Antihistamines The first-generation antihistamines (e.g., diphenhydramine, chlorpheniramine) have

pronounced CNS effects and impair psychomotor performance, simulated driving, and
on-road driving.102 In contrast, most second-generation antihistamines (i.e., nonsedating)
do not produce these types of impairments when taken in recommended doses, except
for cetirizine. Nonsedating antihistamines (e.g., loratadine, fexofenadine) are preferred if
an antihistamine is needed for allergy treatment; however, even these agents may cause
impairments if taken in higher than recommended doses.
See Anticholinergics in this section.

Antiparkinson agents The mainstay of treatment for Parkinson disease is levodopa, dopamine agonists (e.g.,
pramipexole, ropinirole), amantadine, and anticholinergics (e.g., trihexyphenidyl).
Individuals with Parkinson disease are already at risk of excessive daytime somnolence,
but treatment with these medications can further contribute to this symptom. Individuals
taking antiparkinsonian agents have reported sudden, unexpected lapses of attention and
falling asleep, known as “sleep attacks.” The risk of sleep attacks seems greatest with use of
dopamine agonists, but may occur with any therapy.121,122

Antipsychotics Most, if not all, antipsychotic medications have a strong potential to impair driving
performance through cognitive, visual, and motor effects. Most antipsychotics used in the
outpatient setting are second-generation (atypical) antipsychotics. Second-generation
antipsychotics have varying degrees of anticholinergic and sedative effects, with
clozapine having the most pronounced effects. These agents also cause varying degrees
of extrapyramidal effects that may impair psychomotor performance, with risperidone,
lurasidone, and ziprasidone having the most pronounced effects.

Benzodiazepines and Studies have demonstrated impairments in vision, attention, motor coordination, and
nonbenzodiazepine driving performance with benzodiazepine use. Evening doses of long-acting benzodiazepines
hypnotics (e.g., flurazepam, diazepam) markedly impair psychomotor function the following day,
while comparable doses of short-acting benzodiazepines produce a lesser impairment.102
Zolpidem, eszopiclone, and zaleplon are nonbenzodiazepine hypnotics. Zolpidem has
been associated with driving at night without recollection the next morning and increased
crash risk.104 Women and older adults have higher blood concentrations of zolpidem;
therefore, the maximum dose is lower for these patient groups (5 mg of regular release
zolpidem). Less information exists about eszopiclone, but it has a duration of action similar
to that of zolpidem, so the same cautions should apply. Zaleplon has a short half-life and
is used for sleep-onset difficulties and is unlikely to impair next day driving. Trazodone, an
antidepressant often used as a sedative, has been associated with increased crash risk.104
In general, it is recommended to avoid benzodiazepines and nonbenzodiazepine hypnotics in
older adults because of the risk of several adverse health outcomes, including increased risk
of car crashes.120 However, if hypnotics are needed, evening doses of short-acting hypnotics

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Table 9.14 - Medications/cont.

are preferred with periodic attempts to discontinue therapy. Individuals taking hypnotics
should allow enough time to sleep after the dose (approximately 8 hours) before driving.
Older adults who take daytime doses of benzodiazepines (for anxiety) should be advised of
the potential for impairment, even in the absence of subjective symptoms.

Muscle relaxants Most skeletal muscle relaxants (e.g., carisoprodol and cyclobenzaprine) have significant CNS
effects. Long-term use should be avoided.

Narcotics analgesics Tolerance may develop to many of the CNS effects of narcotic analgesics, but the visual
impairment may persist. Impaired driving with narcotics may be most prominent with initial
therapy or with dose increases. Meperidine may have a higher risk of neurotoxicity compared
with other narcotics, and in general should be avoided in older adults.120
Individuals should be monitored for frequency of use, tolerance, and dependence.
Clinicians should always be alert to signs of abuse. (For more information, see the
recommendations for substance abuse in Section 5.)

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106. Monárrez-Espino, J., Laflamme, L., Rausch, C., Elling, B., & Möller,
J. G., Joffe, D., & Pierce, R. J. (2004). Sleepiness, sleep-disordered
J. (2016). New opioid analgesic use and the risk of injurious single-
breathing and accident risk factors in commercial vehicle drivers.
vehicle crashes in drivers aged 50-80 years: a population-based
American Journal of Respiratory and Critical Care Medicine, 170,
matched case-control study. Age Ageing, 45(5), 628-634. https://
1014-1021. https://doi.org/10.1164/rccm.200312-1782OC.
doi.org/10.1093/ageing/afw115.
94. Teran-Santos, J., Jimenez-Gomez, A., Cordero-Guevara, J., and
107. Qato, D. M., Wilder, J., Schumm, L.P., Gillet, V., & Alexander, G.C.
the Cooperative Group Burgos-Santander. (1999). The association
(2016). Changes in prescription and over-the-counter medication
between sleep apnea and the risk of traffic accidents. New England
and dietary supplement use among older adults in the United
Journal of Medicine, 340(11), 847-851. https://doi.org/10.1056/
States, 2005 vs 2011. JAMA Internal Medicine, 176(4), 473-482.
NEJM199903183401104.
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95. Mulgrew, A. T., Nasvadi, G., Butt, A., Cheema, R., Fox, N, Fleetham,
108. Musich, S., Wang, S.S., Ruiz, J., Hawkins, K., & Wicker, E. (2017).
J. A., & Ayas, N. T. (2008). Risk and severity of motor vehicle crashes
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in patients with obstructive sleep apnoea/hypopnea. Thorax, 63,
a US Medicare population. Drugs Aging, 34(7), 555-565. https://doi.
536-541. https://doi.org/10.1136/thx.2007.085464.
org/10.1007/s40266-017-0470-x.
96. George, C. F. (2001). Reduction in motor vehicle collisions following
109. LeRoy, A. A., & Morse, M. L. (2008, May). Multiple medications
treatment of sleep apnea with nasal CPAP. Thorax, 56(7), 508-512.
and vehicle crashes: analysis of databases (Report No. DOT
97. Vaz Fragoso, C.A., Arauio, K. L., Van Ness, P.H., & Marottoli, R. A. HS 810 858). Washington, DC: National Highway Traffic Safety
(2008). Prevalence of sleep disturbances in a cohort of older drivers. Administration. Retrieved from https://www.nhtsa.gov/DOT/
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Sciences, 63, 715-723. Retrieved from https://www.ncbi.nlm.nih.gov/ Files/810858.pdf.
pmc/articles/PMC3719852/.
110. Weiler, J. M., Bloomfield, J. R., Woodworth, G. G., Grant, A.
98. Hayashino, Y., Yamazaki, S., Nakayama, T., Sokejima, S, & Fukuhara, R., Layton, T. A., Brown, T.L. & Watson, G. S. (2000). Effects
S. (2008) Relationship between diabetes mellitus and excessive of fexofenadine, diphenhydramine, and alcohol on driving
sleepiness during driving. Experimental and Clinical Endocrinology & performance. a randomized placebo-controlled trial in the Iowa
Diabetes, 116(1), 1-5. https://doi.org/10.1055/s-2007-984442. Driving Simulator. Annals of Internal Medicine, 132(5), 354-363.
99. Vaz Fragoso, C. A., Araujo, K., Van Ness, P., & Marottoli, R. A. (2010). 111. Tashiro, M., Horikawa, E., Mochizuki, H., Sakurada, Y., Kato,
Sleep disturbances and adverse driving events in a predominantly M., Inokuchi, T., & Yanai, K. (2005). Effects of fexofenadine and
male cohort of active older drivers. Journal of the American hydroxyzine on brake reaction time during car driving with cellular
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113. A
 ranko, 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
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org/10.1111/j.1600-0773.1985.tb01305.x.
114. H
 asin, D. S., Saha, T. D., Kerridge, B. T., et al. (2015). Prevalence of
marijuana use disorders in the United States between 2001-2002
and 2012-2013. JAMA Psychiatry, 72(12), 1235-1242. https://dx.doi.
org/10.1001%2Fjamapsychiatry.2015.1858.
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 an, B., Compton, W. M., Blanco, C., & Jones, C. M. (2018).
Trends in and correlates of medical marijuana use among adults in
the United States. Drug and Alcohol Dependence, 186, 120-129.
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116. H
 artman, R. L., & Huestis, M. A. (2013). Cannabis effects on driving
skills. Clinical Chemistry, 59(3), 478-492. https://doi.org/10.1373/
clinchem.2012.194381.
117. H
 artman, R. L., Brown, T. L., Milavetz, G., Spurgin, A., Pierce, R.
S., Gorelick, D. A., Gaffney, G., & Huestis, M. A. (2015). Cannabis
effects on driving lateral control with and without alcohol. Drug
and Alcohol Dependence, 154, 25-37. https://doi.org/10.1016/j.
drugalcdep.2015.06.015.
118. L enné, M. G., Dietze, P. M., Triggs, T. J., Walmsley, S., Murphy, B.,
& Redman, J. R. (2010). The effects of cannabis and alcohol on
simulated arterial driving: Influences of driving experience and task
demand. Accident Analysis & Prevention, 42(3), 859-866. https://
doi.org/10.1016/j.aap.2009.04.021.
119. R
 ogeberg, O., & Elvik, R. (2016). The effects of cannabis intoxication
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 he 2019 American Geriatrics Society Beers Criteria® Update
Expert Panel. (2019) The 2019 American Geriatrics Society Beers
Criteria® for potentially inappropriate medication use in older
adults. Journal of the American Geriatrics Society. Published online
January 31, 2019. https://doi.org/10.1111/jgs.15767.
121. A
 vorn, J., Schneeweiss, S., Sudarsky, L. R., Benner, J., Kiyota, Y.,
Levin, R., & Glynn, R. J. (2005). Sudden uncontrollable somnolence
and medication use in Parkinson disease. Archives of Neurology,
62(8), 1242-1248. https://doi.org/10.1001/archneur.62.8.1242.
122. H
 obson, D. E., Lang, A. E., Martin, W. R., Razmy, A., Rivest, J., &
Fleming, J. (2002). Excessive daytime sleepiness and sudden-onset
sleep in Parkinson disease: a survey by the Canadian Movement
Disorders Group. Journal of the American Medical Association,
287(4), 455-463. https://doi.org/10.1001/jama.287.4.455.

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CHAPTER 10 M
 EETING FUTURE TRANSPORTATION NEEDS OF OLDER ADULTS

KEY POINTS
n Transportation planning needed regarding content, n Clinician involvement and
discussions should begin early efficiency, and effectiveness. communication with driver
and be revisited often. n Clinicians should be aware licensing agencies should be
n A holistic approach that of and use driving evaluation encouraged and facilitated.
incorporates assessment and resources in their area, n Coordination among
intervention and that facilitates including driving rehabilitation clinicians, licensing agencies,
the transition to driving specialists (DRS’s). and relevant state/local/
limitation or cessation when n As new technologies are community agencies/
necessary is encouraged. developed, their role in organizations is encouraged
n A tiered assessment strategy enhancing safety of older to help older adults and
offers potential advantages adult drivers, passengers, their caregivers become
for gauging risk in clinical and pedestrians should be aware of and able to access
offices and licensing agencies, assessed. transportation resources in
although more evidence is their community.

T
he previous chapters provide the clinical To accomplish these objectives, coordinated
team with recommendations and tools for efforts among the health care and transportation
enhancing the driving safety of older adults. communities, policymakers, community planners,
As in other aspects of patient care, however, further the automobile industry, and government agencies
research will lead to more effective care. Further are needed to achieve the common goal of safe
progress on the following would be beneficial: transportation for the older population. As this
n In-office tools that can help predict crash risk or population continues to expand and live longer,
determine fitness to drive the challenge is to keep pace with its transportation
needs. Although many transportation alternatives
n Improved access to driver assessment and
are developing (e.g., fully automated vehicles, golf
rehabilitation
cart communities, private car rideshare programs),
n Training in the appropriate use of advanced review of the use of these by older adults is beyond
technology in vehicles as these technologies the scope of this chapter.
evolve
This chapter discusses the research, initiatives,
n Safer roads
applications, and system changes deemed essential
n Expansion of transportation alternatives for improving driving safety of older adults.
n Increased crashworthiness of vehicles
n Intervention trials to lower risk, maintain driving
life expectancy, and/or improve driving safety

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VEHICLE DESIGNS TO OPTIMIZE protection and restraint systems designed for

SAFETY OF OLDER ADULT DRIVERS fragile occupants that may enhance the safety of
AND PASSENGERS older adult drivers and passengers in the event
Age-related changes in vision, cognition, and motor of a crash.
ability may affect an individual’s ability to enter/ n Add-on features that may also make current
exit a motor vehicle with ease, assess critical driving vehicle designs safer and more accessible for
information, and handle the complexities of a motor older adult drivers. For example, handholds and
vehicle in traffic safely. Older adults are also less supports on door frames may facilitate entry/
able to endure and recover from injuries sustained exit for both drivers and passengers. Padded
in an automobile crash. Vehicle manufacturers steering wheels and seat adjuster handles (rather
are encouraged to explore and implement than knobs) may benefit drivers with decreased
enhancements in vehicle design to address and hand grip, and adjustable steering wheels and
compensate for these physiologic changes, such as: foot pedals may aid drivers with limited range of
n Designs based on the anthropometric motion or who are of smaller stature.3
parameters of older adults (i.e., physical
Crashes involving older adult drivers and fatality
dimensions, strength, fragility, and range of
rates have fallen in recent years, despite the
motion) may be optimal for entry/exit; seating
increased fragility of older adults. It may be possible
safety and comfort; seat belt/restraint systems;
to enhance these gains by better understanding
and placement and configuration of displays,
the factors that enter into older drivers’ vehicle
mirrors and controls.
selection and incorporating the issues outlined
n Headlamp design improvements that enhance above into this process.4 An effort to promote the
nighttime visibility and reduce glare. selection of vehicles that may be a better fit for
n High-contrast legible fonts and symbols for older adults is in place at the American Automobile
in-vehicle displays, to help compensate for age- Association website.5 Other adjustable controls
related changes in vision.1 and displays may allow older drivers to tailor their
n More prominent analog gauges that are easier vehicle to their changing abilities and needs. Safety
to see and interpret than small digital devices.2 features that may benefit older adults include smart
headlights, emergency response systems, reverse
n Continued use of computers which have
monitoring, blind spot/lane departure warning,
revolutionized the motor vehicle industry by
stability control, assisted parking, voice-activated
managing airbag safety systems, antilock brakes,
controls, crash mitigation systems, and drowsy
and navigation systems.
driver alerts.6 Electronic stability control is now
n In-vehicle tools to assess for high-risk standard equipment on all new vehicles and may
conditions that are entering the marketplace lead to further safety gains as it becomes more
(such as a driver monitoring system that can prevalent in the vehicle fleet.7
monitor a driver’s gaze position and eyelid
closure ratio to assess for distraction and fatigue Vehicle technology is advancing and being
and can provide a warning). implemented at a rapid pace. Fully automated
vehicles have captured media and public
n Vehicle designs that offer enhanced crash

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attention, as well as scrutiny of their safety and driving ability and because of the limitations of
liability concerns. In spite of this, many individual potential measures. Global cognitive measures are
technologies are becoming available on existing easy to administer and score but do not adequately
vehicles.8 Although these may not often consider address the complex abilities necessary for safe
age or functional limitations in their development, driving. The limited ability of global cognitive
they will be used by drivers with a range of measures to predict adverse driving events has
capabilities, who have varying needs, expectations increasingly led to a focus on other measures
of, and preferences for such technologies.9,10 Thus, that address relevant cognitive domains such
there may be concerns about weighing benefits as executive function, attention, information
versus risks of these technologies for older drivers. processing speed, or visuospatial ability. Again,
Several recent studies have demonstrated potential no single measure has stood out, in part because
benefits of some technologies, highlighting the of the multifactorial nature of driving risk and
importance of older persons’ knowledge of, because studies involve heterogeneous groups of
and training in, the appropriate use of these drivers who may have very different risk factors.
technologies.11-13 One approach is to narrow testing to individuals
with a specific disorder or particular disease (e.g.,
IMPROVED CLINICIAN TOOLS FOR glaucoma, dementia); however, this will obviously
ASSESSMENT OF DRIVING SAFETY not be broadly applicable. Another approach is to
Clinicians need an assessment approach that look at combinations of tests that capture common
reliably identifies older adult drivers at increased risk factors.14 A recent study demonstrated one
risk of a car crash. A tiered assessment strategy analytic approach for combining tests to optimize
can be considered for clinical settings in which predictive ability.15 As several large longitudinal
older adult drivers are screened routinely (on the studies (e.g., Candrive, LongRoad) continue,
basis of certain risk criteria) or if concerns about their findings may continue to advance our
their driving arise (a similar strategy for licensing understanding of these issues in the near future.
agencies is discussed below). Depending on
Clinical teams desire a quick, cost-effective, widely
screening results, the driver would be scheduled
available comprehensive tool to determine driving
for more detailed assessment or an on-road driving
recommendations. Until such a tool is available,
evaluation. Fully implementing such a strategy in
given the multiple complexities of driving, the
different clinical settings would involve logistical
clinical team may be better served by tailoring
challenges. The ideal tests would assess the
assessment and intervention to the particular
primary functions related to driving and form the
strengths and limitations of each older adult driver.
basis for interventions to correct or ameliorate
Clinicians can evaluate older adults’ potential driver
any identified conditions or functional deficits. In
risk by assessing functions related to driving (see
addition, this tool should be brief, inexpensive,
Chapter 3) and reviewing the presence and/or
easy to administer, and validated to predict crash
severity of important medical conditions, functional
risk and/or ability to pass a performance-based,
deficits, and use of potentially driver-impairing
standardized, reliable and valid road test.
medications (see Chapter 9). Given the projected
At present, no one comprehensive tool is available, increase in prevalence of dementia, clinicians
in part because of the multifactorial nature of should also try to ascertain caregiver concerns and

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factor these into the assessment and intervention activity of daily living.
process.16 Clinicians should discuss transportation
A new model for occupational therapy generalists,
planning early in the course of disease and revisit
OT-DRIVE, has been developed to help assess
the topic frequently as the condition progresses.17
underlying functional abilities and determine when
to refer to DRS’s.18 Other initiatives are addressing
INCREASED AVAILABILITY AND
AFFORDABILITY OF DRIVER when to incorporate non-OT driving evaluators.19
REHABILITATION SERVICES
In the effort to keep older adult drivers on the
When the results of clinician assessment are unclear, road safely as long as is reasonable, increased
or when further correction of functional deficits access to and affordability of driver assessment and
through clinical team management is not possible, rehabilitation are essential. Clinicians need to be
DRS’s are an excellent resource. DRS’s can perform aware of DRS services and programs in their area
a focused clinical assessment, observe the older and use these resources whenever possible. Further
adult during the actual driving task, and train him research in this field is encouraged to demonstrate
or her in the use of adaptive techniques or devices the efficacy and cost-effectiveness of DRS services,
to compensate for medical conditions or functional and to create standardized off-road and on-
deficits (see Chapter 5). road driving tests that have respectable levels of
reliability, validity, and test stability. Correlating
Unfortunately, access remains a major barrier to use
results of on-road tests with prospective at-fault
of DRS’s by older drivers and referring clinicians.
crash data remains an important area of future
DRS’s are not available in all communities, and
study.
there may be too few to provide services to all
older drivers in need. Another common barrier is
INCREASED INVESTIGATION INTO USE OF
cost because driver assessment and rehabilitation
SIMULATORS AND COMPREHENSIVE AS-
are often not covered by Medicare and private SESSMENT METHODS AND TECHNIQUES
insurance companies.
Validated driver assessment technologies may help
The American Occupational Therapy Association make driver assessment more widely available to
(AOTA) is addressing both issues through a number older drivers. Simulated driving assessments offer
of initiatives. AOTA has devised a framework a number of potential advantages compared with
to increase the number of DRS’s within the on-road testing, including standardization of the
occupational therapy (OT) profession, including driving environment and scenarios encountered
strategies to promote older driver expertise among during testing, time efficiency, and safety for
current OT practitioners, curriculum content for testing high-risk individuals. However, a number
continuing education programs, and training of challenges exist, including potential trade-offs
modules for entry-level OT educational programs. between fidelity/realism versus cost/complexity
AOTA also continues to actively lobby for consistent of systems, tolerability and motion sickness in an
Medicare and insurance coverage of OT-performed older adult population, and complexity of scoring
driver assessment and rehabilitation, under the results. It remains to be seen whether simulator
premise that these services fall within the scope testing will remain an adjunct to the assessment
of OT practice and that driving is an instrumental process or can reliably substitute for on-road

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evaluations, particularly in a population less familiar Although each state has its own procedures,
with simulator use. It will be useful to determine potentially unsafe drivers are usually identified by
if familiarity with computers and electronic games one of four means: failure of the individual to meet
by successive aging cohorts affects the outcome licensing or license renewal criteria; report from the
of simulator performance and/or reduces crashes. individual or family; report from clinicians, DRS’s,
As interventions develop, it will be useful to law enforcement officers, and others; and judicial
determine the role of simulator training in relation report.
to classroom and on-road training. Naturalistic
To meet the standards for licensing, the driver
driving assessment utilizing instrumented vehicles
licensing agency initially requires individuals to pass
or technology placed in drivers’ own vehicles may
assessments of knowledge, vision, and driving skills.
offer a closer approximation of real-world driving
License renewal tends to be less stringent, with
experiences as instrumentation technology and
many states permitting renewal by mail. In recent
data analytic capabilities advance and become
years, certain states have increased their efforts to
more accessible. A recent textbook reviewed the
identify at-risk drivers by stipulating special renewal
potential uses of driving simulation.20
procedures based on different criteria. These
Efforts should continue to better understand the procedures include shortened renewal intervals,
complex role the central nervous system plays in in-person renewal, and mandatory reassessment of
operating a motor vehicle.21,22 As new diagnostic knowledge, vision, or driving skills.
tools are developed to better delineate different
Numerous studies have examined safety
disorders, it will be helpful to determine the
confounders for older adult drivers and
role these can play in determining driver risk.
hypothesized about the most beneficial approach.
State licensing agencies and driver rehabilitation
A review of studies in this area summarized the
programs are encouraged to investigate the use
evidence as suggesting that in-person renewal
of simulation and naturalistic driving to increase
was associated with lower fatal crash risk, license
availability of reliable driver assessment services
restrictions were associated with decreased
to the public. Such approaches, if integrated into
exposure, and more renewal requirements or
or aligned with current practices, could help form
medical reporting were linked with delicensure.23
an intermediate step between clinician assessment
Whether the latter findings are viewed as a positive
and driver rehabilitation or increase the licensing
outcome depends on individual perspective. If
agency’s capacity to offer specialized driver
those targeted for restriction or more intense
assessment to at-risk drivers.
renewal requirements are truly at increased safety
risk, then public safety may benefit. If not, those
ENHANCED ROLE OF THE STATE
LICENSING AGENCY IN PROMOTING individuals’ mobility may be adversely affected
SAFETY OF OLDER DRIVERS without clear gains in public safety.

As the agency that ultimately issues, renews, This area warrants further investigation. States
restricts, and revokes driver licenses, each are encouraged to maintain or adopt renewal
state’s driver licensing agency has the task of procedures for the most effective identification
distinguishing unsafe drivers from safe drivers. of at-risk drivers (see also Enhanced Role of the

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Medical Advisory Board, below). States are also while protecting his or her safety. For older adult
encouraged to base their standards for licensing on drivers who must relinquish their license, the
current scientific data. For example, visual acuity agency can provide guidance in seeking alternative
standards based on outdated research may be transportation and linkages to other agencies that
unnecessarily restrictive to all drivers and to older might be helpful in identifying available resources.
adult drivers in particular. In addition to the vision
At-risk drivers can also be brought to the attention
screens currently in use, driver licensing agencies
of the driver licensing agency by clinician referral.
may also wish to use newer tools (e.g., contrast
However, many clinicians are not aware of their
sensitivity and the useful field-of-view test) that have
state’s referral procedures, and others fear legal
been shown to correlate with crash risk.24,25 Some
liability for breach of confidentiality.30 With the
of these tools, along with other tests of function
advent of the Health Insurance Portability and
and driving skills, have been field tested by the
Accountability Act (HIPAA), clinicians may have
California Department of Motor Vehicles as part
questions about the extent and detail of patient
of its three-tier assessment system. Although this
information they should or can provide in a referral.
approach has many conceptual advantages, as
Driver licensing agencies can encourage clinician
tested there were limitations in its effectiveness.26,27
referral by establishing clear guidelines and simple
Many lessons can be learned from this large- scale,
procedures for referral (e.g., comprehensive referral
practical experiment, and all jurisdictions would
forms that can be accessed online) and promoting
benefit from a better understanding of what
clinician awareness of these guidelines and referral
worked well, what did not, and how to improve on
procedures. A 2012 review critiqued the forms used
the approach and implementation. In Maryland,
by 52 jurisdictions in North America and made a
a tiered approach is used to identify and assess
number of recommendations on best practices.31
medical fitness to drive in clients for whom decline
In many states, clinicians who refer older adults to
in cognitive function is raised in materials submitted
their state’s driver licensing agency are not granted
to the licensing agency. Most of the drivers in the
legal protection against liability for breaching the
cohort are older adult drivers. A free, five-element
patient’s confidentiality. Indeed, several states
screening test is routinely used to assess these
encourage or require clinicians to report impaired
individuals.28,29
drivers without specifically offering this legal
Driver licensing agencies could also create a more protection. Most statutes that provide immunity for
supportive system for older drivers. For example, reporting in good faith apply to physicians only.
the agency can work more closely with the at-risk
Clinicians should join advocacy groups in their
driver’s clinical team or the medical advisory board
states to pass fair laws that protect clinicians who
to correct functional deficits through treatment,
report in good faith and that ensure anonymity
if possible. Drivers with a high potential for
for reporting. Statutes providing immunity should
rehabilitation can be referred by the licensing
include all members of the clinical team who are
agency to a DRS to learn adaptive techniques and
involved in the care and evaluation of drivers for
devices. Licensing agencies can also consider the
whom there are concerns about medical fitness to
older adult’s driving needs by issuing restricted
drive (e.g., physicians, nurse practitioners, physician
(e.g., geographic or time of day) licenses whenever
assistants, DRS’s, social workers, pharmacists,
possible to help the driver maintain driving ability

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occupational therapists, nurses, psychologists, etc.). Motor Vehicle Administration reviews the fitness of
State legislatures are encouraged to establish or individuals to drive safely, while California’s MAB
maintain good-faith reporting laws that provide provides recommendations to licensing agency staff
immunity from breach of confidentiality lawsuits for use in developing policies that affect medically
for clinicians and others who report potentially and functionally impaired drivers.33 Many states lack
impaired drivers to their state licensing authority. an MAB or have one that is suboptimally used.

The state licensing agency should be involved in Each state driver licensing agency is encouraged to
outreach education to clinicians, law enforcement, enhance the role of its MAB to provide improved
drivers, and their caregivers to improve awareness capacity for assessment, rehabilitation, and support
of their obligations regarding the reporting of to older adult drivers. States that lack MABs are
medical conditions to the agency, which could also encouraged to create a multidisciplinary team
promote earlier interventions. A website with of medical experts to develop and implement
easily accessible information and resources is recommendations on the medical fitness of their
essential. Ideally, the medical review unit staff state’s licensed drivers. Such recommendations
and/or members of the medical advisory board should be based on the most current scientific data
should be available for outreach efforts and should and implemented in an efficient review process.
partner with appropriate agencies and groups (e.g.,
The National Highway and Traffic Safety
departments on aging, health care professional
Administration and the American Association of
societies, etc.) to facilitate outreach education.
Motor Vehicle Administrators completed a study of
Future older adult drivers will present with each state’s MAB practices.34 This project detailed
increasingly complex driving ability questions. the function of each state’s MAB, its regulatory
For instance, palliative care providers may be guidelines, and barriers to implementation of
confronted with an older adult’s determination screening, counseling, and referral activities.
to continue driving past the time of medical The executive summary of this study had many
fitness to drive. Such cases will challenge medical important recommendations for states that license
understanding, ethics, and legal counsel.32 Health medically impaired drivers, including:
care teams and licensing agencies should anticipate n Each state should have an active board to set
preparing for diverse driving capacity scenarios in standards and guidelines and to be involved in
the years to come. fitness-to-drive evaluations.
n Board members should be adequately
ENHANCED ROLE OF THE MEDICAL
ADVISORY BOARD compensated.

A medical advisory board (MAB) is generally n Clinicians should be granted immunity for
composed of state-licensed clinicians who work reporting.
in conjunction with the driver licensing agency to n National standards and forms, and referrals
determine whether mental or physical conditions for mobility counseling and/or DRS’s, should be
may impair an individual’s ability to drive safely. considered.
MABs vary among states in size, role, and level of
involvement. For example, the MAB of the Maryland

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INCREASED PUBLIC AWARENESS OF PROMOTION OF SELF-AWARENESS AND

MEDICATION ADVERSE EFFECTS THAT APPROPRIATE SELF-REGULATION
MAY IMPAIR DRIVING
Generally, older adult drivers modify their driving
Many prescription and over-the-counter medications routine by self-regulation. Some drivers participate
have the potential to impair driver performance. in educational programs or occupational therapy
Despite warnings on the label and counseling by interventions in an effort to decrease crash risk
clinicians, many older adults and their caregivers are by increasing their awareness of questionable
unaware of these risks. driving habits and learning adaptive strategies.
Occupational therapy interventions assist older
To address this problem, the National
adult drivers to develop objectivity in themselves
Transportation Safety Board (NTSB) recommended
and their driving environment.36 In late life, both
that the U.S. Food and Drug Administration (FDA)
women and men compensate for individual changes
establish a clear, consistent, and easily recognizable
in their health and capacity to drive, but a recent
warning label for all prescription and over-the-
study found that older women were somewhat
counter medications that may interfere with ability
more likely than older men to stop or limit driving
to operate a vehicle. This recommendation was
over time and that the factors associated with these
the focus of an FDA/NTSB joint public meeting
changes differed by gender.37 Another recent study,
held in November 2001.35 This meeting hosted
using naturalistic driving data, found that older
presentations of epidemiologic and controlled data
women accounted for many of the age and sex
on the effects of sedating drugs and crash risk, as
differences noted in driving frequency compared
well as presentations from innovators of devices
with younger and middle-age drivers.38
designed to test the degree to which drugs may
impair driving. As a result of the meeting, the FDA
OPTIMAL ENVIRONMENTS FOR OLDER
and NTSB concluded that steps must be taken to
ADULT DRIVERS AND PEDESTRIANS
better educate the public and prescribing clinicians
on adverse effects of potentially driver-impairing To promote aging in place, clinical teams are
medications. Efforts to increase older adult driver, encouraged to be realistic regarding environmental
caregiver, and clinician education and to clarify features essential for older adults. A recent
labeling for consumers are encouraged. review noted that older adults prioritized safety
considerations when making mobility choices.
Currently, manufacturers of medications do Additional desirable elements included aesthetics
not routinely test their products for effects on (clean surroundings), land use (commercial/
driving, and they are not required to do so. residential availability), format of street networks,
The identification and routine use of effective and the older adult’s cognitive and physical abilities
testing parameters to identify medications that to utilize these characteristics of their environment.39
may interfere with the ability to drive safely is Many older adult drivers are at a disadvantage on
encouraged. Similarly, such parameters could be roads and highways that are most heavily used by
used to identify medications that do not typically and traditionally designed for a younger population.
impair drivers when used as directed. In a telephone survey of 2,422 people 50 and
older, nearly one of five participants considered

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inconsiderate drivers to be a major problem. Other that cessation had negative effects not only on
commonly identified problems included traffic the former driver, but also on their spouses.45 On
congestion, crime, and fast traffic.40 the positive side, Rapoport reviewed the literature
on cessation interventions and found that while
These problems may be ameliorated through traffic
there are relatively few studies, with varying
law enforcement and better road and traffic control
methodology, they did show a benefit.46 While
designs. One of the top requests of the nearly 200
access to and ability to use technology can be a
Iowans (older drivers, transportation professionals,
limiting factor, several studies have shown that
and senior-related professionals) attending the
programs that provide technology access and
Iowa Older Drivers Forum was the enhanced
training can be beneficial.47,48 Ryerson described
enforcement of speed and aggressive driving
an ongoing collaboration of the AARP Foundation
laws.41 In terms of road and traffic engineering, the
and several organizations to determine if access to
Federal Highway Administration has recognized
and assistance with a ride hailing service will benefit
and addressed the needs of older adult drivers
health.49
in its Handbook for Designing Roadways for
the Aging Population, a supplement to existing Existing forms of transportation clearly need
standards and guidelines in the areas of highway to be optimized for use by older adults. In a
geometry, operations, and traffic control devices.42 telephone survey of 2,422 people 50 and older,
These design features may be implemented in ride-sharing was the second most common mode
new construction, renovation and maintenance of transportation (after driving); however, nearly
of existing structures, and “spot” treatment at a quarter of the survey participants cited feelings
certain locations where safety problems exist or are of dependency and concerns about imposing
anticipated. The Federal Highway Administration as a barrier to use. Public transportation was the
handbook is updated periodically to incorporate the usual mode of transportation for fewer than 5% of
latest research on the effectiveness of design and survey participants, with many citing unavailable
engineering enhancement to accommodate older destinations, problems with accessibility, and fear of
adult drivers. crime as barriers to use. Fewer than 5% used taxis
as their usual mode of transportation because of the
BETTER ALTERNATIVES TO DRIVING high cost.40 Until such barriers are addressed, these
Alternatives to driving are often less than ideal or forms of transportation will remain suboptimal for
nonexistent. When faced with the choice of unsafe many older adults.
driving or losing mobility, older adults may risk Transportation programs created specifically for the
their own safety and that of other road users by older population, such as senior shuttles and vans,
continuing to drive. exist in certain communities. A number of locations
A systematic review and meta-analysis confirmed have adopted the independent transportation
the potential negative effects of driving cessation.43 network model.50 These programs address the Five
One study demonstrated that out-of-home mobility, A’s of Senior-Friendly Transportation: availability,
as defined by the Life Space Diameter, decreased accessibility, acceptability, affordability, and
gradually over time with age, but substantially adaptability (see below).51 As the older population
with driving cessation.44 Curl and colleagues found continues to grow in numbers, the creation of

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new programs or expansion of existing ones is heterogeneity of the older adults these strategies
encouraged to keep pace with passengers’ needs, are designed to assess.
as well as stronger community outreach to increase
To address these issues, the roles and
awareness of such programs.
responsibilities of all parties involved in the process
The Five A’s of Senior-Friendly Transportation* need to be better defined, delineated, and
disseminated. Drivers, caregivers, clinicians, DRS’s,
n Availability: Transportation exists and is
other health professionals, licensing authorities,
available when needed (e.g., evenings,
and other community/state/national agencies and
weekdays, weekends).
organizations have a role to play. Society as a whole
n Accessibility: Transportation can be reached needs to be involved in a discussion of acceptable
and used (e.g., bus stairs are negotiable, seats thresholds of risk. In the process of identifying
are high enough, vehicle comes to the door, drivers potentially at increased risk of driving safety
transit stops are reachable). difficulties, a fair and appropriate assessment of risk
n Acceptability: Deals with standards, including is needed, identifying factors potentially influencing
cleanliness and safety (e.g., the transporting risk, considering interventions to lower risk, and
vehicle is clean, transit stops are in safe areas, identifying ways to facilitate the transition to driving
drivers are courteous and helpful). limitations or cessation if drivers prefer to do so or
if interventions are not possible or successful. More
n Affordability: Deals with costs (e.g., fees are
communication and coordination among the parties
affordable, vouchers or coupons are available to
involved is needed, as well as demonstrating the
defray out-of-pocket expenses).
effectiveness of different steps in the process, and
n Adaptability: Transportation can be modified or more information on feasibility and sustainability.
adjusted to meet special needs (e.g., the vehicle A holistic approach to the process is needed that
can accommodate a wheelchair, trip chaining is considers not just driving but mobility in a broad
possible, escorts can be provided). sense.53 An ideal system would also consider
* Source: Supplemental Transportation Programs for competing risks (e.g., falls, pedestrian safety) and
Seniors, The Beverly Foundation interventions that might benefit these as well. A
recent review highlighted progress in this area, as
The occupational therapy discipline has been at the well as issues that still need to be addressed.54
forefront of driving and community mobility issues.
This work reminds the clinical team to maintain a Evidence emerging in the last 10–15 years has
client-centered approach when counseling older allowed a realistic consideration of expanding from
adult drivers and to avoid the one-size-fits-all a decision regarding driving versus not driving,
perspective. Most clinical team members and or licensing versus revocation of licensing, to a
especially occupational therapists agree that often discussion that includes interventions. Interventions
no single element of physical and cognitive capacity have been developed that enhance relevant
is sufficient to require driving cessation, but rather functional abilities, driver awareness of deficits, and
a multidimensional approach is necessary.52 The clinician and caregiver awareness of how to address
number of different fitness-to-drive assessment the issue, as well as that facilitate the transition to
tools and simulator evaluation techniques reflect the driving cessation.55-64 Many of these studies have

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been preliminary or small scale, and much more

information is needed on how to broaden their
applicability and to determine the ancillary effects.

Although these and other questions need to

be answered, the good news is that much more
preliminary information is available now than at
any time in the past. Consequently, it is realistic
to think holistically of a more comprehensive and
integrated approach to driving safety and mobility
that better balances individual autonomy, mobility,
and safety with public health and safety. This holistic
approach reflects many current national, state,
and local efforts that more broadly consider the
interrelationship and integration of transportation,
health, housing, and environmental factors.
Examples of such initiatives include the Interagency
Partnership for Sustainable Communities by the
Department of Transportation, the Environmental
Protection Agency, and Housing and Urban
Development. A number of other initiatives with
similar or overlapping themes such as Aging in
Place, Complete Streets, and Livable Communities
have been advocated and investigated by AARP,
the Centers for Disease Control, and the American
Public Health Association, among others. Other
initiatives, such as the Access and Mobility
Partnership Grant Program (https://www.transit.
dot.gov/funding/grants/grant-programs/access-
and-mobility-partnership-grants) (formerly known
as the Rides to Wellness Program), administered
by the Federal Transit Administration of the U.S.
Department of Transportation, directly address
the link between transportation and health factors.
Programs such as these are to be encouraged and
studied, with the goal of enhancing and optimizing
their effectiveness, efficiency, and sustainability.

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57. Eby, D. W., Molnar, L. J., Shope, J. T., Vivoda, J. M, & Fordyce, T.
A. (2003). Improving older driver knowledge and self- awareness
through self-assessment: The Driving Decisions Workbook. Journal
of Safety Research, 34(4), 371-381. https://doi.org/10.1016/j.
jsr.2003.09.006.
58. Roenker, D. L., Cissell, G. M., Ball, K. K., Wadley, V. G., & Edwards, J.
D. (2003). Speed-of-processing and driving simulator training result
in improved driving performance. Human Factors, 45, 218-233.
https://doi.org/10.1518/hfes.45.2.218.27241.
59. Marottoli, R. A., Allore, H., Araujo, K. L. B., Iannone, L. P., Acampora,
D., Charpentier, P., & Peduzzi, P. (2007). A randomized trial of a
physical conditioning program to enhance the driving performance
of older persons. Journal of General Internal Medicine, 22, 590-597.
https://dx.doi.org/10.1007%2Fs11606-007-0134-3.
60. Marottoli, R. A., Allore, H., Araujo, K. L. B., Iannone, L. P., Acampora,
D., Gottschalk, M, Peduzzi, P. (2007). A randomized trial of an
education program to enhance older driver performance. The
Journals of Gerontology, Series A: Biological Science and Medical
Sciences, 62A:113-119. https://doi.org/10.1093/gerona/62.10.1113.
61. Stern, R. A., D’Ambrosio, L. A., Mohyde, M., Carruth, A.,
Tracton-Bishop, B., Hunter, J. C., Coughlin, J. F. (2008). At
the crossroads: development and evaluation of a dementia
caregiver group intervention to assist in driving cessation.
Gerontology & Geriatrics Education, 29, 363-382. https://doi.
org/10.1080/02701960802497936.
62. Ball, K., Edwards, J. D., Ross, L. A., & McGwin, G. Jr. (2010) Cognitive
training decreases motor vehicle collision involvement of older
drivers. Journal of the American Geriatrics Society, 58, 2107-2113.
https://doi.org/10.1111/j.1532-5415.2010.03138.x.
63. Meuser, T. M., Carr, D. B., Irmiter, C., Schwartzberg, J. G., &
Ulfarsson, G. F. (2010). The American Medical Association Older
Driver Curriculum for health professionals: changes in trainee
confidence, attitudes, and practice behavior. Gerontology &
Geriatrics Education, 31, 290-309. https://doi.org/10.1080/0270196
0.2010.528273.
64. Liddle, J., Haynes, M., Pachana, N. A., Mitchell, G., McKenna, K., &
Gustafsson, L. (2014). Effect of a group intervention to promote older
adults’ adjustment to driving cessation on community mobility: a
randomized controlled trial. Gerontologist, 54, 409-422. https://doi.
org/10.1093/geront/gnt019.

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CPT CODES ®

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APPENDIX 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®) 2018
Professional Edition. Chicago, IL: American Medical Association; 2017.

When selecting the appropriate CPT® codes for driver assessment and counseling, first determine the
primary reason for the patient’s office visit, as usual. 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 applied.

Table 1 Evaluation and Management—Preventive Medicine Services

If the primary reason for the patient’s visit falls under the E/M category of Preventive Medicine services,
choose one of the following codes:

99386 40–64 years old New Patient, Initial Comprehensive Preventive Medicine
99387 ≥65 years old 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 laboratory/diagnostic procedures.

These codes are used to report the Preventive Medicine E/M service for a new patient
(or one who has not been seen in 3 or more years), which may include assessment and
counseling on driver safety.

99396 40–64 years old Established Patient, Periodic Comprehensive Preventive Medicine
99397 ≥65 years old 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 laboratory/diagnostic procedures.

Note: Preventive Medicine service codes 99386-99387 and 99396-99397 can be reported only once per year. If an abnormality is
encountered or a preexisting problem is addressed in the process of performing this Preventive Medicine E/M service, then the
appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 should be added to the Office/Outpatient
service code to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day
as the Preventive Medicine service. See example below.

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

99401 Approximately 15 minutes Preventive Medicine, Individual Counseling

99402 Approximately 30 minutes Preventive medicine counseling and risk factor reduction interventions
99403 Approximately 45 minutes provided as a separate encounter will vary with age and should address such
99404 Approximately 60 minutes issues as family problems, diet and exercise, substance use, 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 on 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 the patient can be included in the
patient’s chart as additional documentation. (A sample letter can be found in
Chapter 6.)

Table 2 Additional Codes

The codes below can be used for administration of CADReS (see Chapter 3). If you complete the entire
assessment, you can include codes 95831, 96160, 96161 and either 99172 or 99173. The CADReS Score
Sheet can serve as the report.

95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk.
96160 
Administration of a patient-focused health risk assessment instrument (eg, health hazard appraisal) with
scoring and documentation, per standardized instrument.
96161 
Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the
benefit of the patient, with scoring and documentation, per standardized instrument.
99172 
Visual function screening, automated or semiautomated bilateral quantitative determination of visual acuity,
ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may include all or some
screening of the determination[s] for contrast sensitivity, vision under glare).
99173 
Screening test of visual acuity, quantitative, bilateral
The screening test used must employ graduated visual acuity stimuli that allow a quantitative estimate of
visual acuity (eg, Snellen chart).
99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407 Smoking and tobacco use cessation counseling visit; intensive, longer than 10 minutes
99408 
Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief
intervention (SBI) services; 15–30 minutes
99409 
Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief
intervention (SBI) services; greater than 30 minutes

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

Example

Periodic comprehensive preventive medicine evaluation for an 82-year-old woman with hypertension, diet-
controlled type 2 diabetes mellitus, and osteoarthritis. She is accompanied by her daughter, who requests
an evaluation because of concern about her mother’s driving safety.

During the appointment, the patient reports that she has had a cough and a low-grade fever over the last
week.

In addition to performing the comprehensive preventive medicine examination, the physician performs a
problem-focused history and examination to evaluate the cough and fever.

The following codes are applied:

99397 Established Patient, Periodic Comprehensive Preventive Medicine, ≥65 years old

99212-25 Office or other outpatient visit, with Modifier-25 indicating that a significant separately identifiable E/M
service was provided by the same physician on the same day as the preventive medicine service

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CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

PATIENT/CAREGIVER EDUCATION

n 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 clinicians to make copies of these handouts

for their patients, have them available in the office setting,
educate office staff to distribute them when appropriate, and
use them as talking points when discussing driving issues
with patients.

176
 Expert Information from
Healthcare Professionals Who
Specialize in the Care of Older Adults TSHEET
IP
Safety Tips for Older Drivers
Many older adults can drive safely well into their 80s or even beyond. However, since various
physical issues linked to aging can interfere with safe driving, it’s important that older drivers—and
the people who care for them—evaluate their needs to keep them safe while they’re on the road.

These tips and resources can help older drivers take

essential steps to maintain driving safety:
Buckle up before starting the car—every single time. If your seatbelt
Seat belts
is uncomfortable, adjust the shoulder mount or buy a shoulder pad
save lives.
that slips over the belt.

Talking or texting while driving distracts you from the road and
Mute your cell
other vehicles. Leave your cell phone on silent, and do not answer
phone.
it while you’re driving.

Eating can also distract you while driving. If you must eat or drink,
Do not eat pull into a safe area such as a parking lot and finish all refreshments
while driving. before getting back on the road.

As people age, their ability to process alcohol may change. Even one
Do not drink
cocktail or a glass of wine or beer may make older drivers unsafe on
and drive.
the road, especially when mixed with different medications.

Listening to music or audio books or even chatting with passengers can

Limit
distract some older drivers. If you’re among them, turn off the sound
distractions.
and avoid having conversations with others in the car.

Make sure there is always enough space between your car and the
Watch the
vehicles in front of you. Also, maintain a safe distance from traffic
road.
behind you.

APPENDICES 177
 Older adults, even those with good vision, can experience visual
Drive during daylight
problems at night. General darkness and glare from oncoming
as much as possible.
headlights makes it more difficult to see.

Rain, snow, fog and other hazardous conditions can be

Avoid driving in especially dangerous for older drivers. Let the bad weather
bad weather. clear before you get on the road. If you must travel, use public
transportation or a car service.

Try to avoid highways that have ramps, which can be dangerous for
Choose safer older drivers. Also making left turns on highways or busy roads. It’s
routes. better to go a little out of your way to avoid difficult intersections
and turns.

Peak rush hour traffic can be stressful for all drivers, but particularly
Try to drive when
for older drivers. Try to limit driving to those times when traffic is
there’s less traffic.
lighter.

Stressed or Stay where you are until you’re well rested and calm. Driving when
tired? you’re not at your best can be dangerous.

Some medications can make you feel drowsy and less alert than
usual, or can affect reaction time and other attention issues. Some
Know your
prescriptions may warn against driving while taking the medication.
medications.
Review your medications with your primary care provider or a
pharmacist to see if your medication(s) could lead to unsafe driving.

These professionals are trained to evaluate older drivers for the

following issues:
* Muscle strength, flexibility, and range of motion
Consult a * Coordination and reaction time
driving * Judgment and decision-making skills
rehabilitation * Ability to drive with specialized, adaptive devices
specialist.
After the evaluation, the specialist may recommend ways for you
to drive more safely. Suggestions may include special equipment
or training. You can find a specialist here: http://www.aded.net/.

APPENDICES 178 2
Investigate the CarFit program
CarFit is an educational program sponsored by the American Automobile Association (AAA), AARP
Driver Safety, and American Occupational Therapy Association. At a CarFit event, health professionals
and experts who specialize in helping older drivers will work with you to make sure your car is properly
adjusted for your safety. A CarFit exam takes about 20 minutes to complete. Find a CarFit program near
you here: https://car-fit.org.

New vehicle technologies

Recently, the American Automobile Association (AAA) and the University of Michigan Transportation
Research Institute (UMTRI) looked at 16 new vehicle technologies. They found that these six features
helped to reduce crashes and make driving less stressful for older adults.
™™ Forward collision warning
These systems, which are available in many newer cars, can warn you if you’re about to have a crash.
When a potential collision is detected, the car automatically applies the brakes. The AAA/UMTRI
study suggested that this technology might improve reaction times and reduce crashes by up to
20%.

™™ Automatic crash notification

Some cars are equipped with communication technology. In case of a crash -- typically one that
triggers airbags to go off --the car signals emergency services that you’ve been involved in a crash.
Emergency services can be notified about the crash without anyone having to call 911.

™™ Parking assist with rear-view display

Back-up cameras allow drivers to clearly see what’s behind them as they back up. This makes
parking easier. Some cars are also equipped with an obstacle-detection warning system, which will
notify you if you’re about to hit something.

™™ Self-parking systems
Some cars have technology that takes over steering while the car parallel parks itself.

™™ Navigation assistance
According to the study, turn-by-turn GPS systems make older drivers feel safer, more confident, and
more relaxed while driving. However, some of these systems may be distracting and difficult to use.
Make sure to choose one that is easy for you to use.

40 FULTON STREET DISCLAIMER: This information is not intended to diagnose health problems or to
18 TH FLOOR take the place of medical advice or care you receive from your physician or other
healthcare provider. Always consult your healthcare provider about your medications,
NEW YORK, NY 10038 symptoms, and health problems. February 2019
212.308.1414 TEL
©2019 Health in Aging Foundation. All rights reserved. This material may not be
THE OFFICIAL FOUNDATION OF 212.832.8646 FAX reproduced, displayed, modified, or distributed without the express prior written
THE AMERICAN GERIATRICS SOCIETY
[email protected] permission of the copyright holder. For permission, contact [email protected].

APPENDICES 179 3
 Expert Information from
Healthcare Professionals Who
Specialize in the Care of Older Adults TSHEET
IP
Testing Driver Safety
When it comes to driving, there is no set age when people become less safe behind the
wheel. Safety depends on both physical and mental health, which vary widely from person to
person. However, the following items can be considered as warning signs and suggest that you
should get tested for your ability to drive safely:
■ Getting lost in familiar areas

■ Ignoring traffic signs and signals

■ Becoming easily agitated or angered when driving

■ Falling asleep or being unable to concentrate when driving

■ Reacting too slowly to dangerous situations

■ Forgetting or ignoring driving basics – when to yield right of way, for example

■ Having trouble judging distances

Several tests and reviews can help determine how safe a driver an older adult may be.

If you feel that you are having difficulty driving safely,

consider taking these actions:

Start with a Have your primary care healthcare provider examine you for changes that may
good physical. affect your driving, including your fitness level.

Have your An optometrist or an ophthalmologist can evaluate your vision for problems
vision checked. that may reduce your ability to drive safely.

An occupational therapist trained as a driving rehabilitation specialist can

Get a driving evaluate your driving to see how safe you are when driving, or if you could
evaluation. benefit from having your skills rehabilitated. Occupational therapists can
thoroughly review your general skills and note areas that need improvement.

APPENDICES 180
 If you’re concerned that you may be having memory problems, dementia, or
Consider
other problems that affect your ability to think and make decisions, talk to your
cognitive
primary care provider. The provider can do some simple tests to assess your
testing.
mental skills and determine whether you have the mental ability to drive safely.

Many states have laws that require testing or other requirements for older
Check your drivers. Also, check your driver’s license to see when it’s time for renewal.
state’s rules. Learn more about specific state requirements here:
https://www.ghsa.org/state-laws/issues/mature%20drivers

Some medications can make you feel drowsy and less alert than usual, or can
affect reaction time and other attention issues. Some prescriptions may warn
Know your
against driving while taking the medication. Review your medications with your
medications.
primary care provider or a pharmacist to see if your medication(s) could lead to
unsafe driving.

Vision testing for older adults

https://www.aoa.org/patients-and-public/good-vision-throughout-life/adult-vision-19-to-40-
years-of-age/adult-vision-over-60-years-of-age?sso=y

Eye care for older adults

https://www.aao.org/eye-care-for-older-adults

Safety: Older adult drivers

https://www.cdc.gov/motorvehiclesafety/older_adult_drivers/

Resources Evaluations for older drivers

https://www.aota.org/about-occupational-therapy/professionals/rdp/articles/older-drivers.aspx

Dementia and driving

https://www.alz.org/help-support/caregiving/safety/dementia-driving

Self-Assessment test for older drivers

https://seniordriving.aaa.com/evaluate-your-driving-ability/

Organizations that provide testing and instruction for older drivers

https://one.nhtsa.gov/people/injury/olddrive/Driving%20Safely%20Aging%20Web/page8.html

Fitness-to-Drive Screening Measure Online

http://fitnesstodrive.phhp.ufl.edu/us/

40 FULTON STREET DISCLAIMER: This information is not intended to diagnose health problems or to
18 TH FLOOR take the place of medical advice or care you receive from your physician or other
healthcare provider. Always consult your healthcare provider about your medications,
NEW YORK, NY 10038 symptoms, and health problems. April 2019
212.308.1414 TEL
©2019 Health in Aging Foundation. All rights reserved. This material may not be
THE OFFICIAL FOUNDATION OF 212.832.8646 FAX reproduced, displayed, modified, or distributed without the express prior written
THE AMERICAN GERIATRICS SOCIETY
[email protected] permission of the copyright holder. For permission, contact [email protected].

APPENDICES 181
2
 Expert Information from
Healthcare Professionals Who
Specialize in the Care of Older Adults TSHEET
IP
Becoming a Non-Driver? Find Alternate
Transportation Options.
You’ve been concerned about the safety of an older adult because they are still driving and probably
shouldn’t be. Or, you might be worried about your own safety on the road, because you’ve realized that
your skills are no longer as sharp as they need to be to meet the demands of driving.
Driving often represents independence for older adults. Plus, getting to social events, medical
appointments, stores, recreational activities, etc, is important for healthy living as you age.
In fact, when older adults stop driving, their health can worsen. According to a recent study published
in the Journal of the American Geriatrics Society, giving up the keys nearly doubles the symptoms of
depression for older adults, and it may also increase declines in physical and mental health.

So when older adults stop driving, it’s crucial to maintain their

independence by creating alternative transportation solutions.

To do so, make a transportation plan. That means sitting down with the older
adult and determining where he or she drives on a regular or even occasional
Make a Plan
basis. Write down the specifics of each trip, including the general time of day,
the length of drive and stay, and any other details.

Then, research the travel options available in your area, and select those that
match the older adult’s specific needs for each trip. You might even want to list
them on your transportation plan.
Research
For example, if an older adult attends a weekly faith-based gathering, think
Travel
of different ways he or she could get there. Maybe people from the faith
Options
community could provide rides on a rotating basis. The key is to make sure
the older adult can continue to enjoy his or her usual activities by having
transportation options covered.

APPENDICES 182
 Transportation options will vary depending on your community.
These may include:

Some faith-based and community non-profit organizations often have volunteers who
Volunteer
will drive older adults to various places. Each organization offers different options.
programs. Rides are either free, on a donation basis, or through membership dues.

These include mini-buses and small vans run by public transportation, aging
organizations, and private agencies. These services may require you to make
reservations in advance but you often have scheduling options and flexibility.
Paratransit
Generally, the transportation provided is curb-to-curb, meaning you meet the vehicle
services. at the curb or roadside and get dropped off at a curb or roadside stop. Some services
will pick you up at your door and deliver you right to a specific address. Reduced fares
may be offered to senior citizens.

Some agencies provide drivers or escorts who will help you get from your home into
Door-through- a waiting vehicle. This service is particularly helpful to older adults who are disabled
door services. or need support while walking. Your local aging organization will help see if this is
available in your neighborhood.

Buses, trains and subways, trolleys, and other mass transit options have established
Public routes and times. They may offer reduced fares for older adults and may be accessible
transportation. for people with disabilities. Your local public transportation department can provide
information about fares, schedules, and accessibility.

Car services can be accessed several different ways. In some cities, you can simply hail a
cab on the street. (Make sure you can hail a cab on the other end of the trip as well.) You
might also be able to call ahead for a cab, or access rides from transportation network
Taxi services. companies (eg, Uber or Lyft). These companies often require downloading an app onto a
mobile device such as a cell phone and may only be available in larger population areas.
They also may require pre-registering and often providing credit card information.

n How much do rides cost?

n W
 hat method is used to charge for rides? Is it calculated by mileage or by
It’s a good idea time?
to do some n How far in advance you need to make a reservation?
research ahead n Are the vehicles accessible if you use a wheelchair or walker?
of time to find n W
 ill drivers help you in or out of the car if you need assistance or have
out the following packages?
information about
n W
 hat areas do the cars serve? Is there a maximum distance a driver will
any car services take you?
you might use:
n Are drivers properly licensed, insured, and checked by appropriate agencies?
n D
 o drivers use their own vehicles? If so, are they properly inspected,
registered and insured? Do they have safety belts and other safety features?

APPENDICES 183 2
 Depending on the older adult’s needs, these services may
also be helpful:

Some public transportation departments and local organizations that

support older adults provide free training classes to help both older adults
and people with disabilities access and use local public transit safely and
Travel independently. These services help individuals find the best routes to take to
training. reach their destinations, the cost of the trip, and methods of payment (exact
change, travel cards, tokens, discounts, vouchers, etc).
Many agencies also provide one-on-one demonstrations about how to ride
local public busses and trains.

In some communities, mobility managers can help guide you through

the various local transportation options. They understand the local
Mobility transportation network and can explain how it works. Your local aging
managers. organization or public transit agency may be able to connect you to a
mobility manager.

Area Agencies on Aging, Aging and Disability Resource Centers, and other
Transportation social service organizations may offer financial help with transit fares if you
voucher qualify (usually for lower-income older adults or people with disabilities). You
programs. have to apply for these programs, and you are still responsible for reserving
and accessing the transportation service you need.

800.677.1116 Elder Care Locator

https://eldercare.acl.gov/Public/Index.aspx
Resources
National Association of Area Agencies on Aging
https://www.n4a.org

40 FULTON STREET DISCLAIMER: This information is not intended to diagnose health problems or to
18 TH FLOOR take the place of medical advice or care you receive from your physician or other
healthcare provider. Always consult your healthcare provider about your medications,
NEW YORK, NY 10038 symptoms, and health problems. February 2019
212.308.1414 TEL
©2019 Health in Aging Foundation. All rights reserved. This material may not be
THE OFFICIAL FOUNDATION OF 212.832.8646 FAX reproduced, displayed, modified, or distributed without the express prior written
THE AMERICAN GERIATRICS SOCIETY
[email protected] permission of the copyright holder. For permission, contact [email protected].

APPENDICES 184 3
 Expert Information from
Healthcare Professionals Who
Specialize in the Care of Older Adults TSHEET
IP
Top Tips for Discussing
When it’s Time to Stop Driving

A
s someone you care for ages, you may become worried about his or her ability to continue to
drive safely. Some people can drive competently well into their 80s and
even beyond, while other people may have difficulties in their 60s or even younger.
When you’re responsible for an older adult’s overall safety, you may wonder when it’s appropriate to
start talking about safety behind the wheel.
Your first step in this process is to observe the older adult while driving.
The following situations can indicate possible driving problems:

n Getting lost, even when driving short, familiar routes

It’s important not to comment
n Failing to obey traffic signs or signals on or to criticize the older
n Cutting off other drivers, straddling lanes, or making wide turns driver’s behavior during the
drive. Instead, have a chat
n Reacting slowly to emergencies
about any issues after you’re
n Falling asleep behind the wheel or appearing inattentive both out of the car. Calmly
n Becoming easily angered or agitated state any unsafe actions,
n Using poor judgment, such as not yielding right-of-way without sounding judgmental
or angry. Be sure to be specific.
n Forgetting to use mirrors or turn signals or to check for blind spots
n Having trouble judging distances

If you see that the older driver had problems like the ones
mentioned above, consider these steps:

A healthcare professional can evaluate whether the older adult is physically

Schedule a able to drive safely. The provider can also advise you if any medications the
check-up. older adult is taking could affect his or her ability to drive safely.

An eye care professional, such as an optometrist or an ophthalmologist, should

Get a vision test. test the older driver’s vision to make sure they are visually able to drive safely.

APPENDICES 185
 There are professionals who specialize in evaluating whether older adults can drive
safely. A driving rehabilitation specialist (DRS) is a professional who has the skills
Have a to evaluate an individual’s overall ability to operate a vehicle safely. Based on the
professional individual’s performance the DRS will develop a plan, make recommendations about
strategies, equipment, and provide training to improve a person’s driving safety and
evaluate the
overall health and well-being. However, there are not many DRS’s in the United States.
older adult’s If you do not have access to a DRS in your area, an occupational therapist may also be
driving skills. able to evaluate many driving-related limitations. The American Occupational Therapy
Association (AOTA) and ADED: The Association for Driver Rehabilitation Specialists
are organizations that can assist you in finding a professional.

Know when to have Ask yourself: Do you feel comfortable letting the older adult drive you
the conversation. somewhere? The answer may be a signal that it is time to start the conversation.

Talk to others in the older driver’s circle. Ask them if they share your concerns about
the older adult’s ability to drive safely. Rehearse the discussion with them so you can
Enlist support.
be calm and caring. Depending on the circumstances, you may even ask one or more
of them to participate in the driving conversation with the older adult.

Make the You don’t want the older adult to feel like “everyone is ganging up on them,” so make
conversation certain to frame the conversation in a supportive, concerned way. Don’t let your own
compassionate. anxiety or fear about addressing driving skills lead you to sound angry.

Explain to the older adult why you’re worried about his or her driving. Cite examples:
Discuss specifics,
“Dad, you went through a stop sign last time we drove together. And you forgot to
but avoid blame. use your turn signals.” Or, “Mom, you got lost on the way to the supermarket.”

Be prepared for Driving represents independence to many older adults. When they think you might
resistance and be taking away their ability to get around, they may become defensive, even irate.
even anger.

Schedule time If the older adult resists what you’re saying or gets agitated, gently end the conversation.
for another talk. Let them take in what you’ve said, then revisit the topic a day or two later.

Make sure to take the time to hear what the older person thinks about his or her
Ask for the older
driving ability and honest feeling of security behind the wheel. It’s very possible that
adult’s opinion.
if you’ve noticed problems, he or she may have, too, and may feel vulnerable.

If the medical professionals and the driving specialist you consulted agree that it’s
Appeal to the
time for the older adult to stop driving, appeal to his or her sense of responsibility.
older driver’s Remind the older driver that driving poses a risk not only to self but also to others,
sense of respon- who could potentially be injured – or worse – in case of a crash. Older drivers might
sibility. want to think about how they would feel if they were to cause an injury.

40 FULTON STREET DISCLAIMER: This information is not intended to diagnose health problems or to
18 TH FLOOR take the place of medical advice or care you receive from your physician or other
healthcare provider. Always consult your healthcare provider about your medications,
NEW YORK, NY 10038 symptoms, and health problems. February 2019
212.308.1414 TEL
©2019 Health in Aging Foundation. All rights reserved. This material may not be
THE OFFICIAL FOUNDATION OF 212.832.8646 FAX reproduced, displayed, modified, or distributed without the express prior written
THE AMERICAN GERIATRICS SOCIETY
[email protected] permission of the copyright holder. For permission, contact [email protected].

APPENDICES 186
2
 Expert Information from
Healthcare Professionals Who
Specialize in the Care of Older Adults TSHEET
IP
Alternative transportation and other resources

D
riving is how many of us reach the services we need every day for activities such as health
care, nutrition, social activities, financial services, and shopping. There are many resources
which can be used to help access these activities and services when driving or other means
of transportation are limited. The following list may be useful for finding alternative transportations
and locating other resources as well in your area.

General Aging Resources

Eldercare Locator
https://eldercare.acl.gov/
800-677-1116 weekdays
The Eldercare Locator is a public service of the U.S. Administration on Aging that connects older
adults and their caregivers to local services.

National Association of Area Agencies on Aging

www.n4a.org/
Assists in finding resources for older adults in the local community.

Aging Life Care Association

http://www.aginglifecare.org/
520-881-8008
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 website above to find a local geriatric
care manager.

National Association of Social Workers (NASW)

http://www.helpstartshere.org
A social worker can provide counseling to an older adult, assess social and emotional needs, and
assist in locating and coordinating transportation and community services. To find a local qualified
clinical social worker, use the Find a Social Worker option on the Help Starts Here website.

APPENDICES 187
 Alternative Transportation Options

American Public Transportation Association (APTA)

http://www.apta.com/resources/links/
Find a local transportation provider in your state.

Easter Seals
http://es.easterseals.com/site/DocServer/Transportation_Solutions.pdf?docID=2081

Transportation Solutions for Caregivers

National Aging and Disability Transportation Center

https://www.nadtc.org/
Information on transportation options for older adults.

Coordinating Council on Access and Mobility

https://www.transit.dot.gov/ccam
A partnership of federal agencies working to improve the availability, quality, and efficient delivery of
transportation services to people with disabilities, older adults, and people with low incomes.

40 FULTON STREET DISCLAIMER: This information is not intended to diagnose health problems or to
18 TH FLOOR take the place of medical advice or care you receive from your physician or other
healthcare provider. Always consult your healthcare provider about your medications,
NEW YORK, NY 10038 symptoms, and health problems. February 2019
212.308.1414 TEL
©2019 Health in Aging Foundation. All rights reserved. This material may not be
THE OFFICIAL FOUNDATION OF 212.832.8646 FAX reproduced, displayed, modified, or distributed without the express prior written
THE AMERICAN GERIATRICS SOCIETY
[email protected] permission of the copyright holder. For permission, contact [email protected].

2
APPENDICES 188
 Drivers 65 Plus:
Check Your Performance
A Self-Rating Tool with
Facts and Suggestions for Safe Driving

AAA Foundation for Traffic Safety

APPENDICES 189
 Drivers 65 Plus

By the year 2030, one of every Introduction

five drivers in America will be
65 years of age or older. Freedom Think about what tasks you do every time you get behind the wheel
to travel by automobile will of a car. You must coordinate the actions of your hands, feet, eyes, ears,
continue to be an important and body movements. At the same time, you must decide how to react to
factor to maintain personal what you see, hear, and feel in relation to other cars and drivers, traffic signs
independence and mental health. and signals, conditions of the highway, and the performance of your car.
The central idea of this booklet These decisions are usually made close to other vehicles and must be
is to help you drive as long converted quickly into action — brake, steer, accelerate, or a combination
as safely possible. of these — to maintain or adjust your position in traffic. And these
decisions must be made frequently.
Age should never be used as the
As a mature driver, you bring a wealth of experience to the driver’s seat;
sole indicator of driving ability.
that is why, on average, drivers in their fifties and sixties have just about
In fact, drivers 65 and older
the lowest crash rates of anyone on the road. However, as some of the skills
represent a wide range of
required for optimal driving performance begin to decline at older ages,
abilities, and no individual should
research shows that crash rates begin to increase as drivers reach their late
have his or her driving privileges
60’s or early 70’s, and increase more rapidly after about age 75.
determined solely on their age.
However, it is not uncommon Additionally, your body is not as resistant to injury as it might have been
for some of the skills necessary 30 or 40 years ago. If you are involved in a crash, you are likely to suffer
for safe driving – vision, reflexes, more serious injuries as compared to a younger person in a similar crash.
flexibility, and hearing – to begin This makes it increasingly important for you to do everything you can to
to deteriorate as we age. keep your driving skills sharp and to minimize your chances of being
involved in a crash in the first place.
As a mature driver, you bring a wealth of If you notice that you are
experience to the driver’s seat.
beginning to experience some Purpose of this Booklet.
of these natural age-related
changes, you can adjust your This self-rating form is designed to help you examine your ability to keep
driving habits to keep driving driving safely. Through knowledge and self-awareness, you can make better
safely – after all, one of the most informed decisions about when to get behind the wheel and when to seek
critical assets for safe driving is other forms of transportation.
experience, and experience The rating form on the next page is for your private use.
does not decline with age. Answer the 15 questions as honestly as possible. Use the rating guide to
It’s important to recognize your compute your score and to identify your strengths and weaknesses.
limitations and to be aware of Next, read the Suggestions for Improvement section that corresponds to
everything you can do to be each question to see how you can improve your driving.
safe on the road.
Now, please follow the instructions on pages 2 and 3.

1
APPENDICES 190
 Drivers 65 Plus: Self-Rating Form

Scoring: There are 5 steps.

Always Some- Never
INSTRUCTIONS: For each of the following 15 questions, or Almost times or Almost
check the symbol (3) of the one answer that best describes you. Always Never Step 1: Write the Check Mark Total recorded in the
square on the previous page in the square X5=
to the right.
1. I signal and check to the rear when I change lanes ....................................... Step 2: Write the Check Mark Total recorded in the
triangle on the previous page in the triangle
2. I wear a seat belt ..............................................................................................
to the right. X3=
3. I try to stay informed on changes in driving Step 3: Multiply the number in the square by 5.
and highway laws and techniques................................................................... Step 4: Multiply the number in the triangle by 3.

4. Intersections bother me because there is so much to watch from Step 5: Add the results of Steps 3 and 4. YOUR SCORE IS
all directions ......................................................................................................
Interpretation of Score:
5. I find it difficult to decide when to merge with traffic on
The lower the score, the safer you are as a driver.
a busy interstate highway ................................................................................
The higher the score, the more danger you are to yourself and others.
6. I think I am slower than I used to be in reacting No matter what your score, look at the Suggestions for Improvement
to dangerous driving situations........................................................................ section for each area in which you checked a square or triangle.
These are the areas in which you can improve the most.
7. When I am really upset, it affects my driving .................................................
Score Meaning
8. My thoughts wander when I drive....................................................................
0 to 15 GO! You are aware of what is important to safe driving and are practicing what you
9. Traffic situations make me angry .................................................................... know. See the Suggestions for Improvement in the following section of this booklet,
to learn how to become an even safer driver.
10. I get regular eye exams to keep my vision at its sharpest .............................
16 to 34 CAUTION! You are engaging in some practices that need improvement to ensure safety.
11. I check with my doctor or pharmacist about how the medications
Look to the Suggestions for Improvement section to see how you might enhance your driving.
I take affect my driving ability. (If you do not take any medication, skip this question)........
35 and over STOP! You are engaging in too many unsafe driving practices, and might pose a hazard to
12. I try to stay informed of current information about yourself and others. Examine the areas where you checked squares or triangles. Read the
health and wellness habits................................................................................
Suggestions for Improvement section for ways to correct these problem areas.
13. My children, other family members or friends have
expressed concern about my driving ability..................................................... These scores are based on what drivers 65 and over have told us about driving practices and habits.
Your score is based on your answers to a limited number of important questions. For a complete evaluation
One Three
Note new headings: None or Two or More of your driving ability, many more questions would be required, along with medical, physical, and licensing

examinations. Nevertheless, your answers and score give some indication of how well you are doing
14. How many traffic tickets, warnings, or “discussions” with law
enforcement officers have you had in the past two years? ........................... and how you can become a safer driver.

In general, a checked square for an item reflects an unsafe practice or situation that should be
15. How many collisions (major or minor) have you had during
the past two years? ........................................................................................... changed immediately. A checked triangle means a practice or situation that is unsafe, or on its way
to becoming unsafe, if nothing is done to improve it. Checking circles is a sign that you are doing
Self Scoring: Count the number of checkmarks in the squares and record the total in the square below. what you should to be (and remain) a safe driver.
Follow the same procedure for the triangles and circles.
Most of the square and triangle answers represent practices or situations that can be improved by
most drivers. The following section contains suggestions for improvement, divided into each of
These are your Check Mark Totals. For score and interpretation, see next page. the 15 areas. You should focus on those areas for which you checked squares or triangles.

2 3
APPENDICES 191
 Drivers 65 Plus: Suggestions for Improvement
3 I try to stay informed on changes in driving and highway laws and techniques.
I signal and check to the rear when I change lanes. With new roads being built, new traffic signals being installed, and intersections being
1 converted into traffic circles or roundabouts in an increasing number of cities, it is critical for you
Checking rearview and side mirrors, looking to the rear to cover the blind spots, and signaling to continually refresh your knowledge of the roads and traffic patterns near where you drive.
well before your maneuver are the only ways to avoid hitting a car when changing lanes.
Knowledge of signs and symbols can help you, especially if your ability to see them is diminishing.
But why don’t you do these things all the time? In some cases, you might simply forget. In Sometimes, just knowing what the shapes of signs mean can help you anticipate their message.
observational studies older drivers report being unaware of having failed to look to the rear Familiarity and knowing what to do can eliminate hesitation and uncertainty when you need
before changing lanes or backing up. Many of our driving habits are exactly that – habits. And to make a quick decision.
we can stop being aware of our actions, especially if we’ve driven crash-free for a long time.
We all want to share the road safely, so we need to understand traffic laws, devices, signs,
Many older drivers stop looking over their shoulders because of decreased flexibility. and symbols. Here’s how you can learn more about them:
If you have arthritis, then you know how painful a quick look over the shoulder can be.
• Call, visit or go online to your state’s motor vehicle administration to obtain the current
If looking over your shoulder to check for traffic is difficult for you, try to: drivers licensing manual for your state. Study the manual as though you were taking the test.
• Drive with a partner to act as a co-pilot whenever possible. Ask if they have other ways for you to stay current.

• Install extra-wide rearview mirrors and side mirrors to decrease your blind spots. • Take a re-training or refresher course. Contact your local AAA club to find a course near
You’ll need to learn how to use the side mirrors correctly, because those of convex lens you or visit AAASeniors.com.
design can make objects appear smaller and farther away than they actually are. • Make a point of checking your local newspapers for changes in traffic patterns and special
• Ask your physician about medications and exercises that might improve your intersections or signage, so you feel prepared and confident.
flexibility; the AAA Foundation for Traffic Safety has a brochure available online at
AAAFoundation.org called A Flexibility Fitness Training Package for Improving Older
4 Intersections bother me because there is so much to watch from all directions.
Driver Performance to help you improve your flexibility.
Intersections are dangerous for all of us. You must interact with other drivers and pedestrians
• Take a re-training or refresher course that helps older drivers adjust to the whose movements and decisions are difficult to anticipate. In fact, crashes at intersections
limitations due to aging. Call your local AAA club to see if they offer a course. are quite common among older drivers, especially when left-turns are required.
• Make a concerted effort to be aware of your driving habits and decide to always How comfortable you feel around intersections can be an early warning sign that you need a
look before changing lanes. refresher course or other assistance. Listen to your instincts and take a good look at your driving
skills. What bothers you most about intersections? Is it an inability to handle all the information
I wear a seat belt. quickly enough? Are you unsure about how to position the car for a left or right turn? Do you find it
2
difficult to turn the steering wheel because of arthritis or some other physical problem? Is it hard to
Seat belts cut your risk of death nearly in half if you are involved in a serious crash, and of course, judge the speed of oncoming vehicles? Sometimes, this sort of analysis can lead you to solutions.
it’s the law in nearly every state. Even if you plan to drive only short distances under
ideal conditions, it makes sense to wear your seat belt every time you ride. If you find intersections difficult, review the following steps for improvement:
To provide optimal protection, seat belts should be worn properly with the • If one or two intersections on your regular routes give you particular trouble, study them while on
shoulder belt across your shoulder and upper thigh bones, because serious foot. Watch the problems other drivers have to handle. Notice how the traffic signals assist drivers
injury can occur if not worn properly. Fastening your seat belts is and pedestrians. This way you know in advance what the common problems are and how to handle
unquestionably the single best way to protect yourself in a crash. them when they occur. This kind of analysis can help you handle other intersections as well.
You can increase your chances of surviving a collision or reducing injury • Plan your trips to avoid busy intersections or use them at less congested times. Plan an alternate
by taking the following steps: route to avoid left turns from busy intersections. Remember that making three right turns can help
Wear
Wearyour
your seat belt
seat belt
correctly…
correctly... across
across your
your
• Wear your seat belt properly at all times. shoulderand
shoulder and chest
chest –- you avoid turning left. In many places you will be able to do this by driving straight through the
NOT under an
NOT under an arm, arm,
across
acrossyour
yourhip hipbones
bones –- intersection, turning right at the next street, and then making two more right turns. Then, you end
• If your seat belt is extremely uncomfortable or cannot be properly fastened, NOTyour
NOT yourstomach.
stomach. It’sIt’s
comfortable...it’s
comfortable… it’seasy.
easy. up driving straight through the original intersection in the direction that you originally wanted to go.
take it to a competent mechanic for alterations. Many cars have adjustable
shoulder belt mounts or you can buy devices that improve the fit.
*New
*New YorkYork
Belt Use
Medical
Coalition
Coalition
Medical
Society,
for Belt
for Safety
StateSociety.
Safety
of New York
Use
• Take a re-training or refresher course that helps older drivers adjust to the limitations of age.
State of New York
What you learn may give you the confidence to recognize that you can handle intersections correctly.
• If your car does not have an automatic reminder to fasten seat belts, leave
yourself a note on the dashboard or sun visor. Remind your passengers to buckle up.

4 5
APPENDICES 192
 5 I find it difficult to decide when to merge with traffic What can you do to improve your “emergency” skills?
on a busy interstate highway. • Take a re-training or refresher course that helps older drivers adjust to the limitations
Many drivers experience feelings of insecurity and nervousness about entering a busy interstate of age. There, you can learn and practice ways to improve your ability to more rapidly
highway or any high-speed road. If you dislike the speed of traffic and the number of cars on anticipate and avoid dangerous situations.
interstates or have stopped using them entirely, then you will probably want to improve your
• Visit Roadwise Review Online at SeniorDrivers.org, to use a free screening tool
skills so you can use them more confidently.
developed to help seniors measure certain mental and physical abilities important to driving,
If you live where interstates are convenient to access and you travel them often, you probably see end of this booklet for more information. A next step would be to visit an occupational
have gained experience and feel confident about driving on them. However, if you drive them therapist and have your physical and mental driving skills evaluated. In many cases, practice
infrequently or not at all, you might be fearful of what you “don’t know” about them. More cars, exercises can improve your skills. Many hospitals offer out-patient counseling.
faster traffic, and increased congestion can make interstates intimidating to any driver.
• Avoid driving in congested, fast-moving traffic, whenever possible.
Here are some suggestions for improving your skills on interstate highways:
• Keep yourself physically fit and mentally stimulated. Avoid driving if you are tired, ill, have
• If you decide that you do not know enough about interstates to drive on them safely and that been drinking, or have taken any other drug that slows your mental or physical responses.
reluctance to enter them is in part because of a fear of the unknown, take a refresher course to
• Exercise to maintain or increase your muscular strength and the flexibility of your joints.
learn how to use them properly.
Always check with your doctor before starting a new exercise program.
• If you feel you have the ability to drive on interstates, but want to improve your skills, ask
• If your joint and muscle impairments are serious, ask your doctor about medical, physical,
another experienced driver whose opinion you trust to ride with you and suggest what you
and surgical therapies. Anti-inflammatory drugs and various surgical procedures can lessen
should and should not do. Then, practice when traffic is less congested.
impairment sufficiently to permit safe driving.
• If you feel so uncomfortable on interstates that you feel you may be in danger, try to
• Consult an occupational therapist or driver rehab specialist to equip your car with devices
avoid them. There is always another, parallel route. You are your own best judge of whether
that compensate for losses of flexibility and strength and learn how to use them. Make sure
they are safe for you, regardless of how safe they may be for others.
your next car has power steering, power brakes, automatic seat adjustment, and other
features to help you control your car better. See the information on Smart Features for
6 I think I am slower than I used to be in reacting to Mature Drivers and CarFit at the end of this booklet.
dangerous driving situations.
Emergencies and dangerous situations may be relatively uncommon, but fast and safe reaction 7 When I am really upset, it affects my driving.
to them is essential. Most older drivers tend to have excellent judgment when driving. It is in
It takes only a moment of inattention to produce a collision. As you age, experience and
reacting to emergencies that some older drivers most markedly demonstrate a slowing down.
good judgment make you a better driver. However, if you were aggressive and hostile on
Older drivers can have trouble integrating information from several sources at once, and the road when young, you are likely to be much the same today. The difference is that now,
therefore respond more slowly to dangerous situations. because of decreased driving skills, you may not have the ability to recover from those
Responding quickly to a traffic situation requires that several skills be sharp. First, you must dangerous highway situations that arise out of aggression and hostility.
see or hear the danger. Second, you have to recognize that the situation is dangerous and Take the following steps to minimize the impact of your emotions on driving safely:
requires action. Third, you must decide how to act. And fourth, you must act appropriately.
• When you know that you are very emotional about something, delay driving until
A slight slowing down in each of these skills can result in a much slower overall response
you have calmed down.
time to traffic emergencies.
• Awareness is the first step toward controlling anger. The second step is handling it in a healthy
manner, such as taking a walk several times around the block or more if necessary, or talking
with a friend or a professional counselor. Getting behind the wheel in a highly emotional state,
whether joy or anger, diverts attention from the task of driving and invites trouble.

6 7
APPENDICES 193
 8 My thoughts wander when I drive. The worst part of anger is how drivers express it. If you find yourself driving erratically,
driving too fast, or tailgating someone “to teach them a lesson,” then you need to stop and
Driving is a complicated and demanding task, requiring
ask yourself: “Is it worth it?” Anyone with a heart condition knows that reacting to every little
continuous concentration and even momentary lapses can lead
annoyance and frustration with anger can be dangerous; we all need to understand that
to danger. Anyone can be distracted momentarily by accident,
reacting to driving situations with aggressive driving can be just as fatal as a heart attack.
but the number one focus of all drivers should always be the
important task of driving. Fortunately, there are many things you can do to make driving less stressful and make
your own responses less emotional:
Of course, you have probably seen drivers in animated
• Accept the fact that anger will do nothing to get you out of irritating traffic situations.
conversations or talking on cell phones and noticed how it affected their driving – driving
On the contrary, it may get you into collisions. Taking a few slow, deep breaths and forcing
erratically or drifting from their lanes. Other drivers drink coffee, groom themselves, or
yourself to smile are excellent stress-relievers.
try to glance at reading materials while driving. In an emergency, these inattentive drivers
may not be able to return from their diversion in time to take evasive action. • Choose to be a responsible driver. Recognize when you are becoming angry. Then examine
why anger seems to reach irrational proportions. Ask yourself: “Why am I getting upset?”
One area in which you have total control is your decision to give driving your full
Then, try to take the necessary corrective steps. Keep cool.
attention. Give driving the attention it deserves and you will buy yourself valuable
seconds of reaction time in an emergency. • Try to avoid the kind of traffic you know is likely to generate anger. The smoother the
traffic flow, the less the anger, and the fewer the collisions.
There are several things you can do to keep your thoughts from wandering:
• If you think that you might be converting fear of traffic into anger, take steps to boost
• Treat driving as a complicated task requiring your full attention.
your skills and confidence, such as taking a re-training or refresher course.
• If you catch yourself daydreaming or otherwise failing to concentrate on your
driving, identify what is distracting you and try to overcome it.
10 I get regular eye exams to keep my vision at its sharpest.
• Take the necessary steps to remove or reduce distractions, whether they are those
Eighty-five to ninety-five percent of all sensing clues in driving come through the eyes. Poor
over which you have control, such as turning off the radio, or those for which you will
visual capacity is directly related to poor driving. Reduced performance from faulty vision shows
need help, such as dealing with emotional issues.
up in delayed response to signals, signs, and traffic events in ways that can lead to a collision.
• As you drive, play the “What If” game to stay alert and mentally prepare for
Between ages 40 and 60 our night vision becomes progressively worse. Pupils become smaller,
driving emergencies. Ask yourself what you would do if certain situations occurred.
the muscles less elastic, and the lenses become thicker and less clear. A 60-year-old driver requires
10 times the light required by a 20-year-old.
9 Traffic situations make me angry.
As we age we also become more sensitive to glare, which makes driving at night difficult.
Anger behind the wheel comes out in dangerous ways. Most people trapped in
Your eyes’ lenses can become thicker and yellowed with age, resulting in a fogging vision and
slow-moving traffic feel frustrated, and this frustration can lead to anger at the situation.
sensitivity to glare. A 55-year-old takes eight times as long to recover from glare as a 16-year-old.
However, some people direct their anger at other people, instead of the traffic situation
itself. This can lead to inappropriate reactions, honking horns, yelling at other Drivers receive 98 percent of their visual communication through peripheral vision. Around
drivers, cutting others off in traffic, or blocking intersections. age 70, peripheral vision can become a serious problem and those with poor peripheral vision
have collision rates twice as high as those with normal peripheral vision.
When drivers become overly-emotional in reaction to a situation, it is a clear sign that
other emotions are the true cause and driving has become an outlet for expressing anger. Colors also become harder to see. For example, red colors do not appear bright to
many older eyes, and it may take some senior drivers twice as long as it took in earlier
Many emotions can turn into anger. Fear of other drivers who are driving recklessly, can years to detect the flash of brake lights.
bring on violent anger. Anxiety over being late and anger at other situations in one’s life
can also provoke unwarranted anger. All these emotions are counter-productive. Another visual ability that declines over the years is depth perception: how close or how far
you are in relation to a car or object ahead. This capacity is especially critical when trying
to judge how fast other cars are coming, which contributes to the problems you may have
in making left turns.

8 9
APPENDICES 194
 Aging does bring vision problems, but we all share these difficulties in a fairly predictable, It is important to avoid alcoholic beverages when taking medications. With few exceptions,
natural way. No matter how well you have taken care of your eyes, these problems will develop; combining alcohol and other drugs significantly multiplies the impairment of your driving
however, seeing a doctor on a regular basis is the only way to be sure that your vision is the skills. The only safe practice is to avoid alcohol completely if there is any chance that you
best it can be. Doctors cannot correct all vision problems, but only doctors can help you with will have to drive. One’s tolerance for alcohol decreases steadily with age. Food, mood,
those vision problems that are correctable, such as visual acuity (ability to focus) and fatigue, medication, general health, weight, and size of body can all make a difference in
disease-related vision loss. predicting overall effect. Keep in mind the penalties of driving while impaired by alcohol
or other drugs (medications included): heavy fines, jail sentences, and revocation of license.
There are several things you can do to handle the loss of vision that comes with aging:
You can ensure that your medications are not combining to impair your driving skills
• First and foremost, set up periodic examinations with your eye doctor. Tell the doctor
by taking the following steps:
that you are interested not simply in an eye-chart test, but in a thorough examination that
will help you to remain a safe driver. • Check with your local pharmacist or physician to determine what the side effects of
a prescribed medication might be and what, if anything, you can do to counter them,
• Take the corrective steps recommended by your doctor. If eyeglasses are prescribed, keep
particularly as they apply to driving. Also visit AAASeniors.com for information on
them up to date by letting the doctor know at once if they are not working well for you.
medications and driving.
If your doctor recommends a cataract operation, keep in mind that this is a simple, out-patient
procedure that may dramatically improve your vision. • If you have more than one physician prescribing medications, make sure all of them
know about all the drugs you are taking, both prescribed and over-the-counter.
• Enroll in an older driver training course where you can learn specific techniques for coping
Bring all your medicines with you when you go to the doctor.
with the limits imposed by aging eyes. Attend a CarFit event, car-fit.org, to learn how
to improve your comfort and safety behind the wheel, including properly adjusted mirrors to • Read all labels and instructions on prescriptions and over-the-counter drugs to determine
minimize blind spots in your field of view. You may also learn about how to use special devices, side effects and their relationship to whether you should drive. Keep in mind that
such as larger mirrors, that you can install. combinations of medicines can magnify their effects beyond the individual warnings.

• Accept the limits of “aging eyes,” and reduce the amount of driving you do after dark • Convince yourself that the only safe action is not to drink alcoholic beverages at all if
and at twilight (one of the most dangerous times). The chances of having a collision are three you intend to drive, and to refuse to ride with anyone who has been drinking or who
times greater at night than in daytime. you suspect might be impaired by one or more drugs.

• Avoid tinted windshields and always keep your windshield and headlights clean.
12 I try to stay informed of current information about
health and wellness habits.
11 I check with my doctor or pharmacist about how the medications
I take affect my driving ability. What you eat, how much you exercise, and regular visits to the doctor (and following
the doctor’s advice) can help you keep driving longer and extend your life.
While you might be wary of the effects of prescription drugs, even over-the-counter
drugs can reduce driving ability. Individual lifestyles have a direct relationship to longevity and quality of life. It all begins
with your attitude about how much control you believe you have over the quality of your
The drugs that slow us down generally also slow down or reduce our capacity to make
life. It ends with how much of it you are willing to exercise.
decisions and process information rapidly. And quick decisions are needed to maneuver
a vehicle safely. Tranquilizers or cold remedies, such as cold tablets, cough syrup, and We all want to be able to handle the demands of safe driving. To keep your license,
sleeping pills, can reduce driving ability. you must remain alert and quick to respond in emergency situations. You also need to
keep up to date about health habits that keep your mind and body in shape and able to
Combinations of drugs present another danger, because these combinations can bring on
handle the demands of safe driving.
unexpected side effects and bad reactions. If you have more than one doctor prescribing
medications without knowing what the others are prescribing, you could be in danger. True, this booklet has emphasized the reductions in driving skills that come with age.
But even though research points to changes in the central nervous system as the culprits,
Another drug, which you may not think of as a drug, with this same effect is alcohol.
you can reduce this slowing down with increased motivation to improve and stay in shape.
Alcohol has a powerful impact on our total system, physical and psychological.
Exercise reduces the extent of slowing, and extended exercise may eliminate it completely.

10 11
APPENDICES 195
 Learn to appreciate the close ties between personal health habits and driving skills.
14 How many traffic tickets, warnings, or “discussions” with
The same attitude that encourages you to remain informed on health practices will law enforcement officers have you had in the past two years?
also help you to feel in control of your future as a driver. You can stay informed by
Some older drivers are aware of their limits and cope with them. Others, however,
following these steps:
overestimate their real capabilities and do not adjust their driving habits. The most
• Be realistic about how much control you have and want in terms of health habits common mistakes among older drivers include failure to yield, failure to observe signs
as they relate to your life in general and to your driving. and signals, careless crossing of intersections, changing lanes without due regard for
• Learn more about the relationships between good health practices and how they others, improper backing, and driving too slowly. Inattention and having too much
can help you drive safely longer. Keep in mind that the slowness that comes with aging information to handle at one time seem to be the root of most of these conditions.
can be deterred or overcome by motivation, regular exercise, and practice. There are several positive steps you can take if you have received traffic
tickets or warnings:
• Take as much control as you can of your health habits and lifestyle, recognizing
the obvious connection between command of personal health and ability to drive. • Examine why you got the ticket or warning to determine the true cause. Did you
miss a stop sign because you were inattentive or because you simply did not see it?
• Understand the value of nutrition, exercise, medical check-ups, and the effects of
Then act on that information. This booklet contains several specific recommendations
medications, drugs, and alcohol. Your doctor can give you information about all of
for particular problems.
these areas and tell you where to get more information.
• Use the citation or ticket as a warning sign. Act quickly, since citations relate
13 directly to collisions.
My children, other family members or friends have
expressed concern about my driving ability. • Enroll in a driver training course where you can brush up on your driving skills
and learn new ways to handle the challenges faced by older drivers.
It is difficult to accept criticism, but it can be a valuable source of information
about your driving skills.
15 How many collisions (major or minor) have you had during
Listen to criticism, so you can improve your driving skills and avoid collisions. the past two years?
Once you start having collisions, the law can take your license away.
A collision is the best predictor of another collision. One collision is often a signal that
Here are some suggestions for how to listen to criticism and comments and turn
others are on the way. Denial of diminishing skills is the older driver’s greatest danger.
them into a positive effect on your driving:
Denial results in a continuation of the most dangerous driving habits and keeps the
• Lend an open ear to the comments of those concerned about your driving, driver from learning new and better ways to drive. Without correction, dangerous
and keep an open mind. Be sure that you are not dismissing the value of these driving habits can lead to tragedy.
comments out of denial.
If you have been involved in a collision, act at once by taking one or more
• Look for clues to overcome the dangers of those comments that you judge as valid. of the following steps:
It is possible that a driving refresher course or corrective action, such as treatment for • Remember that your insurance may be cancelled if you are involved in too many
faulty vision, might help. collisions, even minor ones.
• Look at your responses to the other questions in this self-evaluation. • Take a refresher course. Even if the collision was not your fault, you will learn valuable
Be very honest with yourself, so you can locate specific problem areas and correct them. defensive driving techniques that will help you anticipate trouble before it happens.
Human beings are never too old to learn new skills.
• Ask someone whose judgment you trust to ride with you and tell you when you
• Begin to prepare for the day when driving will no longer be possible for you, so you forget to signal or do something else that is unsafe. It is hard to pay attention to traffic and
can remain mobile after you stop driving. With adequate planning, a non-driving life assess our own skills at the same time. An objective assessment is always enlightening.
does not have to be restrictive.
• If your collision(s) occurred at night or in bad weather, and you suspect that these
factors contributed to the collision, avoid driving at these times.
• Begin to prepare for the day when driving will no longer be possible for you, so you
can remain mobile after you stop driving. Be honest with yourself; if you are a danger
on the road, take responsibility and either improve your skills or stop driving.

12 13
APPENDICES 196
 Driving Improvement Courses DriveSharp
AAA offers both classroom and online driver improvement courses, including a course DriveSharp is a computer-based software with three interactive exercises clinically
designed for older drivers, the Mature Operator Course. Contact your local AAA or proven to help you see more; improve your ability to monitor multiple moving objects - like
CAA club to find out about driving improvement courses available in your area. pedestrians, bicyclists, and other cars; and increase your processing speed. Using DriveSharp you
To reach your local AAA office, use your phone directory or call (407) 444-7000. can spot and react to things more quickly, improve your short-term memory; and cut your risk
of a car crash by up to 50 percent. Visit DriveSharpNow.com for more information.
CarFit
SeniorDrivers.org
Developed as a community-based activity, the CarFit program is designed to improve
the “fit” between mature drivers and their vehicles followed by actions they can take SeniorDrivers.org is a wonderful resource for seniors, their family, and researchers to find
to enhance comfort and safety behind the wheel. Developed in collaboration with the in-depth information about senior driving. The site offers screening programs to test driving
American Society on Aging, AARP and the American Occupational Therapy Association, skills, training programs to help seniors improve skills and information about alternative
the program also provides an opportunity to open a positive, non-threatening transportation options. It also has a searchable database containing state specific licensing
conversation about older driver safety and wellness. In addition, CarFit offers specific, information pertaining to senior drivers. Roadwise Review Online, DriveSharp brain training
practical community resources to help older drivers maintain and strengthen their and other senior related brochures are all available through the site.
wellness to extend their safe, independent driving years.
AAASeniors.com
Smart Features for Mature Drivers This web site provides expert advice about how aging affects one’s ability to drive safely.
In partnership with the University of Florida’s National Older Driver Research and Users also will find a step-by-step guide on how to begin a conversation with an older driver
Training Center, AAA developed a resource guide that identifies vehicle features about the need to work together to develop an action plan for the transition from older
that can assist drivers with visual, physical and mental changes that are frequently driver to passenger. Additionally, users will find a variety of tools and resources from
encountered as they age. Smart Features for Mature Drivers addresses conditions educational brochures and driver improvement courses, to skill assessment tools and
often faced by seniors, highlights features that best address each condition and free community-based programs.
provides examples of vehicles exemplifying those features.

Roadwise Review Online

Roadwise Review Online is a free screening tool developed to help seniors measure
certain mental and physical abilities important to driving. It identifies and provides
early warning about declines in critical safe driving abilities. This is one of the first
Internet-based self-screening tools available to consumers using scientifically validated
measures that predict the risk of causing a crash due to age-related functional decline.
It complements and supplements the Performance Checklist in this brochure.
You can access Roadwise Review Online at SeniorDrivers.org.

14 15
APPENDICES 197
 If you notice that you Notes:

are beginning to experience

some natural age-related
changes, you can adjust your
driving habits to keep driving
safely – after all, one of the most
critical assets for safe driving is
experience, and experience
does not decline with age.
It’s important to recognize your
limitations and to be aware of
everything you can do to be
safe on the road.

16 17
APPENDICES 198
 AAA Foundation for Traffic Safety is a 501(c)(3) non-profit organization.
The Foundation’s mission is to prevent traffic deaths and injuries
through research into their causes and to educate the public about
strategies to prevent crashes and reduce injuries.

AAA Foundation for Traffic Safety 202-638-5944

607 14th Street, NW, Suite 201, Washington, DC 20005
www.aaafoundation.org

AAAFTS
APPENDICES 199 AAAFTS
 How to
Understand &
O
Influence
lder Drivers

APPENDICES 200
 How to Understand and Influence Older Drivers i

Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Talking About Driving Safely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Step 1: Collecting Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Step 2: Developing a Plan of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Step 3: Following Through on the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Developing a Mobility Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

APPENDICES 201
 How to Understand and Influence Older Drivers 1

PREFACE
For most of us, driving represents freedom, control, and competence. Driving
lets us go to the places we want or need to go. For many of us – even as we get
older – driving is important economically. We drive to get to and from work,
and sometimes as part of our jobs. Driving is important socially; it lets us stay
connected to our communities and favorite activities.

Driving appears to be relatively easy, but in fact it is a complex skill. Our

ability to drive safely is affected by changes in our physical and mental
conditions. Many of these changes take place as we get older, though in
different ways and at different times.

Research shows that age is not the sole predictor of driving ability and safety.
But there is ample evidence to show that most of us experience age-related
declines in our physical and mental abilities – declines that can signal a
greater crash risk.

One key to safety is knowing when a driver is at increased risk – even if we

ourselves are that driver. So we must know what signs to look for, and pay
attention to them. We need to understand how our driving environment
changes, and what we should do to respond to those changes. We can
learn about community resources that can keep us driving safely longer or
keep us connected to the activities in our lives if we must cut back or stop
driving altogether.

Driving or riding in a car is how most older adults get around. Most people
65 and older change how they drive as they age, choosing to drive only
during daylight hours, for example, or limiting where they drive, or cutting
back on how often they drive. This booklet helps families and friends of older
drivers understand when and how such changes may be needed and how
to keep older persons better connected to the people and activities that are
important to them.

This booklet is also intended to broaden the discussion about older driver
safety and mobility. It:

w gives information on helping older drivers make informed decisions about

their driving behavior, and
w lists suggestions on how to begin conversations with the older driver
about safety concerns. These conversations seldom happen often enough,
and when they do, the older person fears – sometimes accurately – that
someone is trying to take the car keys away. Unfortunately, discussions
about continuing to drive often begin too late. And very often, families are
asking the wrong questions.

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2 How to Understand and Influence Older Drivers

The decision about driving for older adults is an emotionally charged issue,
but it does not have to be that way.

TALKING ABOUT DRIVING SAFELY

Talking with an older person about their driving is
often difficult. Most of us delay that talk until the
person’s driving has become what we believe to be
dangerous. At that point, conversations can be tense
and awkward for everyone involved. But there are
things you can say and do to make those conversations
more productive and less tense.

To hold such a discussion you should take three steps:

w collect information;
w develop a plan of action; and
w follow through on the plan.

Step 1: Collecting Information

The first step requires family and friends to collect information about what is
happening with the older driver. This takes time and may require gathering
information from a variety of people who have opportunities to observe the
older person’s driving.

The more information you collect, the better and more complete a picture of
the driver you will have, and the more informed your discussions can be. The
information can help you, other family members, health care professionals,
and the older driver decide what needs to be done.

A word of caution: It is not uncommon for families, caregivers, and friends

to be wrong in their judgment of a driver’s risk or driving ability. A person’s
driving performance – not age – is what determines fitness to drive.
Collecting a variety of information can give you more confidence in the
accuracy of the determination that something needs to be done.

Even collecting the best information and planning ahead does not mean the
decision about what to do with an at-risk or unsafe driver will be easy. But the
information and planning can give all concerned more assurance that the best
interest of the older driver is at the center of the decision making process.

Your observations

Your concern about the driving behavior of a family member or friend

may stem from your observations of the person driving, stories about the
APPENDICES 203
 How to Understand and Influence Older Drivers 3

driver, or both. It’s important to turn that concern to action. Be deliberate

and careful about recording your own observations and observations of
other people about the driver. Are there trends that signal the person may
be at increased risk while driving? Be sure to date the written notes on
your observations. If the driver’s physician becomes involved in the driving
decision at a later time, the dated notes will become helpful.

To get the most complete picture, collect information not only about their
driving but also about other personal indicators (described below) because
these may signal the person is at risk while driving.

Driving Observations

Ideally, you will have a conversation about your interest in ensuring that
the driver remains safe on the road. Explain that riding with the driver is
the best, most practical way to make observations about his or her driving.
Another option may be to follow the driver in your own vehicle.

You should watch the person drive at different times of the day, in different
types of traffic, and in different road conditions and weather. Over time, a
picture will emerge of things the driver can do well and things the driver may
not do as well.

You should be paying attention to make sure that the driver:

w stops at all stop signs and looks both ways to check for cross traffic;
w stops at red lights;
w appropriately yields the right-of-way;
w responds properly to other vehicles, motorcyclists, bicyclists, pedestrians,
and road hazards;
w merges and changes lanes safely; and
w stays in the lane when turning and driving straight.

In addition, you want to observe whether the person is:

w slowing or stopping inappropriately, such as at green lights or in

intersections;
w driving too fast for road conditions;
w driving so slowly as to impede the safe flow of traffic;
w driving aggressively; or
w getting lost routinely on routes that should be familiar for the driver.

Obviously, some of these driving behaviors pose an immediate concern.

Drivers must stop at red lights and stop signs, and yield to other cars as the
APPENDICES 204
4 How to Understand and Influence Older Drivers

traffic laws require. Failure to do these things puts the driver and others at
extreme risk and requires immediate action to stop the driver.

Non-Driving Observations

Even when older people are not in the car, their actions,
statements, or even the way they look may cause you
concern or may indicate a problem that could threaten
their safety when they are driving. Some of these things
you see and hear may be triggered by major events
happening in the person’s life. These could include
the loss of a spouse or a close friend. But an illness or
changes in one’s medications can also make it hard for
the person to drive safely.

No single sign can be taken as a warning that the person is at risk or is an

unsafe driver. But if you observe several of the warning signs, you should
strongly consider taking action to help.

Such danger signals may include:

w forgetfulness (frequent and combined with other signs);

w unusual or excessive agitation;
w confusion and disorientation;
w loss of coordination and trouble with stiffness in joints;
w trouble walking, swallowing, hearing, or following verbal instructions;
w dizziness when changing positions, tripping, and falling;
w shortness of breath and general fatigue; and
w difficulty following verbal instructions, and/or giving inappropriate
responses to those instructions.

At some time or another, many of us may have difficulty with some of the
items above. But if you frequently observe these behaviors or signs in a family
member or friend, they likely signal the need for you or a health professional
to take action. These behaviors can indicate the person is at risk if he or she
continues to drive.

Driver Self-Assessment

In addition to your own and others’ observations about the older driver,
encourage the person to evaluate his or her own driving performance. Several
organizations have free self-assessment guides that a person can use. A self-
assessment cannot solely determine whether or not the person is a safe driver.

APPENDICES 205
 How to Understand and Influence Older Drivers 5

But an assessment may prompt the person to be more open to a conversation

with you and other concerned individuals about driving.

w AAA clubs have an assessment tool called “Roadwise Review” that

people can use on their computers at home. Roadwise Review takes users
through a series of brief tasks that examine a person’s vision, reaction
time, and other measures related to driving safety. It also directs users to
sources of more information about driving safety. Some AAA clubs charge
for the screening tool, while others give it away free to members.
w AARP’s Driver Safety Program offers its “Are You a Smart Driver” self-
assessment quiz, which asks drivers to answer ten questions about today’s
driving environment and how they react to driving on today’s roads. Go
to www.aarp.org/home-garden/transportation and click on the link in the
“Are You a Smart Driver?” box.
w The AAA Foundation for Traffic Safety has a self-rating tool (http://
seniordriving.aaa.com) that asks a person to respond to 15 statements
about driving situations and gives suggestions based on the person’s
answer.
Again, the value of these screening tools listed above is to prompt a person to
talk with family and friends and health care professionals, and, if needed, to
seek a more formal assessment of driving skills.

Observations of others in your community

Friends and professionals in the community often stand ready to help you
get a more complete picture of the person whose safety may be at risk. In
developing a complete picture of the older driver, however, it is crucial that
you respect that driver’s dignity, privacy, and personal autonomy.

If you live in the same city or town, keeping tabs on how well a family
member or friend is driving is easier than if you don’t live nearby. But
either way, you need to build a network of helpers. They may be able to give
you information to help determine whether action is needed to keep the
older adult driver safe and sound.

Some members of the network – health care professionals including eye care
specialists, pharmacists and physicians – cannot speak with you unless and
until they have a signed release form from the driver.

Other Resources

Collecting information helps you develop an action plan, if one is needed, to

enhance the safety and mobility of the older person. It can also help you to
determine if actions need to be taken to reduce a person’s driving risk.

APPENDICES 206
6 How to Understand and Influence Older Drivers

Physicians and law enforcement officers are often the first people families and
friends go to when they seek outside help for a person they believe to an at-
risk or unsafe driver.

Other community resources also exist to help you build a better action plan.
These include your local:

w Area Agency on Aging;

w Driving Rehabilitation Specialist
w Department of Motor Vehicles office
w AAA (American Automobile Association) and AARP Driver
Safety Programs
w Alzheimer’s Association Chapter

Area Agencies on Aging

A network of more than 650 Area Agencies on Aging has been established
nationwide to provide information about virtually all programs and
services that are helpful to older people, their families, and caregivers. In
many cases, Area Agencies can provide information about transportation
choices available in the community. An agency may provide some of those
programs and services directly or may arrange for them through contracts
with other community service organizations. Call the Eldercare Locator at
800-677-1116 and ask for your local Office on Aging, or go to the web site
at www.eldercare.gov.

Driver Rehabilitation Specialist

A driver rehabilitation specialist can provide an in-depth evaluation of a

person’s driving. The specialist can determine if and how a particular disease
or condition such as Parkinson’s, stroke, or diabetes is affecting a person’s
driving. The specialist, who is often an occupational therapist, may offer
interventions such as training to improve the person’s driving safety. The
specialist also may suggest installing specialized equipment in the vehicle to
keep a person driving safely longer, as well as provide the training on how to
use that equipment.

To find a driving rehabilitation specialist near you, go to the American

Occupational Therapy Association’s Older Driver Resource Center at
www.aota.org/en/Practice/Productive-Aging/Driving.aspx, or call the
Association of Driver Rehabilitation Specialists at 866-672-9466, or go to
its Web site at www.aded.net. You also can call hospitals and rehabilitation
facilities in your area to find an occupational therapist to help with the
driving skills assessment and intervention.

APPENDICES 207
 How to Understand and Influence Older Drivers 7

Department of Motor Vehicles

If, based on your personal observations or knowledge, you are concerned

that a family member or friend has a medical condition or has experienced
a mental decline that would lead to unsafe driving, contact the State’s
Department of Motor Vehicles (DMV) where the older driver lives.

In almost every State, a family member can report a driver to the DMV by
writing a letter. Your letter should describe specific examples of what you
consider to be unsafe driving behavior and/or medical conditions that you
believe place the driver at risk. The DMV is required to carefully
examine your claims to ensure the driver is not being harassed
unfairly. Depending on your State, the letter you write may or
may not be confidential, meaning the older driver could find out
you have written the letter.

Even if the driver is re-examined and passes the required tests,

the DMV may still require future periodic reviews. The DMV
may require the driver’s physician to submit a report every so
often. This would most frequently occur in cases involving an
individual who has had seizures, for example. The DMV also
might require periodic road tests, such as for people with progressive medical
conditions or some forms of dementia. Finally, the DMV may require the
driver to submit a report from an eye care specialist if the person has a
progressive eye disease such as macular degeneration.

Before contacting the DMV about the person’s driving behavior, a family
member or friend should carefully consider sitting down with the driver first
to discuss the concerns and possible plans of action that best meet everyone’s
needs and concerns.

AAA/AARP Driver Safety Programs

Several national organizations offer educational programs for older adult

drivers. These “refresher” courses present participants with up to 10 hours
of classroom tips and reminders about driving safely on today’s roads.

AARP’s Driver Safety Program is the largest national program that educates
older adults on driving safely, self-assessment, and finding transportation
alternatives. Go to www.aarp.org/home-garden/transportation/driver_safety
and click on the link in the “Find a Class Near You” box.

The AAA and the National Safety Council also offer courses through many
of their local offices. Insurers in most States offer a car insurance discount for
individuals who complete these classroom “refresher” courses. Sometimes the
discount applies for several years after the course is taken. At that time, however,
the individual must re-take the course to renew the insurance discount.
APPENDICES 208
8 How to Understand and Influence Older Drivers

Alzheimer’s Association Chapter

For someone who has been diagnosed with Alzheimer’s disease or other
dementia, the issue is not whether the person will have to stop driving, it is
when that must happen. There are some early and clear warning signs that
Alzheimer’s is affecting a person’s ability to drive safely. These signs include,
but are not limited to, when the driver:

w drifts out of the lane;

w becomes confused when exiting or entering a highway;
w has trouble making turns, especially left turns;
w gets lost in familiar places; or
w stops inappropriately – such as at green lights or in the middle of an
intersection when not turning.

Local Alzheimer’s Association chapters or local Alzheimer’s support groups

have caring people with expertise in helping families and caregivers deal with
the driving issue. To find your local Alzheimer’s support group:

w contact your local Area Agency on Aging

Call the Eldercare Locator at 800-677-1116
Monday through Friday, 9 a.m. to 8 p.m. (ET),
or go on-line to www.eldercare.gov.
w Go on-line or call the Alzheimer’s Disease Education and Referral Center:
http://www.nia.nih.gov/alzheimers.
800-438-4380

Step 2: Developing a Plan of Action

In Step 1, you were encouraged to collect a broad sampling of information

about the person’s driving, and other behaviors and actions. From this
you will need to look at options for formally assessing driving skills, and
transportation resources other than driving available in the community.

Once you have this information, sit down and talk with the person to
determine:

w Is the person driving safely within the acknowledged limits of his or

her capabilities?
w If there is a problem, is it correctable?

w Do other transportation options need to be identified?

APPENDICES 209
 How to Understand and Influence Older Drivers 9

Tips for Conversation

If the information you collected indicates a safety problem, you can do

several things to increase the likelihood that a conversation about driving will
go well.

1. Base the recommendations in the action plan on the observations from

Step 1 (page 2).
2. Be sensitive to ways you can help older adults
preserve their self-respect. Try reasoning and use
compassion. Appreciate the significance of a driver’s
license to the older person. Empathize with and listen
to the older driver.
3. To lead the conversation, pick someone in the family
or a trusted friend who the older adult driver may
“hear” better than others. In some families, it works
better to have just one person have the conversation.
In other families, having several family members express their concern
will underscore the family’s concern for the older person’s safety.
4. Present your concerns in the least-threatening terms of your own feelings
and perceptions. Use “I” messages rather than “You” messages. For
example, say, “I am concerned about your safety when you are driving,”
rather than, “You’re no longer a safe driver.”
5. Among the points you might want to make in your conversation:
w Indicate that you have noticed changes in the person that seem to be
making it more difficult to drive.
w Note that we all age in different ways and at different rates.
w Reinforce that thousands of older adults each day are taking control
of similar situations by changing how and when they drive. Many stop
driving at night or avoid rush-hour traffic and bad weather. Many
stick to familiar nearby streets and rearrange their schedules to keep
doing the things that keep them active in their communities, such as
volunteering and socializing.
6. Don’t be put off by negative reactions. Remember that it is hard for people
to cut back on or stop their driving if they are not ready to do so, or if they
believe they are good drivers. Major lifestyle changes are never easy.
7. Highlight a positive outcome by focusing on how the older adult driver
will be able to continue to stay connected to specific things that are
important. Do not judge the person’s priorities.
8. If possible, identify a trusted friend or family member who has already
had to cut back on or stop driving, and who is taking actions to stay
connected to the things that are important to them. Ask if he or she would
APPENDICES 210
10 How to Understand and Influence Older Drivers

be willing to speak with the older person about how it is possible to keep
connected to meaningful activities in the community.

If you still believe that there is a safety problem, work together to develop a
written action plan (see sample plan on page 13.) Ideally, discussing a plan
of action should take place before problems exist. Regardless of the timing,
however, the goal of such a plan should be to preserve the independence and
freedom of the person. The plan should keep the person connected to the
activities that give meaning to and that enhance the quality of life.

Developing that plan will take time. It will involve a series of conversations
with the person. While many concerned family members and friends might
play a central role in holding these conversations, others might turn to health
professionals, such as a physician, to start and/or continue
the discussion about driver safety. In many of those cases,
the family and friends serve more in a support role for the
older person.

The focus of any action plan should be (1) to enhance the

independence and decision-making of the older adult,
and (2) to maximize community safety. Determine if
there are situations where the person can continue to
drive successfully. In some cases, the plan may require
changing the time of day when the older person does errands or drives to
appointments to avoid heavy traffic. In other cases, the plan may require
changing places where one shops or socializes with friends to avoid driving
on busy roads or in more dangerous driving situations. It may also mean
doing an activity less often or arranging for the person to carpool to an
activity and thus share the driving responsibility.

Implementing a plan that changes how and when a person drives can have
an enormous effect on families. Families themselves often must begin to play
more active roles in ensuring the older adult can continue to get around the
community. For family members who live nearby, the change in roles may
mean providing rides for the older person; whereas for family who live more
than an hour away, the change could mean spending time on the phone to
coordinate transportation services or providing financial support to pay for
those services.

Action plans range from the simple to the complex. An action plan might
call for the older adult to get a formal driving evaluation from a driving
rehabilitation specialist to identify areas of strength and need. A plan also
might clearly spell out ways people can get to events and activities when
they cannot drive themselves.

APPENDICES 211
 How to Understand and Influence Older Drivers 11

Many communities have programs offered through public transportation

systems that give people practice and confidence in using public
transportation to get around. Still, many older adults are reluctant for several
reasons to use public transportation when they stop driving. Some older
adults with health problems may not find these options practical or possible.
Therefore, it is important for older adults to become familiar with and
confident using transportation alternatives before they are asked to become
reliant on alternatives to their car.

As noted earlier, Area Agencies on Aging have information about virtually

all transportation programs and services in their areas. To find information
about your local Area Agency on Aging, contact the Eldercare Locator, a
national service you can call toll-free at 800-677-1116. Ask for your local
Office on Aging, or go to the Web site at www.eldercare.gov.

Step 3: Following Through on the Plan

Older adult drivers should be deeply involved in every step of their

transportation planning and implementation process. Doing so demonstrates
that family members respect the older person’s opinions and needs, are
genuinely concerned about the older person’s safety, and have given the issue
significant thought, time, and attention. The conversation about putting
the plan into action needs to be approached with sensitivity and respect for
the older person. Even if the older person has been involved in developing
the action plan, the conversation can easily provoke anger, defensiveness and
denial. This is less likely to happen if the older driver has been involved in each
step of the planning process.

Review the Plan Periodically

Over time, changes in a person’s abilities or even interests can mean that
adjustments need to be made to the older person’s action plan so that he or
she can get around the community safely. Therefore, it is important to review
the transportation plan at least twice a year to ensure it still works for the
person who has had to reduce or stop his or her driving.

Families and friends also need to remember that many communities are
developing new community transportation resources and are refining
existing ones. Some of these new resources may better meet the needs of the
older person than those that you have listed in your current plan. The key:
keep in touch with your local Area Agency on Aging to find out if new and
better choices are available to the older person.

APPENDICES 212
12 How to Understand and Influence Older Drivers

DEVELOPING A MOBILITY ACTION PLAN

The goal of the action plan is to keep the older person on the go (“mobile”)
in and around the community and connected to the activities that give the
person’s life meaning. Ideally, the person who is cutting back on driving or
stopping driving can continue to take part in all current activities. But that
person may need to find other ways to get to the activity, to get an errand
completed, or to find other times to participate in such activities.

Case in Point

William, 79, has been playing cards with a group of friends each Wednesday
evening for the past six years. But during the past several months, driving at
night has become more difficult because of the glare of headlights. William
does not want to ask his son for a ride, public transportation doesn’t run
close to his friend’s house where the game is always held, and taxis don’t fit in
his budget. Yet William also doesn’t want to give up playing, which keeps him
connected with friends and gets him out of the house for one of the few times
each week to socialize. After a few phone calls, William works out that he’ll
host the game once a month and those other times he’ll bring refreshments to
the game in exchange for one of his playing partners driving him to the game.

In filling out the chart below, list all of those activities that fit. Do not leave
off events or activities because you believe they are not “essential.” Again, the
goal of this action plan is to list needs and find alternative ways, if necessary,
to meet those needs. It may be accomplished by changing the times or
locations where the activities take place, identifying alternative means of
getting to the activities, or agreeing to carpool or share rides to activities. For
example, if a person has difficulty getting out to the grocery store, the person
should consider the value of having groceries delivered to the house.

APPENDICES 213
 How to Understand and Influence Older Drivers 13

Routine Errands

(List activities such as going to the grocery store, the pharmacy, the hairdresser, or
the doctor.)

Activity How You Get There Now New Ways to Complete Errand

Regular Educational, Social or Religious Events/Activities

(List events that happen at least once a month, such as going to an adult learning
center, senior center or attending religious services.)

Activity How You Get There Now New Ways to Get There

Other Community, Social and/or Special Events

(List special events such as birthday parties, community fairs, voting, or events that
may happen on the spur of the moment, such as going out to dinner or a movie.)

Activity How You Get There Now New Ways to Get There

APPENDICES 214
14 How to Understand and Influence Older Drivers

NOTES

APPENDICES 215
 DOT HS 810 633
July 2013

APPENDICES 216 9837-072913-v2a

 Expert Information from
Healthcare Professionals Who
Specialize in the Care of Older Adults TSHEET
IP

10 Tips for Aging Well

Simply living longer isn’t enough. What we really want is to live longer well, staying healthy
enough to continue doing the things we love. While having good genes certainly helps, a
growing body of research suggests that how well you age depends largely on you and what you
do. Fortunately, research also finds that it’s never too late to make changes that can help you live
a longer and healthier life.

Here, from the American Geriatrics Society’s Health in Aging Foundation, are ten tips for living
longer and better:

You need fewer calories when you get older, so choose nutrient-rich foods like
brightly colored fruits and vegetables. Eat a range of colors— the more varied,
the wider the range of nutrients you’re likely to get. Aim for two servings of
Eat a rainbow salmon, sardines, brook trout, or other fish rich in heart healthy omega-3 fatty
acids a week. Limit red meat and whole-fat dairy products. And choose whole
grains over the refined stuff.

Walking as little as 30 minutes, three times a week can help you stay
physically fit and mentally sharp, strengthen your bones, lift your spirits—and
lower your risk of falls. That’s important because falls are a leading cause
Sidestep falls of fractures, other serious injuries, and death among older adults. Bicycling,
dancing, and jogging are also good weight-bearing exercises that can help
strengthen your bones. In addition to exercising, get plenty of bone-healthy
calcium and vitamin D daily.

Drinking a moderate amount of alcohol may lower your risks of heart disease
and some other illnesses. But what’s “moderate” changes with age. It means
Toast with a
just 1 drink per day for older men and ½ a drink daily for older women. (A
smaller glass “drink” is 1 oz of hard liquor, 6 oz of wine, or 12 oz of beer.) Since alcohol
can interact with certain drugs, ask your healthcare professional whether any

Contrary to popular belief, older people don’t need less sleep than younger
adults. New recommendations from the National Sleep Foundation suggest
Know the low- 7 to 8 hours of shut-eye a night. If you’re getting that much and are still
down on sleep in sleepy during the day, see your healthcare professional. You may have a sleep
later life disorder called sleep apnea. People with sleep apnea stop breathing briefly,
but repeatedly, while sleeping. Among other things, untreated sleep apnea
can increase your risk of developing heart disease.

APPENDICES 217
 Flatten your Conquering your adversary in a complex computer game, joining a
(virtual) opponent, discussion club, learning a new language, and engaging in social give-and-
sharpen your mind take with other people can all help keep your brain sharp, studies suggest.

Older adults are having sex more often and enjoying it more, research finds.
Unfortunately, more older people are also being diagnosed with sexually
Enjoy safe sex transmitted diseases. To protect yourself, use a condom and a lubricant every
time you have sex until you’re in a monogamous relationship with someone
whose sexual history you know.

When you visit your healthcare professional, bring either all of the prescription
and over-the-counter medications, vitamins, herbs and supplements you take,
Get a or a complete list that notes the names of each, the doses you take, and how
often you take them. Ask your healthcare provider to review everything you
medications brought or put on your list. He or she should make sure they’re safe for you to
check take, and that they don’t interact in harmful ways. The older you are, and the
more medicines you take, the more likely you are to experience medication side
effects, even from drugs bought over-the-counter.

Roughly 1 in 5 older adults suffers from depression or anxiety. Lingering

Speak up when sadness, tiredness, loss of appetite or pleasure from things you once enjoyed,
you feel down difficultly sleeping, worry, irritability, and wanting to be alone much of the time
or anxious can all be signs that you need help. Tell your healthcare professional right away.
There are many good treatments for these problems.

They’re not just for kids! Must-have vaccines for seniors include those
Get your shots that protect against pneumonia, tetanus/diphtheria, shingles, and the flu,
which kills thousands of older adults in the US every year.

Find the right See your healthcare professional regularly, answer his or her questions
frankly, ask any questions you have, and follow his or her advice. If you have
healthcare
multiple, chronic health problems, your best bet may be to see a geriatrics
professional and healthcare professional—someone with advanced training that prepares her to
make the most care for the most complex patients. The AGS’ Health in Aging Foundation can
of your visits help you find one; visit www.healthinaging.org.

40 FULTON STREET DISCLAIMER: This information is not intended to diagnose health problems or to
18 TH FLOOR take the place of medical advice or care you receive from your physician or other
healthcare provider. Always consult your healthcare provider about your medications,
NEW YORK, NY 10038 symptoms, and health problems. February 2015
212.308.1414 TEL
©2019 Health in Aging Foundation. All rights reserved. This material may not be
THE OFFICIAL FOUNDATION OF 212.832.8646 FAX reproduced, displayed, modified, or distributed without the express prior written
THE AMERICAN GERIATRICS SOCIETY
[email protected] permission of the copyright holder. For permission, contact [email protected].

2
APPENDICES 218
 CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS

CLINICAL TEAM RESOURCES

APPENDICES 219 177

 CADReS Score Sheet

Name:__________________________________________ Date: ________________

1. Visual fields: Shade in any areas of deficit.

Patient’s L R

2. Visual acuity:_ _________OD ___________ OS __________OU

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

______________________________________________

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

3. Rapid pace walk:____________ seconds

Longer than 10 seconds is abnormal; consider referral for driving evaluation and/or
evaluation of gait disorder. Was test performed with a walker or cane? If yes, please specify:
_______________________________________________________________

4. Range of motion: Specify “within normal limits (WNL)” or “not WNL.” If not WNL, describe.

Right Left

Neck rotation

Finger curl

Shoulder and elbow flexion

Ankle plantar flexion

Ankle dorsiflexion

With any deficiencies or pain, consider referral to physical therapy for exercises or pain
management or to occupational therapy if impacting ADLs/IADLs as indicated, and/or
consider referral for comprehensive driving evaluation if adaptation for driving is needed.

5. Maze Test: Risk Categories _____ Seconds _____ Errors _____

APPENDICES 220
 If completed in 61 seconds or longer, with or without errors, then the person is not
cognitively fit to drive safely.
If completed in up to 60 seconds, but with two or more errors, then the person is not
cognitively fit to drive safely.

If completed in up to 60 seconds, with zero or one error, then the person is cognitively fit to
drive safely.

6. MoCA: Total score:_____

A score of 26 or above is normal (add a point if the older adult has less than 12 years of
formal education). A score of 18 or less indicates driving safety risk. A score above 18 but
below 26 warrants further evaluation, including a comprehensive driving evaluation.

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

A score longer than 180 seconds is abnormal; consider referral for a comprehensive driving
evaluation and/or evaluation for cognitive, visual, or motor impairment.

8. 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.

If any elements are abnormal, consider referral for a comprehensive driving evaluation
clinic and/or evaluation for cognitive, visual, or motor impairment.

APPENDICES 221
 Assessment/Plan

APPENDICES 222
 Table of Selected Studies Supporting the use of Screening Tools in CADReS

APPENDICES 223
Citation Target Tools (significant)/Outcome Main Findings
Population Measure
Classen, S., Witter, D. P., Parkinson’s MMSE Individuals with PD did more poorly on UFOV, Rapid
Lanford, D. N., Okun, M. S., Disease Rapid Pace Walk Pace Walk, global score of the BTW, and maneuvers
Rodriguez, R. L., Romrell, UFOV scores. UFOV and Rapid Pace Walk accounted for most
J., et al. (2011). Acuity of variance with the on-road test and can be considered
Contrast Sensitivity as good screening tools for PD.
Outcome: Global rating score (on
road outcome) and maneuvers
scores for on road assessment
Zook, N. A., Bennett, T. L., Older adult Hopkins verbal learning task Hopkins verbal learning test, Integrated visual and
& Lane, M. (2009). Integrated visual and auditory auditory continuous performance, and Trails B more
continuous performance predictive of on-road than CBDI or UFOV.
Trails B
Outcome: on road assessment
Stav W. B., Justiss, M. D., Older adults Contrast Sensitivity, slide B Using stepwise regression, the strongest model
McCarthy D. P., Mann, W. Rapid Pace Walk included: Contrast Sensitivity slide-B, Rapid Pace Walk,
C., & Lanford, D. N. (2008). UFOV Rating UFOV rating, and MMSE total score. These accounted
MMSE total score for 44% of the variability in Global Rating Scale of the
Outcome: Global Rating Scale of standardized road test. All assessments listed were
the standardized road test significantly correlated with the Global Rating Score
individually.
Wood, J. M., Anstey, K. J., Older adults UFOV 2 UFOV 2, dot motion sensitivity, knee extension strength,
Kerr, G. K., Lacherez, P. F., Dot motion sensitivity postural sway, trail making B, and color choice reaction
& Lord, S. (2008) Knee extension strength time were significantly correlated with on road
Postural sway assessment performance.
Trails B Sensitivity: 91%, specificity: 70%
Color choice reaction time
Outcome: on road assessment
 Molnar, F. J., Marshall, S. Older adults MMSE Used assessment battery in ER for acceptability and

APPENDICES 224
C., Man-Son-Hing, M., Driving habits potential predictors of crashes. Significant positive
Wilson, K. G., Byszewski, A. Ottawa Driving & dementia associations with past or current MVC were found for
M., & Stiell, I. (2007). Bothered by diabetes components of: MMSE, Driving Habits, Ottawa Driving
Timed Toe Tap Test and Dementia, “bothered a great deal by Diabetes
Outcome: motor vehicle crashes Mellitus”, and the Timed Toe Tap Test.
De Raedt, R., & Ponjaert- Older adults Trail A Battery included: MMSE, Trail making, acuity, clock
Kristoffersen, I. (2001). Acuity drawing, age as factor
De Raedt, R., & Ponjaert- Clock drawing MMSE did not add anything to model.
Kristoffersen, I. (2001). Age as factor Combined: Specificity – 85% Sensitivity – 80%
Outcome: on road assessment
Owsley, C., Stalvey, B.T., 274 older Tested for acuity, contrast Contrast sensitivity strongly related to crashes,
Wells, J., Sloane, M. E., & adults with sensitivity, and glare. especially when in two eyes, but also one. Visual acuity –
McGwin, G. (2001). cataracts and not related to crashes.
103 without
Decina, L.E. & Staplin, L. Visual exams of 12,400 drivers in Acuity, visual fields, contrast sensitivity related to
(1993). PA. crashes for drivers 66-75 years and 76 years & over.
Freeman, E.E., Munoz, B., Older adults Salisbury Eye Evaluation Project, Driving cessation over time: Those with worse scores in
Turano, K.A., & West, S.K. 2520 older adults followed for 8 acuity, contrast sensitivity, and visual field cut most
(2005). years with 4 collection points. likely to cease driving.
Crizzle, A.M., Classen, S., & PD Evidence review that examined No standard battery is able to predict driving
Uc, Y. (2012). measures for predicting on road and performance of PD, more vigorous studies needed.
simulator performance. Some evidence for subtest 2 of UFOV, contrast
sensitivity, Trails B and B-A, functional reach, Rey-
Osterrieth Complex Figure Test.
Classen, S., McCarthy, D. PD 19 individuals with Parkinson’s UFOV had strongest correlations with on road and
P., Shechtman, O., Awadzi, Disease and 104 age matched driving errors. Those who failed on-road did worse on
K. D., Lanford, D.N., Okun, controls. Compared UFOV with on Trails B and UFOV than those who passed. Cut off
M. S., Rodriguez, R. L., road assessment outcome, global scores for UFOV subtests suggested.
Romrell, J., Bridges, S., rating scale, and sum of maneuvers
Kluger, B., & Fernandez, H. scale.
 H. (2009).

APPENDICES 225
Amick, M. M., Grace, J., & PD 25 with Parkinson’s Disease with Safe and marginal groups performed differently on
Ott, B. R. (2007). two of three physical issues (tremor, contrast sensitivity, Trails B (time), Rey-O
bradykinsesia, and rigidity). No presence/accuracy, UFOV subtest 3.
cognitive impairments. Compared
assessments to on road
performance.
Uc, E.Y., Rizzo, M., AD 33 Alzheimer’s compared to 137 Significant difference between groups in landmark and
Anderson, S.W., Shi, Q., & normal controls on cognitive tests, traffic identification; Driving errors higher in AD group;
Dawson, J.D. (2005). vision tests, on road drive to Trails B, auditory verbal learning test, contrast
identify landmarks and traffic signs. sensitivity, judgment of line orientation were predictors
of total landmark and traffic sign identification.
Grace, J., Amick, M. M., AD 21 dementia, 21 Parkinson, 21 Dementia made significantly more errors on on-road
D'Abreu, A., Festa, E. K., controls. Compared motor and than controls; Rey-Osterrieth figure was sensitive to
Heindel, W. C., & Ott, B. R. cognitive function with on road poor on road performance, Trails A and B sensitive to
(2005). performance. dementia subjects.
Whelihan, W.M., DiCarlo, AD 23 with CDR of .5 and 23 controls. Trails B, Maze navigation time, UFOV, letter cancelation
M.A., & Paul, R.H. (2004). Battery of screening measures significantly related to on-road for patient group, but for
compared with outcome measure of controls, it was only age. Regression showed maze
road assessment. navigation time, Trails B time, and UFOV part 1
accounted for 46% of variance (Trails B added
insignificantly). UFOV too challenging for even early
dementia. Maze navigation may be good screening tool.
Jones, V. C., Gielen, A. C., Older adults 67 older adults screened with four Identifying low, medium and high risk impairment of
Bailey, M. M., Rebok, G. of 9 assessment tools. High-risk older adults with assessments and crash outcomes.
W., Gaines, J. M., Joyce, J. completed qualitative interviews. Only Trails B differentiated the medium from the high
& Parrish, J. M. (2011). risk group. UFOV and MVPT did not.
Edwards, J. D., Bart, E., Older adults 1,248 participants tested at baseline Final regression models: Age at baseline, days driven per
O'Connor, M. L., & Cissell, and 5 years later on physical and week and slower processing speed (UFOV performance,
G. (2010). cognitive issues. subtest 2) were significant indicators of risk for driving
cessation. Other models showed rapid pace walk,
 MVPT, Trails B.

APPENDICES 226
Munro, C.A., Jefferys, J., Older adults 980 adults 67-87 years who had lane Significant predictors of lane change errors included:
Gower, E. W., Munoz, B. E., change data Brief Test of Attention, Hopkins, Trails B, VMI, and Visual
Lyketsos, C. G., Keay, L., … Subjects enrolled in the Salisbury Attention.
West, S. K. (2010). Eye Evaluation and Driving Study Multiple regression demonstrated:
Brief Test of Attention and VMI scores predicted lane
change errors. Also those participants that resided in
rural vs. urban predicted lane change error.
Made on assumption that lane change translates into
errors of driver safety.
Classen, S., Horgas, A., Older adults 127 older adults to compare The strongest predictor of failing the BTW was advanced
Awadzi, K., Messinger- demographics, cognitive age, and time to complete Trails B were major
Rapport, B., Shechtman, functioning, comorbidities, predictors of failure and driving errors. Having a
O., & Joo, Y. (2008). medications, and failing driving neurological diagnosis was associated with test failure
evaluation. and increased driving errors.

Oswanski, M. F., Sharma, Retrospective study Mean score for the three measurements significantly
O. P., Raj, S. S., Vassar, L. 232 over 55 years old referred to different between two groups.
A., Woods, K. L., Sargent, driving program. Subjects ROC for MVPT was >32 with 60% sensitivity and 83%
W. M., & Pitock, R. J. categorized into two groups: specificity.
(2007). capable & incapable ROC clock task was >3 with 70% sensitivity and 65%
specificity.
Processing time < 6.27 seconds with 61% sensitivity and
79% specificity

This table was modified from tables developed with funding from the Gaps and Pathways Project, the AOTA/NHTSA Cooperative
Agreement.
 Medical Advisory Board Example Letter
[Official letterhead, state licensing authority or the state transportation Medical Advisory
Board]

Dear Mr./Mrs. :

You are receiving this letter because it has come to our attention that you may have a medical
condition that could affect your driving. Please provide the information requested on the
enclosed form within the next 30 days.

Upon receipt of your form, our staff will perform a thorough, individual review of your medical
fitness to continue driving. Additional information or assessments may be requested in order to
complete your review. This may include information from your primary health care provider or
an assessment by a driving rehabilitation specialist.

The purpose of this action is safety for you, your family, and the community. Because of the
broader commitment to highway safety, drivers that fail to respond and/or provide the
information requested by the due date may be considered for suspension of their driving
privilege.

Sincerely,

State Licensing Authority/ State Transportation Medical Advisory Board

APPENDICES 227
 Modified Driving Habits Questionnaire

Current Driving
1. Do you wear glasses or contacts when you drive? ____ Yes ____ No

2. Do you wear a seatbelt when you drive? ____ Always ____ Sometimes ____ Never

3. Which way do you prefer to get around?

____ Drive yourself
____ Have someone drive you
____ Use public transportation or a taxi

4. How fast do you usually drive compared with the general flow of traffic?
____ Much faster ____ Somewhat slower
____ Somewhat faster ____ Much slower
____ About the same

5. Has anyone suggested over the past year that you limit your driving or stop driving?
____ Yes ____ No

6. How would you rate the quality of your driving?

____ Excellent ____ Good ____ Average ____ Fair ____ Poor

7. If you had to go somewhere and didn’t want to drive yourself, what would you do?
____ Ask a friend or relative to drive you
____ Call a taxi or take the bus
____ Drive yourself regardless of how you feel
____ Cancel or postpone your plans and stay at home
____ Other (specify): __________________________

Exposure

8. In an average week, how many days per week do you normally drive? ___ days per week

9. Please consider all the places you drive in a typical week. Check those places and list how
many times a week and the number of miles from home.

___ Store ____ times a week ____ miles from home

___ Church ____ times a week ____ miles from home
___ Work/School ____ times a week ____ miles from home
___ Relative’s home ____ times a week ____ miles from home
___ Friend’s home ____ times a week ____ miles from home

APPENDICES 228
 ____ Out to eat ____ times a week ____ miles from home
____ Appointments ____ times a week ____ miles from home

Are there other places you go in a typical week?

_____________ ____ times a week ____ miles from home
_____________ ____ times a week ____ miles from home
_____________ ____ times a week ____ miles from home

Avoidance

13a. During the past 3 months, have you driven while it has been raining?
____ Yes (go to 13b)
____ No (go to 14)

13b. Would you say that you drive when it is raining with: (please check only one answer)
____ No difficulty at all
____ A little difficulty
____ Moderate difficulty
____ Extreme difficulty

14a. During the past 3 months, have you driven alone?

____ Yes (go to 14b)
____ No (go to 15)

14b. Would you say that you drive alone with: (check only one answer)
____ No difficulty at all
____ A little difficulty
____ Moderate difficulty
____ Extreme difficulty

15a. During the past 3 months, have you parallel parked?

____ Yes (go to 15b)
____ No (go to 15c)

15b. Would you say that you parallel park with: (check only one answer)
____ No difficulty at all
____ A little difficulty
____ Moderate difficulty
____ Extreme difficulty

15c. Why do you not parallel park?

____ Not necessary (not many parallel parking spots)
____ Visual problems
____ Never learned how

APPENDICES 229
 ____ Other (specify) ___________________

16a. During the past 3 months, have you made left-hand turns across oncoming traffic?
____ Yes (go to 16b)
____ No (go to 17)

16b. Would you say that you make left-hand turns in traffic with: (check only one answer)
____ No difficulty at all
____ A little difficulty
____ Moderate difficulty
____ Extreme difficulty

17a. During the past 3 months, have you driven on interstates or expressways?
____ Yes (go to 17b)
____ No (go to 18)

17b. Would you say that you drive on interstates or expressways with: (check only one
answer)
____ No difficulty at all
____ A little difficulty
____ Moderate difficulty
____ Extreme difficulty

18a. During the past 3 months, have you driven on high-traffic roads?
____ Yes (go to 18b)
____ No (go to 19)

18b. Would you say that you drive on high-traffic roads with: (check only one answer)
____ No difficulty at all
____ A little difficulty
____ Moderate difficulty
____ Extreme difficulty

19a. During the past 3 months, have you driven in rush hour traffic?
____ Yes (go to 19b)
____ No (go to 20)

19b. Would you say that you drive in rush hour traffic with: (check only one answer)
____ No difficulty at all
____ A little difficulty
____ Moderate difficulty
____ Extreme difficulty

20a. During the past 3 months, have you driven at night?

APPENDICES 230
 ____ Yes (go to 20b)
____ No (go to 21)

20b. Would you say that you drive at night with: (check only one answer)
____ No difficulty at all
____ A little difficulty
____ Moderate difficulty
____ Extreme difficulty

Crashes and Citations

21. How many crashes have you been involved in over the past year when you were the
driver? Please list the number of all crashes, whether or not you were at fault.
____ crashes

22. How many crashes have you been involved in over the past year when you were the
driver where the police were called to the scene?
____ crashes

23. How many times over the past year have you been pulled over by the police, regardless
of whether you received a ticket?
____ times

24. How many times in the past year have you received a traffic ticket (other than a parking
ticket) where you were found to be guilty, regardless of whether or not you think you
were at fault?
____ times

Driving Space

25. During the past year, have you driven in your immediate neighborhood?
___ Yes ___ No

26. During the past year, have you driven to places beyond your neighborhood?
___ Yes ___ No

27. During the past year, have you driven to neighboring towns?
___ Yes ___ No

28. During the past year, have you driven to more distant towns?
___ Yes ___ No

29. During the past year, have you driven to places outside the state where you live?
___ Yes ___ No

APPENDICES 231
 30. During the past year, have you driven to neighboring states?
___ Yes ___ No

Modified with permission from the Driving Habit Questionnaire (DHQ)

Owsley C, Stalvey B, Wells J, et al. Older drivers and cataracts: driving habits and crash risk. J
Gerontol: Med Sci. 1999;54A:M203–M211.

APPENDICES 232
 Montreal Cognitive Assessment (MoCA)
Version 8.1

Administration and Scoring Instructions

The Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for
mild cognitive dysfunction. It assesses different cognitive domains: attention and concentration,
executive functions, memory, language, visuoconstructional skills, conceptual thinking,
calculations, and orientation. The MoCA may be administered by anyone who understands and
follows the instructions, however, only a health professional with expertise in the cognitive field
may interpret the results. Time to administer the MoCA is approximately 10 minutes. The total
possible score is 30 points; a score of 26 or above is considered normal.

All instructions may be repeated once.

1. Alternating Trail Making:

Administration: The examiner instructs the subject: "Please draw a line going from a
number to a letter in ascending order. Begin here [point to (1)] and draw a line from 1
then to A then to 2 and so on. End here [point to (E)]."

Scoring: One point is allocated if the subject successfully draws the following pattern:
1- A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not
immediately self-corrected (meaning corrected before moving on to the Cube task)
earns a score of 0. A point is not allocated if the subject draws a line to connect the end
(E) to the beginning (1).

2. Visuoconstructional Skills (Cube):

Administration: The examiner gives the following instructions, pointing to the cube:
“Copy this drawing as accurately as you can.”

Scoring: One point is allocated for a correctly executed drawing.

• Drawing must be three-dimensional.
• All lines are drawn.
• All lines meet with little or no space.
• No line is added.
• Lines are relatively parallel and their length is similar (rectangular prisms are
accepted).
• The cube’s orientation in space must be preserved.

A point is not assigned if any of the above criteria is not met.

3. Visuoconstructional Skills (Clock):

Administration: The examiner must ensure that the subject does not look at his/her watch
while performing the task and that no clocks are in sight. The examiner indicates the
appropriate space and gives the following instructions: “Draw a clock. Put in all the
numbers and set the time to 10 past 11.”

Scoring: One point is allocated for each of the following three criteria:

APPENDICES 233
 • Contour (1 pt.): the clock contour must be drawn (either a circle or a square). Only
minor distortions are acceptable (e.g., slight imperfection on closing the circle). If the
numbers are arranged in a circular manner but the contour is not drawn the contour is
scored as incorrect.
• Numbers (1 pt.): all clock numbers must be present with no additional numbers.
Numbers must be in the correct order, upright and placed in the approximate quadrants on
the clock face. Roman numerals are acceptable. The numbers must be arranged in a
circular manner (even if the contour is a square). All numbers must either be placed inside
or outside the clock contour. If the subject places some numbers inside the clock contour
and some outside the clock contour, (s)he does not receive a point for Numbers.
• Hands (1 pt.): there must be two hands jointly indicating the correct time. The hour hand
must be clearly shorter than the minute hand. Hands must be centered within the clock
face with their junction close to the clock center.

4. Naming:

Administration: Beginning on the left, the examiner points to each figure and says: “Tell
me the name of this animal.”

Scoring: One point is given for each of the following responses: (1) lion (2) rhinoceros or
rhino (3) camel or dromedary.

5. Memory:

Administration: The examiner reads a list of five words at a rate of one per second,
giving the following instructions: “This is a memory test. I am going to read a list of
words that you will have to remember now and later on. Listen carefully. When I am
through, tell me as many words as you can remember. It doesn’t matter in what order you
say them.” The examiner marks a check in the allocated space for each word the subject
produces on this first trial. The examiner may not correct the subject if (s)he recalls a
deformed word or a word that sounds like the target word. When the subject indicates
that (s)he has finished (has recalled all words), or can recall no more words, the examiner
reads the list a second time with the following instructions: “I am going to read the same
list for a second time. Try to remember and tell me as many words as you can, including
words you said the first time.” The examiner puts a check in the allocated space for each
word the subject recalls on the second trial. At the end of the second trial, the examiner
informs the subject that (s)he will be asked to recall these words again by saying: “I will
ask you to recall those words again at the end of the test.”

Scoring: No points are given for Trials One and Two.

6. Attention:

Forward Digit Span: Administration: The examiner gives the following instructions: “I
am going to say some numbers and when I am through, repeat them to me exactly as I
said them.” The examiner reads the five number sequence at a rate of one digit per
second.

Backward Digit Span: Administration: The examiner gives the following instructions:
“Now I am going to say some more numbers, but when I am through you must repeat

APPENDICES 234
 them to me in the backward order.” The examiner reads the three number sequence at a
rate of one digit per second. If the subject repeats the sequence in the forward order, the
examiner may not ask the subject to repeat the sequence in backward order at this point.

Scoring: One point is allocated for each sequence correctly repeated (N.B.: the correct
response for the backward trial is 2-4-7).

Vigilance: Administration: The examiner reads the list of letters at a rate of one per
second, after giving the following instructions: “I am going to read a sequence of letters.
Every time I say the letter A, tap your hand once. If I say a different letter, do not tap
your hand.”

Scoring: One point is allocated if there is zero to one error (an error is a tap on a wrong
letter or a failure to tap on letter A).

Serial 7s: Administration: The examiner gives the following instructions: “Now, I will
ask you to count by subtracting 7 from 100, and then, keep subtracting 7 from your
answer until I tell you to stop.” The subject must perform a mental calculation, therefore,
(s)he may not use his/her fingers nor a pencil and paper to execute the task. The examiner
may not repeat the subject’s answers. If the subject asks what her/his last given answer
was or what number (s)he must subtract from his/her answer, the examiner responds by
repeating the instructions if not already done so.

Scoring: This item is scored out of 3 points. Give no (0) points for no correct
subtractions, 1 point for one correct subtraction, 2 points for two or three correct
subtractions, and 3 points if the subject successfully makes four or five correct
subtractions. Each subtraction is evaluated independently; that is, if the subject responds
with an incorrect number but continues to correctly subtract 7 from it, each correct
subtraction is counted. For example, a subject may respond “92 – 85 – 78 – 71 – 64”
where the “92” is incorrect, but all subsequent numbers are subtracted correctly. This is
one error and the task would be given a score of 3.

7. Sentence repetition:

Administration: The examiner gives the following instructions: “I am going to read you a
sentence. Repeat it after me, exactly as I say it [pause]: I only know that John is the one
to help today.” Following the response, say: “Now I am going to read you another
sentence. Repeat it after me, exactly as I say it [pause]: The cat always hid under the
couch when dogs were in the room.”

Scoring: One point is allocated for each sentence correctly repeated. Repetitions must be
exact. Be alert for omissions (e.g., omitting "only"), substitutions/additions (e.g.,
substituting "only" for "always"), grammar errors/altering plurals (e.g. "hides" for "hid"),
etc.

8. Verbal fluency:

Administration: The examiner gives the following instructions: “Now, I want you to tell
me as many words as you can think of that begin with the letter F. I will tell you to stop
after one minute. Proper nouns, numbers, and different forms of a verb are not permitted.
Are you ready? [Pause] [Time for 60 sec.] Stop.” If the subject names two consecutive

APPENDICES 235
 words that begin with another letter of the alphabet, the examiner repeats the target letter
if the instructions have not yet been repeated.

Scoring: One point is allocated if the subject generates 11 words or more in 60 seconds.
The examiner records the subject’s responses in the margins or on the back of the test
sheet.

9. Abstraction:

Administration: The examiner asks the subject to explain what each pair of words has in
common, starting with the example: “I will give you two words and I would like you to
tell me to what category they belong to [pause]: an orange and a banana.” If the subject
responds correctly the examiner replies: ‘‘Yes, both items are part of the category
Fruits.’’ If the subject answers in a concrete manner, the examiner gives one additional
prompt: “Tell me another category to which these items belong to.” If the subject does
not give the appropriate response (fruits), the examiner says: “Yes, and they also both
belong to the category Fruits.” No additional instructions or clarifications are given.
After the practice trial, the examiner says: “Now, a train and a bicycle.” Following the
response, the examiner administers the second trial by saying: “Now, a ruler and a
watch.” A prompt (one for the entire abstraction section) may be given if none was used
during the example.

Scoring: Only the last two pairs are scored. One point is given for each pair correctly
answered. The following responses are acceptable:
- train-bicycle = means of transportation, means of travelling, you take trips in both
- ruler-watch = measuring instruments, used to measure
The following responses are not acceptable:
- train-bicycle = they have wheels
- ruler-watch = they have numbers

10. Delayed recall:

Administration: The examiner gives the following instructions: “I read some words to
you earlier, which I asked you to remember. Tell me as many of those words as you can
remember.” The examiner makes a check mark (√) for each of the words correctly
recalled spontaneously without any cues, in the allocated space.

Scoring: One point is allocated for each word recalled freely without any cues.

Memory index score (MIS):

Administration: Following the delayed free recall trial, the examiner provides a category
(semantic) cue for each word the subject was unable to recall. Example: ‘‘I will give you some
hints to see if it helps you remember the words, the first word was a body part.’’ If the subject is
unable to recall the word with the category cue, the examiner provides him/her with a multiple
choice cue. Example: “Which of the following words do you think it was, NOSE, FACE, or
HAND?” All non-recalled words are prompted in this manner. The examiner identifies the words
the subject was able to recall with the help of a cue (category or multiple-choice) by placing a
check mark (√) in the appropriate space. The cues for each word are presented below:

APPENDICES 236
 Target Word Category Cue Multiple Choice
FACE body part nose, face, hand (shoulder, leg)
VELVET type of fabric denim, velvet, cotton (nylon, silk)
CHURCH type of building church, school, hospital (library, store)
DAISY type of flower rose, daisy, tulip (lily, daffodil)
RED color red, blue, green (yellow, purple)

* The words in parentheses are to be used if the subject mentions one or two of the multiple
choice responses during the category cuing.

Scoring: To determine the MIS (which is a sub-score), the examiner attributes points according to
the type of recall (see table below). The use of cues provides clinical information on the nature of
the memory deficits. For memory deficits due to retrieval failures, performance can be improved
with a cue. For memory deficits due to encoding failures, performance does not improve with a
cue.

MIS scoring Total

Number of words recalled spontaneously … multiplied by 3 …
Number of words recalled with a category cue … multiplied by 2 …
Number of words recalled with a multiple choice cue … multiplied by 1 …
Total MIS (add all points) ---/15

11. Orientation:

Administration: The examiner gives the following instructions: “Tell me today’s date.” If
the subject does not give a complete answer, the examiner prompts accordingly by
saying: “Tell me the [year, month, exact date, and day of the week].” Then the examiner
says: “Now, tell me the name of this place, and which city it is in.”

Scoring: One point is allocated for each item correctly answered. The date and place (name of
hospital, clinic, office) must be exact. No points are allocated if the subject makes an error of
one day for the day and date.

TOTAL SCORE: Sum all subscores listed on the right-hand side. Add one point for subject who
has 12 years or fewer of formal education, for a possible maximum of 30 points. A final total
score of 26 and above is considered normal.

Please refer to the MoCA website at www.mocatest.org for more information on the MoCA.

APPENDICES 237
 Name:
MONTREAL COGNITIVE ASSESSMENT (MOCA ®) Education: Date of birth:
Version 8.1 English Sex: DATE:
VISUOSPATIAL / EXECUTIVE Copy Draw CLOCK ( Ten past eleven ) POINTS
cube ( 3 points )

[ ] [ ] [ ] [ ] [ ] /5
Contour Numbers Hands
NAMING

[ ] [ ] [ ] /3

MEMORY FACE VELVET CHURCH DAISY RED

Read list of words, subject must
repeat them. Do 2 trials, even if 1st trial is successful. 1ST TRIAL NO
Do a recall after 5 minutes. POINTS
2ND TRIAL
ATTENTION Read list of digits ( 1 digit/ sec. ). Subject has to repeat them in the forward order. [ ] 2 1 8 5 4
Subject has to repeat them in the backward order. [ ] 7 4 2 /2
Read list of letters. The subject must tap with his hand at each letter A. No points if ≥ 2 errors
[ ] FBACMNAAJKLBAFAKDEAAAJAMOFAAB /1
Serial 7 subtraction starting at 100. [ ] 93 [ ] 86 [ ] 79 [ ] 72 [ ] 65
4 or 5 correct subtractions: 3 pts, 2 or 3 correct: 2 pts, 1 correct: 1 pt, 0 correct: 0 /3
LANGUAGE Repeat: I only know that John is the one to help today. [ ]
The cat always hid under the couch when dogs were in the room. [ ] /2
Fluency: Name maximum number of words in one minute that begin with the letter F. [ ] (N ≥ 11 words) /1
ABSTRACTION Similarity between e.g. banana - orange = fruit [ ] train - bicycle [ ] watch - ruler /2
DELAYED RECALL (MIS) FACE VELVET CHURCH DAISY RED Points for
/5
Has to recall words UNCUED
X3 WITH NO CUE [ ] [ ] [ ] [ ] [ ] recall only
Memory
Index Score X2 Category cue
(MIS) X1 Multiple choice cue
MIS = / 15

ORIENTATION [ ] Date [ ] Month [ ] Year [ ] Day [ ] Place [ ] City /6

© Z. Nasreddine MD www.mocatest.org MIS: /15
(Normal ≥ 26/30)
Administered by: / 30
Training and Certification are required to ensure accuracy Add 1 point if ≤ 12 yr edu

APPENDICES 238
 Adaptive Equipment to Compensate for Impairments in Motor Performance

Category I: “Gadgets” that may assist mobility, comfort in the vehicle, or visibility
 The adaptive devices in this category are available via websites, catalogs, or in stores
carrying automotive devices.
 To be in this category they do not directly interfere or alter the control of a moving vehicle.
 Items in this category do not require a Comprehensive Driving Evaluation and/or a
prescription from a driving rehabilitation specialist.

A. Handybar® (transfers, driver or passengers)

1. Much like an arm on an armchair, this tool can be helpful for drivers, passengers
and caregivers. It may reduce the work/stress on the person assisting with
ingress/egress from a vehicle.
2. Precautions/concerns/limitation:
a. There are several manufacturers and styles. The “blade” style may be too
wide to fit in some vehicle models.
b. Some advertise the additional utility to break windows and cut the seatbelt
if necessary.
c. The device cannot be left in place; therefore it requires a convenient (in
reach) and safe location for storage.

B. Ribbon or seatbelt Easy Reach Handle® (reach the seatbelt)

1. An option when reaching for the seatbelt is painful or difficult (particularly if this is
a reason the seatbelt is not worn).
2. A piece of ribbon may be sufficient or they can purchase a gadget such as the “easy
reach” adaptive device that attaches to the seatbelt.
3. Precautions/concerns/limitations:
a. Warn that any device must not interfere with the seatbelt in any manner.
Closely note the placement and avoid any possible interference with the
seatbelts function to freely retract and feed.

C. Plastic garbage bag or seat slide (transfers)

1. A plastic garbage bag is an inexpensive assist to sliding into place. (Commercially
available products such as the seat slide are also available).
2. This can also be useful as a caregiver resource.
3. Precautions/concerns/limitations:
a. Once in the seat the bag creates a slippery surface. Recommend that it be
removed when vehicle is in motion.

D. Leg lifter (transfers, pivot into the seat)

1. A loop is placed over foot to assist in “lifting the leg” into the vehicle.
2. Manually show how to assist pulling the leg into the vehicle by pulling on pant leg
or lifting thigh.

Created by Elin Schold Davis,

AOTA Older Driver Initiative Coordinator [email protected]
APPENDICES 239
 E. Key holder (decrease pain/trauma with turning key)
1. Generally inexpensive and available in various styles and designs.
2. Precautions/concerns/limitations:
a. Consider placement of ignition to be sure the key holder does not interfere.

Category II: Devices readily available but may interfere with vehicle safety devices.
 Consumers need to be well informed of the pros and cons when choosing to use devices in
this category.
 There are no current “guidelines.” Referral to an occupational therapist or driving
rehabilitation specialist may be justified for offering guidance in this purchase.

A. Wedge cushion (seat height to raise line of sight, check impact on reach to pedals)
1. Variables include the quality of foam (firm, stable) and shape. Determining the
benefit of the shape, wedge or block style cushion, will depend on the person’s
needs and the contours of the vehicle seat.
2. Precautions/concerns/limitations: Any cushion may impact the ability to reach the
pedals. Cushion material should be as firm as possible. Material that easily flattens
may contribute to “submarining” under the lap belt in the event of a crash.

B. Mirrors (additional side, rearview and panoramic options)

1. Many versions of clip on and stick on mirrors are available to expand the peripheral
field of view for the driver. Some drivers report that they are effective while others
may report that they distort or distract.
2. Precautions/concerns/limitations: a mirror clipped to the rearview mirror may
break off and become a projectile in a crash.

C. Pedal Extenders (built up pedals for short statured drivers)

1. Many versions. Professional installation important for proper placement and
secure attachment.
2. Lack of consensus if this equipment should require a driving evaluation and
prescription.

Category III: Adaptive Equipment requiring evaluation, prescription and professional installation
 Explore a full array of equipment options at The National Mobility Equipment Dealer’s
Association www.nmeda.com.
 The Comprehensive Driving Evaluation report will generate individualized
recommendations and equipment prescriptions. This evaluation should be neutral to
vendor and equipment brands.
 Adaptive equipment does interfere with the Original Equipment Manufacturer (OEM) and
must be properly installed, inspected, and the driver trained in its use. (NMEDA QAP)
 Many states require testing by the licensing authority and may place a restriction on the
driver’s license.

A. Steering Knob (drive with one hand/arm)

Created by Elin Schold Davis,
AOTA Older Driver Initiative Coordinator [email protected]
APPENDICES 240
 1. Evaluation determines need and ideal placement of device on the steering wheel.
2. Some states require this adaptation for one‐handed drivers.

B. Left Foot Accelerator (manage gas with left foot when right foot unable/unreliable)
1. Requires comprehensive driving evaluation, professional installation and training.
2. Requires significant new learning, evaluation of cognition is essential.
3. Controversial. Some programs no longer install, yet many have used very
successfully.

C. Hand Controls (control gas and brake with hands, nonfunctioning or unreliable lower
extremities)
1. Requires comprehensive driving evaluation, professional installation and training.
2. Requires new learning, evaluation of cognition is essential.
3. Many models and configurations are available. Specialist will consider the driver’s
strongest abilities and the access (space) available in the driver’s vehicle when
recommending hand control model(s).

D. A wide range of specialized devices are available for primary (low effort steering, smaller
circumference steering wheel) and secondary controls (blinker, wipers, etc.). Drivers
experiencing pain, impaired reach, or diminished strength may benefit from modifications that
bring control of the vehicle within their physical capabilities.
1. The Comprehensive Driving Evaluation will generate individualized
recommendations and equipment prescriptions. The evaluation should be neutral
to vendor and equipment brands.
2. Adaptive equipment does interfere with the Original Equipment Manufacturer
(OEM) and must be properly installed, inspected, and the driver trained in its use.
(NMEDA QAP)
3. Many states require testing and place a restriction on the driver’s license
4. Equipment and installation is costly. Refer to the driving evaluator with medical
background, typically an occupational therapy practitioner, with professional
training to understand the driver’s medical condition and its progression.

Category IV: Vehicle Modification requiring evaluation, prescription and professional installation

 The Comprehensive Driving Evaluation is likely required to prescribe the complex

components of vehicle modification. This evaluation should be neutral to vendor and
equipment brands.
 Modification clearly interferes with the OEM design and should only be completed by
certified vehicle modifiers. See www.NMEDA.com.
 Many states require testing by the driver licensing authority and may place a restriction on
the driver’s license for driver of a modified vehicle.
 Caregiver needs must be considered when discharging a senior with medical conditions
that impact mobility, ability to transfer into vehicle, etc.

Created by Elin Schold Davis,

AOTA Older Driver Initiative Coordinator [email protected]
APPENDICES 241
  Equipment and installation is costly. Refer to the driving evaluator with medical
background, typically an occupational therapy practitioner, with professional training to
understand the driver’s medical condition and its progression.

A. Vehicle adaption may include wider doors, lowered floor for wheelchair access, or a proper
securement system if driving from the wheelchair. Modifications to the vehicle can allow the
driver to transfer and stow equipment.

B. Vehicle adaptation may consider both the needs of the client and caregiver. When the
senior is now a passenger only, the caregivers may benefit from an adapted vehicle that
supports successful transfers and transport of their passenger’s mobility equipment.
Equipment may ease the physical burden on the caregiver.

C. Transporting mobility equipment such as wheelchairs and scooters may be difficult. Some
vehicles lack the space and access. Some scooter designs fold and lift easier than others.
Some trailer style carriers may be too heavy for the vehicle, potentially interfering with vehicle
function and control.

Created by Elin Schold Davis,

AOTA Older Driver Initiative Coordinator [email protected]
APPENDICES 242
 Resources

Many of these items are available on Amazon, Walmart, CVS, etc.

Websites are offered here as examples, but are not to be considered as a recommendation.

1. Handybar (transfers, driver or passengers)

 Search: Handybar car transfer
 Handybar is the original developer’s brand. The metal tip is slim and fits most
vehicles. Watch for blades or other designs that may not fit the majority of
vehicles.
https://stander.com/product/3001‐handybar/

2. Ribbon or seatbelt Easy Reach Handle (reach the seatbelt)

 Search: Seat Belt Pull or Grabber
 https://www.arthritissupplies.com/easy‐reach‐seat‐belt‐handle.html

3. Wedge cushion (seat height)

 https://www.amazon.com/As‐Seen‐Solution‐Orthopedic‐
Cushion/dp/B00H5VRCEE
 Purchase at several home goods stores
 Prices vary due to style, coverings, foam density and quality. Recommend dense
foam understanding it is likely more costly.

4. Mirrors (instructions re: “how to adjust” is adequate)

 https://www.autoguide.com/the‐10‐best‐blind‐spot‐mirrors‐and‐why‐you‐need‐
them
 Use your professional judgment if choosing to include sample mirrors in your
CarFit demonstration kit. Some are concerned that interior mirrors could break
loose in a crash. Proper installation and training in their use is essential to
optimally benefit from ancillary mirrors.

5. Garbage bag or seat slide (transfers)

 Car Seat Slide https://abledata.acl.gov/product/car‐seat‐slide
 Garbage bags or silky scarves offer a temporary solution such as following hip
surgery.

6. Leg lifter (transfers)

 https://liveoakmed.com/products/rigid‐leg‐lifter
 Select version with stiff loop at one end for ease in placing over foot.

7. Adjustable (built up) Key holder (decrease pain/trauma with turning key)
 Several style choices are available at https://www.performancehealth.com/hole‐
in‐one‐key‐holder

Created by Elin Schold Davis,

AOTA Older Driver Initiative Coordinator [email protected]
APPENDICES 243
 Leg Lifter

Key Holder

APPENDICES 244
 Easy Reach

Handy Bar

APPENDICES 245
 Button Mirror

Pedal Extender

APPENDICES 246
 Left Foot Accelerator

Steering Knob

APPENDICES 247
 National Highway Traffic Safety Administration

Adapting Motor Vehicles

for Older Drivers

APPENDICES 248
 Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . 1

Investigate Cost-Saving
Opportunities and
Licensing Requirements . . . . . . . . . . . 2

Evaluate Your Needs . . . . . . . . . . . . . . 4

Select the Right Vehicle . . . . . . . . . . . 6

Choose a Qualified Mobility

Dealer to Modify Your Vehicle . . . . . 8

Obtain Training on the

Use of New Equipment . . . . . . . . . . . 10

Maintain Your Vehicle . . . . . . . . . . . 11

Resources. . . . . . . . . . . . . . . . . . . . . . . 12

APPENDICES 249
 Introduction
A Proven Process for Maintaining Freedom on the Road

N ew and existing adaptive

technologies continue to broaden
opportunities for older drivers to drive
steps outlined here represent a proven
process — evaluating your needs,
making sure the vehicle “fits” you
comfortably and safely — and enjoy the properly, choosing appropriate
freedom of driving for as long as possible. features, installing and knowing how
Some of these adaptive technologies to use adaptive devices, practicing
are as simple as swivel seats for more good vehicle maintenance — that can
convenient access. Others, such as hand help you avoid costly mistakes when
controls, may be necessary for a driver modifying or purchasing a vehicle to
to safely operate a vehicle. All drivers accommodate age-related changes that
who are facing, or may soon face, age- may affect your driving.
related driving challenges should become
Also included is general information on
familiar with the technologies available to
cost savings, licensing requirements, and
support any special driving needs.
organizations to contact for additional
The information in this brochure is based assistance. Although the brochure
on the experience of driver rehabilitation focuses on drivers of modified vehicles,
specialists and other professionals who each section also contains important
work with people who require adaptive information for people who provide
devices for their motor vehicles. The transportation for passengers with
special needs.

APPENDICES 250

 Investigate Cost-Saving Opportunities
and Licensing Requirements

Cost-Saving Opportunities There are programs that may help pay part
or all of the cost of vehicle modification.

W ith such a wide range of adaptive

equipment solutions available,
associated costs for modifying a
For information, contact your State’s
Department of Vocational Rehabilitation
or another agency that provides vocational
vehicle can vary greatly depending on services, and, if appropriate, the U.S.
an individual’s needs. Some adaptive Department of Veterans Affairs. You can
equipment, such as a special seat-back find phone numbers for these State and
cushion, can provide a better view of the Federal agencies in your local phone book.
road for as little as $50. More complex
equipment, such as hand controls, can Also be aware of the following:
be purchased for under $1,000. However, n Some nonprofits that advocate for
a new vehicle modified with adaptive individuals with disabilities offer
equipment will cost anywhere from programs that may help pay for
$20,000 to $80,000. adaptive devices. Generally, these
groups and programs represent local
Whether you are modifying a vehicle you resources. To learn about any available
now own or purchasing a new vehicle programs in your area, contact your
with adaptive equipment, it pays to do State government office that handles
your homework first. By consulting with services for persons with disabilities.
a driver rehabilitation specialist before n Automotive insurance may cover all or
you buy, you can learn what adaptive
part of the cost of adaptive equipment
equipment you need now or may need in
if your need for such equipment is a
the future, avoid paying for equipment
result of a motor vehicle crash.
you don’t need, and learn about
opportunities for public and private n Workers' compensation typically
financial assistance. covers the cost of adaptive equipment
if your need for such equipment is a
result of a job-related injury.

APPENDICES 251

 n Most major vehicle manufacturers n Some States waive the sales tax for
offer rebates on adaptive equipment, adaptive devices if you have a doctor’s
usually up to $1,000, provided you prescription for their use.
purchase a vehicle less than one year n The cost of adaptive equipment may be
old. Your local automobile dealer can tax deductible. Check with a qualified
supply information on these programs tax consultant to learn more.
and assist you with the application
process. Contact information for Licensing Requirements
vehicle manufacturers offering rebates
on adaptive equipment is listed in the All States require a valid learner’s permit
"Resources" section of this brochure. or driver’s license to receive an on–the–
road driving evaluation. You cannot
n National Mobility Equipment Dealers be denied the opportunity to apply for
Association (NMEDA) members are a permit or license because of age or
also familiar with vehicle manufacturer disability. However, a driver’s license with
rebates, can help you apply for these restrictions may be issued based on your
rebates — and can provide pre- need of adaptive equipment.
purchase advice about the type of
vehicle that will accommodate your
adaptive equipment needs. NMEDA
contact information is listed in the
“Resources” section of this brochure.

APPENDICES 252

 Evaluate Your Needs

D river rehabilitation specialists

perform comprehensive evaluations
to identify the adaptive equipment
Finding a Qualified Driver
Rehabilitation Specialist
most suited to your needs and medical Check with a rehabilitation center in
condition. As part of this process, a your area to find a qualified driver
rehabilitation specialist will take into rehabilitation specialist to perform your
consideration your future equipment evaluation. You’ll find rehabilitation
needs based on your medical condition centers for each State listed on the Web
and the repetitive stress an adaptive aid sites for the Association for Driver
may place on a particular muscle group. Rehabilitation Specialists (ADED) and
the American Occupational Therapy
In addition, you can expect a complete Association, Inc. (AOTA). These
evaluation to include vision screening as associations maintain lists of qualified
well as: driver rehabilitation specialists in areas
n Muscle strength, flexibility, and range across the United States and Canada.
of motion; Contact information for these groups is
n Coordination and reaction time; located in the “Resources” section of this
brochure.
n Judgment and decision-making
abilities; and
n Ability to drive with adaptive
equipment.
After you finish the evaluation you
should receive a report containing
specific recommendations on driving
requirements or restrictions. You should
also be given a complete list of any
recommended vehicle requirements or
modifications. The recommendations
should suggest obtaining on-the-road
training to practice safe operation of the
equipment and learn safe driving habits.

APPENDICES 253

 Paying for an Evaluation the wheelchair or obtain a new one, be
sure to tell your driver rehabilitation
n Vocational rehabilitation agencies and specialist prior to the evaluation.
workers' compensation agencies may
assist in the cost of a driver evaluation. Evaluating Passengers with
n Your health insurance company may Disabilities
pay for part or all of the evaluation.
Find out from your insurance Driver rehabilitation specialists may
company if you need a doctor’s also give advice on compatibility
prescription or other documentation and transportation safety issues for
to receive such benefits. passengers with special needs. They
determine the type of seating needed
n Many driver evaluation programs and the person’s ability to enter and
offer senior drivers a discount on exit the vehicle. They provide advice on
evaluations. Ask if your driver the purchase of modified vehicles and
rehabilitation specialist offers a recommend appropriate wheelchair lifts
discount to seniors. or other equipment that would work in
your vehicle.
Determining the Best Time to
Seek a Driving Evaluation
Consult with your doctor to make sure
you are physically and psychologically
prepared to drive. Being evaluated too
soon after an injury, stroke, or other
trauma may be misleading because it may
show the need for adaptive equipment
that you will not need in the future.
You want to be functioning at your best
when you have a driver evaluation. For
the evaluation, you will need to take
any equipment you normally use, such
as a walker or neck brace. If you use a
wheelchair and are planning to modify

APPENDICES 254

 Select the Right Vehicle

A lthough the purchase or lease of a

vehicle is your responsibility, your
mobility equipment dealer and driver
n Is there adequate parking space at
home and at work for the vehicle and
for loading/unloading a wheelchair?
rehabilitation specialist are qualified n Is there adequate parking space to
to ensure the vehicle you select can maneuver if you use a walker?
be modified to meet your adaptive
n What additional options are necessary
equipment needs. Take the time to
for the safe operation of the vehicle?
consult with these professionals before
you make your purchase decision. If a third party is paying for the vehicle,
adaptive devices, or modification costs,
To find a qualified dealer in your area,
find out if there are any limitations or
contact the National Mobility Equipment
restrictions on what is covered. Always
Dealers Association (NMEDA). To
get a written statement on what a funding
find a qualified driver rehabilitation
agency will pay before making your
specialist, contact the Association
purchase.
for Driver Rehabilitation Specialists
(ADED). Complete contact information Once you select and purchase a vehicle,
for these two organizations is listed in the be aware that you will need to also
“Resources” section of this brochure. purchase insurance to cover your vehicle
while it's being modified — even though
The following questions can help with
it will be off the road during this period.
vehicle selection. They can also help
determine if you can modify a vehicle Standard Features to Look for in a New
you already own: Passenger Vehicle
n Does the vehicle have the cargo
Before purchasing a new vehicle,
capacity (in pounds) to accommodate
always sit in it first to make sure you
the equipment you require?
are comfortable. Check to see that you
n Will there be enough space and cargo can enter and exit the vehicle with ease.
capacity to accommodate your family If possible, take it out for a test drive.
or other passengers once the vehicle is How well does the car fit your body? To
modified? prevent air bag-related injury, you should
keep 10 inches between your breast bone
and the steering wheel, which contains

APPENDICES 255

 the driver’s side air bag. At the same time, n Oversized knobs with clearly visible
you’ll need to be able to easily reach the labels;
pedals while maintaining a comfortable n Support handles to assist with entry
line of sight above the adjusted steering and exit;
wheel. Also, make sure the vehicle
n Large or adjustable-size print for
provides you with good visibility in
dashboard gauges;
all directions — front, rear, and sides.
Your dealer can demonstrate the use of n Seat adjusters that can move the seat in
adaptive features, such as adjustable foot all directions — particularly raising it
pedals and driver seats, which can help so the driver’s line of sight is 3” above
ensure a good person-vehicle fit. the adjusted steering wheel; and
n Dashboard-mounted ignition rather
Check to see if the model you are
than steering column-mounted
considering purchasing has good crash
ignition.
test results and is resistant to rollover.
Visit www.safercar.gov or call the
Vehicle Safety Hotline at 888-327-4236
to obtain government crash test results
and rollover ratings for specific makes
and models.
When selecting a vehicle, look for and
ask about available features designed to
improve both the comfort and safety of
drivers experiencing physical or visual
challenges associated with aging. Some of
these features are:
n High or extra-wide doors;
n Adjustable foot pedals;
n Large interior door handles;

APPENDICES 256

 Choose a Qualified Mobility Dealer
to Modify Your Vehicle

E ven a half inch change in the

lowering of a van floor can affect a
driver’s ability to use equipment or to
Also ensure that the dealer you choose
to modify your vehicle is registered
with the National Highway Traffic
have an unobstructed view of the road. Safety Administration (NHTSA). In
So it’s important that you take the time order to adapt a vehicle to meet your
to find a qualified dealer to modify needs, registered equipment dealers are
your vehicle. Your driver rehabilitation permitted to modify existing federally
specialist may be able to provide referrals mandated safety equipment. In addition,
depending on where you live and your registered mobility equipment dealers
vehicle modification and adaptive must provide you with a written
equipment needs. statement regarding the work that was
performed, as well as list any Federal
Note: Some State agencies specify
Motor Vehicle Safety Standards affected
the dealer you must use if you want
by their modification work on a label
reimbursement. For example, some
adjacent to the original equipment
States require that dealers bidding on
manufacturer’s label or the modifier’s
State vocational rehabilitation jobs
certification label. These labels are
be members of the National Mobility
often found inside the driver’s door. Visit
Equipment Dealer’s (NMEDA’s) Quality
www.nhtsa.dot.gov/cars/rules/adaptive/
Assurance Program. You’ll find contact
Modifier/Index.cfm to find out if a
information for NMEDA within the
mobility equipment dealer is registered
“Resources” section of this brochure.
with NHTSA as a vehicle modifier.
To find qualified mobility equipment
Questions to consider in evaluating a
dealers, begin with phone inquiries to
mobility equipment dealer’s qualifications
learn about credentials, experience, and
are listed below:
references. Ask questions about how they n Is the dealer registered with NHTSA?
operate. Do they work with qualified
driver rehabilitation specialists? Will n Is the dealer a member of NMEDA —
they look at your vehicle before you buy and a participant in this organization's
it? Do they require a prescription from a Quality Assurance Program?
physician or driver evaluation specialist? n What type of training has the staff
How long will it take before they can start received?
work on your vehicle?

APPENDICES 257

 n What type of warranty is provided on n Can the equipment be transferred to a
work? new vehicle in the future?
n Does the dealer provide ongoing n Will existing safety features need to
service and maintenance? be modified to install the adaptive
n Are replacement parts stocked and equipment?
readily available? While your vehicle is being modified, you
If you are satisfied with the answers you will most likely need to be available for
receive, check references; then arrange fittings. This avoids additional waiting
to visit the dealer’s facility. Once you are time for adjustments once the equipment
comfortable with a dealer’s qualifications, is fully installed. Without proper fittings
you will want to ask more specific you may have problems with the safe
questions, such as: operation of the vehicle and have to go
back for adjustments.
n How much will the modification cost?
n Are third-party payments accepted?
n How long will it take to modify the
vehicle?

APPENDICES 258

 Obtain Training on the Use of New Equipment

B oth new and experienced drivers

need training on how to safely use
newly installed adaptive equipment.
Ensuring Safe Operation and
Warranty Compliance
Your equipment installer and driver
rehabilitation specialist should provide
information on the new devices and off-
R egular maintenance is important
for keeping your vehicle and
specially installed adaptive features safe
road instruction. and reliable. It may also be mandatory
for compliance with the terms of your
But literature and off-road instruction warranty. Some warranties specify a time
aren’t enough to equip you to drive safely period during which adaptive equipment
with your new adaptive equipment. must be inspected. These equipment
This equipment can be very complex. check-up schedules may differ from
So it’s extremely important to obtain those for your vehicle. Make sure you
on-the-road training and practice with or your modifier submit all warranty
a driver rehabilitation specialist who cards for all equipment. This will not
has advanced expertise and knowledge only ensure coverage, but will also enable
of adaptive technologies. If your driver manufacturers to contact you in case of a
rehabilitation specialist does not offer recall.
such training, ask him or her for a
referral, or inquire at your local driver
licensing office.
State vocational rehabilitation
departments and workers’ compensation
plans will pay for driver education and
training under certain circumstances.
At a minimum, their staffs can help you
locate a qualified driver rehabilitation
specialist to provide training.
Finally, remember to enlist the help
of a family member or friend to drive
you to all of your training sessions. (It’s
important to have someone else who
can drive your vehicle in case of an
emergency.)

APPENDICES 259
10
 Maintain Your Vehicle

Vehicle Safety Checklist n Remember to keep your windows and

headlights clean. You need to clearly
Your vehicle warranty and owner’s see where you are going. Keeping the
manual will describe regularly required headlights clean will help other cars
vehicle maintenance. Keep in mind that see you too.
your adaptive equipment may need
n Check for damage from road hazards
special attention or more frequent check-
by having your vehicle put on a service
ups than your vehicle alone. However,
lift at least once a year.
the following checklist represents basic
maintenance that applies to all vehicles: Proper maintenance can keep your
n Check tire pressure at least once a vehicle running smoothly, leaving you
month and always before a long road free to concentrate on the road and enjoy
trip. the freedom of driving.
n Change oil as recommended by your
owner’s manual, using the grade
recommended.
n Check all fluids when you change the
oil, including power steering fluid,
brake fluid, and engine coolant.
n Routinely check headlights, brake and
parking lights, reverse lights, and turn
signals.

APPENDICES 260
11
 Resources

Association for Driver Rehabilitation The following manufacturers offer rebates

Specialists (ADED) or reimbursements on new-vehicle
200 First Avenue NW, #505 modification.
Hickory, NC 28601
866-672-9466 Audi
www .aded .net 800-822-2834
www.audiusa.com
American Occupational Therapy
Association (AOTA) DaimlerChrysler Corporation
4720 Montgomery Lane 800-255-9877
P.O. Box 31220 (TDD Users: 800-922-3826)
Bethesda, MD 20824-1220 www.daimlerchrysler.com
301-652-2682 Ford Motor Company
TDD: 800-377-8555 800-952-2248
www.aota.org/olderdriver (TDD Users: 800-TDD-0312)
National Mobility Equipment Dealers www.fordmobilitymotoring.com
Association (NMEDA) General Motors Corporation
3327 West Bearss Avenue 800-323-9935
Tampa, FL 33618 (TDD Users: 800-TDD-9935)
800-833-0427 www.gm.com
www.nmeda.org
Saturn
National Highway Traffic Safety 800-553-6000, Prompt 3
Administration (NHTSA) (TDD Users: 800-833-6000)
1200 New Jersey Avenue SE. www.saturn.com
Washington, DC 20590
888-327-4236 Toyota
TDD: 800-424-9153 800-331-4331
www.nhtsa.gov www.toyota.com/mobility
www.safercar.gov Volkswagen
Department of Veteran Affairs 800-822-8987
800-827-1000 www.vw.com
www.va.gov
State Departments of Vocational Selected photos courtesy of Bruno
Rehabilitation Independent Living Aids.
Listed in telephone book.

APPENDICES 261
12
APPENDICES 262
 DOT HS 810 732
February 2007

APPENDICES 263
 Sample Driving Cessation Plan
Planning for future driving cessation requires research and planning similar to future needs for
finances and housing. Ideally, creating a driving cessation plan starts early, years before driving
needs to stop. Having individual choice and control over transportation options means knowing
what options are available and how to use them.

One concept many older adults find helpful is “transition”. This involves gaining experience and
confidence in the use of several forms of transportation options available in the community.
This planning may also involve exploring requirements for eligibility, availability, routes, and
accessibility.

When driving needs to stop for medically-related changes, transportation options may need to
include support to allow an individual to move from one destination to another safely. The
growing field of Mobility Management may be an option available in your community. Mobility
Managers assist individuals and their families with creating transportation plans with
appropriate supports for safety and comfort. An example of support may be a service offering
door to door service or the provision of an escort who comes to the older adult’s door, to and
from the vehicle and stays with them at their destination until returning safely back into their
home.

APPENDICES 264
 Sample Driving Cessation Plan for _______________________:

APPENDICES 265
1) You are experiencing medically related changes that may require you to stop driving at some point in the future. Your
physician or healthcare professional will assist you in monitoring these changes and will do everything possible to extend
your driving as long as safely possible.

2) We recommend that you make a list of the typical places you go. This list will guide you in your exploration of options other
than driving that can support ongoing participation in the activities you choose.

Where do I How many How often do I Who might be Can I walk Can I take What other
want to go? miles away is it want to go? able to provide there? public services are
from home? me with a Y/N transportation? available for
ride? (family, Y/N getting there?
friends, (paratransit,
neighbors, taxi, volunteer
etc.) drivers, etc.)
Grocery store

Bank

Post office

Senior center

Exercise/physical
activity center

Outdoor park

Library
APPENDICES 266
Doctor’s office

Dental office

Personal care

General
shopping
Entertainment
venue
Club activities

Volunteer
service locations

Resources:

U.S. Administration on Aging Eldercare Locator. Available at https://eldercare.acl.gov. Accessed September 12, 2018.
 Snellen Test

In order to perform this test, please follow the instructions:

APPENDICES 267
 Snellen Test

1. Print the test page in A4 standard format. Place yourself 2.8

meters (or 9 feet) away from the chart. If the test page is in
another format, or if you wish to perform the test facing the
screen, you will have to calculate the distance at which you
must stand facing it, using the following formula: measure the
height of the letter E (first line, 20/200) in millimeters. Then,
divide the value of this measurement by 88. Finally, multiply it
by 6. The result shows the distance at which you must be
placed, in meters.
E.g. (42/88) x 6 = 2.8 m

2. Test your visual acuity with correction (contact lenses or

glasses).

3. Test one eye at a time. Start with the right eye, covering the
left one without pressing on it. Then, examine the left eye by
doing the opposite. If you are using correction glasses, you
can cover the eye with a sheet of paper.

4. Read the letters from the largest to the smallest.

5. To make the examination easier and faster, another person

can help you by showing the letters you must read among the
lines of letters.

6. If you can read the letters of the 8th line, your sight is optimal
(visual acuity 20/20).

7. If your visual acuity is less than 20/20 or if you have doubts

about your sight, visit your ophthalmologist.

NOTE: take the results as a recommendation. The results do not

indicate a diagnosis whatsoever. Performing the test does not
mean you should skip regular visits to your eye doctor,
because you could easily miss signs that only a trained eye
care practitioner would find.

APPENDICES 268
 Snellgrove Maze Test
Administration Instructions

The Maze Test was developed as a pencil and paper test of attention, visuoconstructional ability, and
executive functions of planning and foresight. Participants complete a simple demonstration (or
practice) maze first to establish the rule set, and then complete the Maze Task. Performance is
measured in time (in seconds), using a timer or stopwatch, and the total number of errors. Errors are
determined by the number of times a participant enters a dead end or fails to stay in the lines. Time to
administer is 1–4 minutes. The Maze should be printed on an 8 × 11” paper with the Maze Test at least
5.5” square and the practice 4.5”.

To administer the test, the Practice maze is placed in front of the participant in the correct orientation.
The participant is provided with a pen, and the administrator says:

“I want you to find the route from the start to the exit of the maze. Put your pen here at the start (point
to the start). Here is the exit of the maze (point to the exit). Draw a line representing the route from the
start to the exit of the maze. The rules are that you are not to run into dead ends (point to a dead end) or
cross solid lines (point to a solid line). Go.”

The instructions are repeated, if required, and any rule‐breaks should be corrected. The participant is
permitted to lift the pen from the page. When the participant has attempted the maze, record whether
the task was completed (yes or no), and the number of times the participant required repeating or
reminding of the instructions.

Next the actual Maze Task is placed in front of the participant in the correct orientation. The participant
is provided with a pen, and the administrator says:

“Good, now that I know you understand the task, I’m going to time you as you find the route from the
start to the exit of the maze. Put your pen here at the start (point to the start). Here is the exit (point to
the exit). Draw a line representing the route from the start to the exit of the maze. The same rules apply.
Don’t run into any dead ends (point to a dead end), or cross any lines (point to a solid line). Are you
ready? I’m starting the timer now. Go!”

The instructions are not repeated and any rule breaks are not corrected. If questions are asked, the
response should be: I can’t give you any more help. Do the task as best you can. Stop the timer
immediately upon the participant’s completion of the task. There is a limit of 3 minutes for the Maze
Task. If the maze has not been completed in this time, discontinue. The recording of the test includes
whether the Maze Task was completed (yes or no); the time in seconds to complete the Maze Task, and
the number of errors (entry into a dead end, and/or failure to stay within the lane).

Suggested Cut‐Point Scores

1. If completed in 61 seconds or longer, with or without errors, then the participant is not cognitively fit
to drive safely.

APPENDICES 269
 2. If completed in up to 60 seconds, but with two or more errors, then the participant is not cognitively
fit to drive safely.

3. If completed in less than 60 seconds, with zero or one error, then the participant is likely to have
adequate capacity in the cognitive domains of attention, visuoconstructional skills, and executive
functions of planning and foresight to drive safely.

APPENDICES 270
 Illustration of Errors

APPENDICES 271
 ©

Date: ________________
Patient name: ________________
Task completed: ________________ (yes / no)
Number of times patient
required instructions: ________________

© 2006 Dr. Carol Snellgrove

APPENDICES 272
 ©

Date: ________________
Patient name: ________________
Task completed: ________________ (yes / no)
Time to complete task: ________________ (seconds)
Number of errors: ________________

© 2006 Dr. Carol Snellgrove

APPENDICES 273
 Spectrum of Driver Services: Right Services for the Right People at the Right Time
A description consumers and health care providers can use to
distinguish the type of services needed for an older adult.

COMMUNITY-BASED MEDICALLY-BASED ASSESSMENT,

SPECIALIZED EVALUATION AND TRAINING
EDUCATION EDUCATION AND REFERRAL
Program Driver Safety Driver Rehabilitation Programs
Type
Driving School Driver Screen Clinical IADL Evaluation
Programs (Includes Driver Evaluation)
Typical Program specific Licensed Driving Health care professional Occupational Therapy Practitioner Driver Rehabilitation Specialist#, Certified Driver
Providers credentials Instructor (LDI) (e.g., physician, social worker, (Generalist or Driver Rehabilitation Rehabilitation Specialist*, Occupational Therapist with
and (e.g. AARP and certified by state neuropsychologist). Specialist#). Specialty Certification in Driving and Community Mobility+.
Credentials AAA Driver licensing agency
Other health professional degree
Improvement or Dept. of
with expertise in Instrumental
Program). Education.
Activities of Daily Living (IADL).
Required Program specific Instructs novice Knowledge of relevant Knowledge of medical conditions Applies knowledge of medical conditions with implications
Provider’s knowledge. or relocated medical conditions, and the implication for community to driving.
Knowledge drivers, excluding assessment, referral, and / or mobility including driving.
Assesses the cognitive, visual, perceptual, behavioral and
medical or aging intervention processes. Assess the cognitive, visual, per-
physical limitations that may impact driving performance.
Trained in course conditions that ceptual, behavioral and
Understand the limits and
content and might interfere physical limitations that may Integrates the clinical findings with assessment of on-road
value of assessment tools,
delivery. with driving, for impact driving performance. performance.
including simulation, as a
purposes of
measurement of fitness to Knowledge of available services. Synthesizes client and caregiver needs, assists in decisions
teaching / training
drive. about equipment and vehicle modification options available.
/ refreshing / Understands the limits and value
updating driving of assessment tools, including Coordinates multidisciplinary providers and resources,
skills. simulation, as a measurement of including driver education, health care team, vehicle choice
fitness to drive. and modifications, community services, funding / payers,
driver licensing agencies, training and education, and
caregiver support.
Typical 1) Classroom 1) Enhance 1) Counsel on risks associated 1) Evaluate and interpret risks as- Programs are distinguished by complexity of evaluations,
Services or computer driving with specific conditions sociated with changes in vision, types of equipment, vehicles, and expertise of provider.
Provided based performance. (e.g., medications, fractures, cognition, and sensory-motor
1) Navigate driver license compliance and basic eligibility
refresher for post-surgery). functions due to acute or chronic
2) Acquire driver through intake of driving and medical history.
licensed conditions.
permit or 2) Investigate driving risk
drivers: review 2) Evaluate and interpret risks associated with changes in
license. associated with changes 2) Facilitate remediation of deficits
of rules of the vision, cognition, and sensory-motor functions in the
in vision, cognition, and to advance client readiness for
road, driving 3) Counsel driving context by the medically trained provider.
sensory-motor function. driver rehabilitation services.
techniques, with family
3) Perform a comprehensive driving evaluation (clinical and
driving strate- members for 3) Determine actions for the 3) Develop an individualized
on-road).
gies, state student driver at-risk driver: transportation plan considering
laws, etc. skill develop- %Refer to IADL evalua- client diagnosis and risks, 4) Advise client and caregivers about evaluation results,
ment. tion, driver rehabilitation family, caregiver, environmental and provide resources, counseling, education, and / or
2) Enhanced self-
program, and / or other and community options and intervention plan.
awareness, 4) Recommend
services. limitations:
choices, and continued 5) Intervention may include training with compensatory
capability to training and / %Discuss driving cessation; %Discuss resources for vehicle strategies, skills, and vehicle adaptations or modifications
self-limit. or undergoing provide access to counsel- adaptations (e.g., scooter lift). for drivers and passengers.
licensing test. ing and education for %Facilitate client training on
alternative transportation community transportation 6) Advocate for clients in access to funding resources
5) Remedial options. options (e.g., mobility and / or reimbursement.
Programs
4) Follow reporting / referral
managers, dementia-friendly 7) Provide documentation about fitness to drive to the
(e.g., license transportation).
structure for licensing physician and / or driver-licensing agency in compliance
reinstatement
recommendations. %Discuss driving cessation. with regulations.
course for
teens / adults, For clients with poor self- 8) Prescribe equipment in compliance with state regulations
license point awareness, collaborate with and collaborate with Mobility Equipment Dealer^ for
reduction caregivers on cessation fitting and training.
courses). strategies.
%Refer to driver rehabilitation 9) Present resources and options for continued community
program. mobility if recommending driving cessation or transition
from driving.
4) Document driver safety risk and
recommended intervention plan Recommendations may include (but not restricted to):
to guide further action. 1) drive unrestricted; 2) drive with restrictions; 3) cessation
of driving pending rehabilitation or training; 4) planned
5) Follow professional ethics on re-evaluation for progressive disorders; 5) driving cessation;
referrals to the driver licensing 6) referral to another program.
authority.
Outcome Provides Enhances skills for Indicates risk or need for follow-up for medically at-risk drivers. Determines fitness to drive and provides rehabilitative services.
education and healthy drivers.
awareness.
#DRS – Health professional degree with specialty training in driver evaluation and rehabilitation. *CDRS – Certified Driver Rehabilitation Specialist-Credentialed by ADED (Association for Driver Rehabilitation
Specialists). +SCDCM – Specialty Certified in Driving and Community Mobility by AOTA (American Occupational Therapy Association).
^Quality Approved Provider by NMEDA (National Mobility Equipment Dealers Association).

Driver Rehabilitation Programs: Defining Program Models, Services, and Expertise.

Occupational Therapy In Health Care, 28(2):177–187, 2014

APPENDICES 274
 Spectrum of Driver Rehabilitation Program Services
A description consumers and health care providers can use to distinguish the services
provided by driver rehabilitation programs which best fits a client’s need.

DRIVER REHABILITATION PROGRAMS

Program Type
Determine fitness to drive and / or provide rehabilitative services.
Levels of BASIC LOW TECH HIGH TECH
Program and
Typical Provider Provider is a Driver Rehabilitation Driver Rehabilitation Specialist#, Certified Driver Driver Rehabilitation Specialist#, Certified Driver Rehabilitation
Credentials Specialist (DRS)# with professional Rehabilitation Specialist*, Occupational Therapist Specialist*, Occupational Therapist with Specialty Certification in
background in occupational therapy, with Specialty Certification in Driving and Community Driving and Community Mobility+.
other allied health field, driver Mobility+, or in combination with LDI.
Certification in Driver Rehabilitation is recommended as the
education or a professional team of
Certification in Driver Rehabilitation is recommended provider for comprehensive driving evaluation and training with
CDRS or SCDCM with LDI**.
as the provider for comprehensive driving evaluation advanced skills and expertise to complete complex client and
and training. vehicle evaluation and training.
Program Service Offers driver evaluation, training Offers comprehensive driving evaluation, training and Offers a wide variety of adaptive equipment and vehicle options
and education. education, with or without adaptive driving aids that for comprehensive driving evaluation, training and education,
affect the operation of primary or secondary controls, including all services available in Low Tech and Basic programs. At
May include use of adaptive driving
vehicle ingress / egress, and mobility device storage / this level, providers have the ability to alter positioning of primary
aids that do not affect operation of
securement. May include use of adaptive driving aids and secondary controls based on client’s need or ability level.
primary or secondary controls (e.g.,
such as seat cushions or additional mirrors.
seat cushions or additional mirrors). High Tech adaptive equipment for primary and secondary controls
At the Low Tech level, adaptive equipment for primary includes devices that meet the following conditions:
May include transportation
control is typically mechanical. Secondary controls may 1) capable of controlling vehicle functions or driving controls, and
planning (transition and options),
include wireless or remote access.
cessation planning, and recommen- 2) consists of a programmable computerized system that
dations for clients as passengers. May include transportation planning (transition and interfaces / integrates with an electronic system in the vehicle.
options), cessation planning, and recommendations for
clients who plan to ride as passengers only.
Access to Driver’s Requires independent transfer into Addresses transfers, seating and position into OEM^ Access to the vehicle typically requires ramp or lift and may
Position OEM^ driver’s seat in vehicle. driver’s seat. May make recommendations for assistive require adaptation to OEM driver’s seat. Access to driver position
devices to access driver’s seat, improved positioning, may be dependent on use of a transfer seat base, or clients may
wheelchair securement systems, and / or mechanical drive from their wheelchair. Provider evaluates and recommends
wheelchair loading devices. vehicle structural modifications to accommodate products such
as ramps, lifts, wheelchair and scooter hoists, transfer seat bases,
wheelchairs suitable to utilize as a driver seat, and / or wheelchair
securement systems.
Typical Vehicle Uses OEM^ controls. Primary driving control examples: Primary driving control examples (in addition to Low Tech options):
Modification:
A) mechanical gas / brake hand control; A) powered gas / brake systems;
Primary Controls:
Gas, Brake, B) left foot accelerator pedal; B) power park brake integrated with a powered gas / brake system;
Steering
C) pedal extensions; C) variable effort steering systems;
D) park brake lever or electronic park brake; D) reduced diameter steering wheel, horizontal steering, steering
E) steering device (spinner knob, tri-pin, C-cuff). wheel extension, joystick controls;
E) reduced effort brake systems.
Typical Vehicle Uses OEM^ controls. Secondary driving control examples: Electronic systems to access secondary and accessory controls.
Modification:
A) remote horn button;
Secondary Secondary driving control examples (in addition to
Controls B) turn signal modification (remote, crossover lever); Low Tech options):
C) remote wiper controls; A) remote panels, touch pads or switch arrays that interface
D) gear selector modification; with OEM^ electronics;

E) key / ignition adaptions. B) wiring extension for OEM^ electronics;

C) powered transmission shifter.
#DRS - Health professional degree with specialty training in driver evaluation and rehabilitation, *CDRS – Certified Driver Rehabilitation Specialist – Credentialed by ADED (Association for Driver Rehabilitation
Specialists). +SCDCM – Specialty Certified in Driving and Community Mobility by AOTA (American Occupational Therapy Association) ^OEM – Original Equipment installed by Manufacturer.
**LDI-licensed driving instructor.

Driver Rehabilitation Programs: Defining Program Models, Services, and Expertise.

Occupational Therapy In Health Care, 28(2):177–187, 2014

APPENDICES 275
 Trail-Making Test for Screening, Part A and B
Administration Instructions

This test of general cognitive function specifically assesses working memory, visual processing,
visuospatial skills, selective and divided attention, processing speed, and psychomotor coordination. In
addition, numerous studies have demonstrated an association between poor performance on the Trail-
Making Tests and poor driving performance.

Instructions for Part A. Using the sample of A, the administrator says: “There are numbers in circles on
this page. Please take the pencil and draw a line from one number to the next, in order. Start at 1 [point
to the number], then go to 2 [point], then go to 3 [point], and so on. Please try not to lift the pen as you
move from one number to the next. Work as quickly and accurately as you can.” If there is an error: “You
were at number 2. What is the next number?” Wait for the individual’s response and say, “Please start
here and continue.”

Test A: If Sample A is completed correctly, the administrator repeats the above instructions for Trails A.
Start timing as soon as the instruction is given to begin. Stop timing when the Trail is completed, or
when maximum time is reached (150 seconds = 2.5 min).

Instructions for Part B. Using the sample of B, the administrator says: “There are numbers and letters in
circles on this page. Please take the pen and draw a line, alternating in order between the numbers and
letters. Start at number 1 [point], then go to the first letter, A [point], then go to the next number, 2
[point], and then the next letter, B [point], and so on. Please try not to lift the pen as you move from one
number or letter to the next. Work as quickly and accurately as you can.” If there is an error: “You were
at number 2. What is the next letter?” Wait for the individual’s response and say, “Please start here and
continue.”

If Sample B is completed correctly, the administrator repeats the above instructions for Trails B. Start
timing as soon as the instruction is given to begin. Stop timing when the Trail is completed, or when
maximum time is reached (300 seconds = 5 min).

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 3–4 minutes to administer, but should be
stopped after 5 minutes.

APPENDICES 276
 Trail Making Test, Part A
Client Name: ______________________ Date: _____________

18 22
20

19 17
21

15 4
5
16
6
23

14 7 1 Start
13
2
8
3

10

12 11
9
24

25

APPENDICES 277
 Trail Making Test, Part B
Client Name: ______________________ Date: _____________

13 10

9 I
8 D
4
B

3
7
1 Start

H 5

C
12

G
A
J

2
L 6

F E

K 11

APPENDICES 278
The American Geriatrics Society (AGS) differentiates driving
capacity from driving fitness. This fact sheet is based on the Capacity and Fitness
AGS approach and uses that distinction. The state ultimately to Drive a Motor Vehicle
decides whether or not an older Veteran has the capacity to
drive (e.g., driving test) and retains legal driving privileges (i.e.,
EDUCATIONAL
HANDOUT SERIES
driver’s license). It is the clinician’s responsibility to fairly
and accurately report factors that may contribute to unsafe U.S. Department of Veterans Affairs
Veterans Health Administration
Employee Education System
driving – fitness to drive.

What VA policies may apply?

VA Clinicians must follow VA laws, regulations and policies, in addition to clinical practices, when
treating Veterans and sharing Veteran health information. The following information may assist in
identifying relevant polices. Veterans with “neurological and brain disorders,” as well as Veterans with
“disabilities associated with aging,” are among those eligible for the VA Driver Rehabilitation Program
(VHA Handbook 1173.16). Clinicians should make reports to the Registry of Motor Vehicles in
accordance with VA privacy rules, state law and clinical ethics. In general, in order for a VA health
care facility, upon its own initiative, to make a report to a State Department of Motor Vehicles (DMV),
there must be a standing written request letter on file from the State agency that complies with
VHA Directive 1605.01, Privacy and Release of Information.
To view VA DMV privacy rules see also “Reporting to State Department of Motor Vehicles Privacy Fact
Sheet” at https://vaww.vets.vaco.portal.va.gov/sites/privacy/vhapo/Pages/FactSheets.aspx.
If you have further questions regarding law and policies for reporting within your state, please
consult with your facility Privacy Officer or district counsel.

How might dementia affect Fitness to Drive?

Most older adults do not have dementia, and the presence of dementia does not necessarily mean
that an older adult lacks capacity for domains such as consent to treatment, choosing a healthcare
agent, or other types of decisions. Patients with mild dementia can often drive safely. Opinions on
fitness to drive for patients with mild dementia should be based on functional abilities (e.g. ability
to pass a road test), and not solely on a diagnosis of dementia per se. As dementia progresses,
different abilities and skills may be affected depending on the dementia subtype and individual
factors, as well as comorbidities. For example, some individuals with dementia retain the basic
ability to operate a motor vehicle, but may become lost when driving or feel challenged when a
complex decision is required quickly.

What supports may help?

When assessing an older Veteran’s fitness to drive, clinicians should consider whether or not
optimizing functional status could allow him or her to continue to drive safely. Identifying and
addressing sensory deficits, including visual deficits and hearing loss, is critical. VA prosthetics
may be able to assist with adaptive devices, and newer cars may include technologies to assist in
safe driving, just as GPS devices may assist in location. Finally, your VA, your state, and/or private
organizations and insurance companies may provide education and rehabilitation to improve
driver performance.

APPENDICES 279
 How do I start?
When the older Veteran driver has significant cognitive impairment and/or lacks insight into their
ability to drive (e.g., in certain cases of dementia, stroke, etc.), it is imperative to obtain the help
of the caregiver, surrogate decision-maker, or guardian, if available. Caregivers play a crucial role
in encouraging the older Veteran to retire from driving and to help the individual find alternative
transportation options. Clinicians should inform caregivers that the clinical team will support and
assist their efforts in any way possible. In rare instances, it may be necessary to appoint a legal
guardian for the older Veteran. In turn, the guardian may forfeit the older Veteran’s car and license
to ensure the individual’s safety. These actions should be taken only as a last resort. From a practical
standpoint, hiding, donating, dismantling, or selling the car may also be useful in these difficult
situations.

What are the most important areas to consider when assessing fitness to drive?
Three key functional areas are considered as the foundation for fitness to drive: vision, cognition,
and motor/somatosensory function. Impairment in one or more of these areas has the
potential to increase the older Veteran’s risk of being involved in a crash. Once these areas are
assessed, the health care provider can determine if referral to a specialist (e.g., ophthalmologist,
neuropsychologist, driver rehabilitation specialist) for further evaluation or intervention is needed.
Domain Potential office-based tests to consider (Select 1 or more from
American Geriatrics Society recommendations.)
General Driving history; Instrumental activities of daily living (IADL);
Recent medication changes
Vision Snellen chart; Visual fields; Contrast sensitivity

Cognition Montreal Cognitive Assessment (MoCA); Trails B; Clock-drawing test; Maze test

Motor/Sensory Rapid pace walk; Get up and go; Range of motion

Which states require mandatory reporting from clinicians who become aware of
a potential for unsafe driving?
State laws vary as to whether clinicians are mandated to contact the division of motor vehicles.
Mandatory reporting states as of 2017 include California, Delaware, New Jersey, Nevada, Oregon,
and Pennsylvania.

APPENDICES 280
 When should I refer to a Driving Rehabilitation Specialist (DRS)?
DRSs are often occupational therapists who have additional training in driver rehabilitation.
DRSs work with older drivers who have dementia and other chronic conditions, especially
neurologic and orthopedic problems. Clinicians should consider ordering a DRS evaluation when
the Veteran, family, friends, and/or the clinician have concerns about the Veteran’s fitness to drive.
An evaluation from a DRS is particularly useful when there is disagreement about whether the
older Veteran is safe to drive. DRSs evaluate the sensory (vision, proprioception), cognitive, and
motor functional abilities which support driving skills, and they may also provide assessment
and/or training in the vehicle and on the road. DRSs can recommend either rehabilitation when
restoration of abilities is deemed possible, or modifications (e.g., hand controls, left foot accelerator)
to compensate for physical impairments. To address issues of normal aging and slowed processing,
DRSs can recommend compensatory strategies that may include route modifications (e.g., no left
turns, avoid rush hour) or suggest restrictions (e.g. daylight driving only, speed restrictions) to
support ongoing driving. DRSs may also recommend to the primary care provider that the older
Veteran is unsafe to drive and should retire from driving.

Suggested Online Resources

Driver Rehabilitation for VA handbook of procedures for https://www.va.gov/VHA-

Veterans with Disabilities all matters regarding the PUBLICAtIONs/ViewPublica-
Program (VHA Handbook Driver Rehabilitation Program tion.asp?pub_ID=5621
1173.16) for Veterans

Driving with Dementia: Video from VA partners More resources can be found
Hanging Up the Keys addresses drivers with by searching the TMS catalog
cognitive impairment. with ‘Driving with Dementia’

Acknowledgement and Disclaimer

This fact sheet is based on the following reference: Pomidor A, ed. Clinician’s Guide to Assessing and Counseling Older
Drivers, 3rd Edition. New York: The American Geriatrics Society; 2015.
This handout was developed as part of an educational effort sponsored by the VHA Employee Education System and
the VHA Office of Geriatrics and Extended Care. This handout is one from the Assessment of Decision Making Capacity
Handout Series which links to a VA TMS educational activity. Information presented in this handout was based on
the consensus of the educational planning committee considering research, practice, and general principles at the
time of its drafting. The purpose of this document is for education. The contents should not be construed as policy,
but rather as an educational resource that may be useful and effective in clinical practice. VA Clinicians must follow
VA laws, regulations and policies, in addition to clinical practices, when treating Veterans and sharing Veteran health
information. Links to free clinical resources may be included in the handout but should not be construed as official
endorsement of these tools.
Cite as: Farrell TW, Page K, Mills WL, Catlin C, Dumas P, Morrow A, Cooper V, Guzman J, McConnell E, Moye J. (2018).
Capacity and Fitness to Drive a Motor Vehicle Handout.
(VHA EES Assessment of Decision Making Capacity Handout Series). Washington DC: VHA Employee Education System.
Additional Resources at: Additional Resources are available at the VA TMS system. Please search the course catalog by keyword ‘capacity’.
References: American Geriatrics Society & A. Pomidor, Ed. (2016, January). Clinician’s guide to assessing and counseling older drivers, 3rd edition.
(Report No. DOT HS 812 228). Washington, DC: National Highway Traffic Safety Administration.
The American Geriatrics Society retains the copyright. National Ethics Committee of the Veterans Health Administration (2007).
Impaired driving in older adult: Ethical challenges for healthcare professionals.
APPENDICES 281