Clinician’s Guide to 

Assessing and Counseling

Older Drivers

3rd Edition
Disclaimer

The project is supported by cooperative agreement number 

DTNH22-14-H-00454 from the National Highway Traffic Safety 

Administration of the U.S. Department of Transportation. The opinions, 

findings, and conclusions expressed in this publication are those of the 

authors and not necessarily those of NHTSA or DOT. The United States 

Government assumes no liability for its content or use thereof. If trade or 

manufacturers’ names or products are mentioned, it is because they are 

considered essential to the object of the publication and should not be 

construed as an endorsement. The United States Government does not 

endorse products or manufacturers.

Suggested APA Format Citation:

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.
Clinician's Guide to Assessing and Counseling Older Drivers, 3rd Edition

An Update of the Physician's Guide to Assessing and Counseling Older Drivers

Table of Contents

Ch. # Title Page

- Front Matter and Introduction i

1 The Older Adult Driver: An Overview 1

2 Is the Older Adult at Increased Risk of Unsafe Driving? 16

3 Screening and Assessment of Functional Abilities for Driving 29

4 Clinical Interventions 52

5 The Driver Rehabilitation Specialist 66

6 Advising the Older Adult About Transitioning from Driving 79

7 Ethical and Legal Issues 95

8 State Licensing and Reporting Laws 114

9 Medical Conditions, Functional Deficits, and Medications That May Affect

Driving Safety

126

10 Meeting Future Transportation Needs of Older Adults 190

App A CPT Codes 206

App B Patient and Caregiver Educational Material

- Am I a Safe Driver?

- Getting by Without Driving

- How to Assist the Older Driver

- NHTSA’s How to Understand and Influence Older Drivers

- Ten Tips to Aging Well

- Tips for Safe Driving

210

212

214 

218 

222 

239 

240

App C Clinical Team Resources

- Clinical Assessment of Driving Related Skills (CADReS) Score Sheet

- Evidence Table for Assessments (selected in Ch. 3)

- Medical Review Board Sample Letter

- Modified Driving Habits Questionnaire

- Montreal Cognitive Assessment (MoCA) and Form

- Motor Vehicle Adaptive Equipment Descriptions and NHTSA’s

Adapting Motor Vehicles for Older Drivers brochure

- Sample Driving Cessation Plan

- Snellen Chart

- Snellgrove Maze Test and Form

- Three Levels of Spectrum of Driver Services

- Trails A Test

- Trails B Test

244

245 

248 

252 

253 

258 

263 

288 

290

292 

295 

297 

298 
i 

Clinician’s Guide to Assessing and Counseling Older Drivers, 3rd Edition

An Update of the Physician's Guide to Assessing and Counseling Older Drivers

COPYRIGHT

Except where authorized, no part of this publication may be reproduced, stored in a retrieval 

system, or transmitted in any form or by any means, electronic, mechanical, photocopying, 

recording, or otherwise without prior written permission of the American Geriatrics Society, 

40 Fulton Street, 18th Floor, New York, NY 10038. Please note that the authors of this guide 

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

review by medical specialists and other experts in the field of older driver safety. 

The publication is produced under a cooperative agreement with the U.S. Department of 

Transportation, National Highway Traffic Safety Administration (NHTSA). NHTSA is authorized 

to distribute the publication to the general public.

Although the Clinician’s Guide to Assessing and Counseling Older Drivers, 3rd Edition, is 

distributed by various companies in the health care field, it is independently prepared. All

decisions regarding its content are solely the responsibility of the authors. Their decisions are

not subject to any form of approval by other interests or organizations.

The information in this guide is provided to assist health care providers in evaluating the ability

of their older patients to operate motor vehicles safely as part of their everyday, personal 

activities. Evaluating the ability of patients to operate commercial vehicles or to function as 

professional drivers involves more stringent criteria and is beyond the scope of this

publication.

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

for health care provider’s clinical judgment. Rather, this guide reflects the scientific literature 

and views of experts as of July 2015, and is provided for informational and educational

purposes only. None of this guide’s material should be construed as legal advice nor used to

resolve legal problems. If legal advice is required, we urge you to consult an attorney who is 

licensed to practice in your State. 

No responsibility is assumed by the authors or the American Geriatrics Society for any injury or 

damage to persons or property, as a matter of product liability, negligence, warranty, or 

otherwise, arising out of the use or application of any methods, products, instructions, or ideas 

contained herein. No guarantee, endorsement, or warranty of any kind, express or implied 

(including specifically no warrant of merchantability or of fitness for a particular purpose) is 

given by the Society in connection with any information contained herein. Independent

verification of any diagnosis, treatment, or drug use or dosage should be obtained. No test or 
ii

procedure should be performed unless, in the judgment of an independent, qualified health 

care provider, it is justified in the light of the risk involved.

ACKNOWLEDGEMENTS

This 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 Physician’s Guide to

Assessing and Counseling Older Drivers that was originally developed by the American Medical

Association (AMA) under a prior cooperative agreement with NHTSA.

EDITORIAL BOARD 

EDITORIAL BOARD CHAIR

Alice Pomidor, MD, MPH, AGSF

Professor, Department of Geriatrics

Florida State University College of Medicine

Tallahassee, FL

EDITORIAL BOARD MEMBERS

Anne E. Dickerson, PhD, OTR/L, FAOTA 

Department of Occupational Therapy 

East Carolina University

Greenville, NC

Shelly Gray, PharmD, MS

Professor and Vice Chair for Curriculum and Instruction, Department of Pharmacy

Director, Geriatric Program and Plein Certificate

School of Pharmacy 

Seattle, WA 

Richard Marottoli, MD

Medical Director of the Dorothy Adler

Geriatric Assessment Center

Yale University

New Haven, CT

Irene Moore, MSSW, LISW-S, AGSF

Professor, Department of Family and Community Medicine 

University of Cincinnati Geriatric Medicine Program 

Cincinnati, OH
iii

Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP 

Professor

University of Maryland 

Baltimore, MD

Elin Schold-Davis, OTR/L, CDRS

Project Coordinator

AOTA Older Driver Initiative 

Bethesda, MD

SUBJECT EXPERT ADVISORY PANEL

David B. Carr, MD

Alan A. and Edith L. Wolff Professor of Geriatric Medicine, and Professor of Neurology

Washington University School of Medicine

St. Louis, MO

Carl A. Soderstrom, MD

Adjunct Professor of Surgery at the University of Maryland School of Medicine

Senior Volunteer Staff Member of the school’s National Study Center for Trauma and EMS 

Chief of the Medical Advisory Board (MAB) of the Maryland Motor Vehicle Administration

Baltimore, MD

ORIGINAL CONTENT AUTHORS, CONSULTANTS, AND ADVISORY PANEL 

FIRST EDITION: PRIMARY AUTHORS

Claire C. Wang, MD, American Medical Association 

Catherine J. Kosinski, MSW, American Medical Association 

Joanne G. Schwartzberg, MD, American Medical Association

Anne Shanklin, MA, American Medical Association

SECOND EDITION: PRINCIPAL FACULTY AUTHORS

Editor: David B. Carr, MD, Associate Professor of Medicine and Neurology 

Washington University at St. Louis, Clinical Director

Planning Committee: David B. Carr, MD, Associate Professor of Medicine and Neurology

Washington University at St. Louis, Clinical Director

Joanne G. Schwartzberg, MD, Director, Aging and Community Health, American Medical

Association

Lela Manning, MPH, MBA, Project Coordinator, American Medical Association
iv

SECOND EDITION: CONTENT CONSULTANTS

Lori C. Cohen, AARP Senior Project Manager, Driver Safety 

Jami Croston, OTD, Washington University at St. Louis

T. Bella Dinh-Zarr, PhD, MPH, Road Safety Director, FIA Foundation North American Director, 

MAKE ROADS SAFE–The Campaign for Global Road Safety

John W. Eberhard, PhD, Consultant, Aging and Senior Transportation Issues

Camille Fitzpatrick, MSN, NP, University of California Irvine Clinical Professor Family Medicine

Mitchell A. Garber, MD, MPH, MSME, National Transportation Safety Board Medical Officer

Anne Hegberg, MS, OTR/L, Marionjoy Rehabilitation Hospital Certified Driver Rehabilitation 

Specialist

Patti Y. Horsley, MPH, Center for Injury Prevention Policy and Practice SDSU EPIC Branch

California Department of Public Health

Linda Hunt, OTR/L, PhD, Pacific University School of Occupational Therapy Associate Professor

Jack Joyce, Maryland Motor Vehicle Administration Driver Safety Research Office Senior 

Research Associate

Karin Kleinhans OTR/L, Sierra Nevada Memorial Hospital Center for Injury Prevention Policy & 

Practice Occupational Therapy Association of California

Kathryn MacLean, MSW, St. Louis University

Mangadhara R. Madineedi, MD, MSA, Harvard Medical School Instructor in Medicine VA 

Boston Healthcare System Director, Geriatrics & Extended Care Service Line

Richard Marottoli, MD, MPH, American Geriatrics Society

John C. Morris, Professor of Neurology Washington University School of Medicine

Germaine L. Odenheimer, MDVAMC, Donald W. Reynolds Department of Geriatric Medicine

Associate Professor

Alice Pomidor, MD, MPH, Florida State University College of Medicine 

Associate Professor, Department of Geriatrics

Kanika Mehta Rankin, Loyola University Chicago School of Law (2nd year) Juris Doctorate 

Candidate, 2011

Yael Raz, MD, American Academy of Otolaryngology
v 

William H. Roccaforte, MD, American Association for Geriatric Psychiatry Nebraska Medical

Center Department of Psychiatry

Gayle San Marco, OTR/L, CDRS, Northridge Hospital Medical Center Project Consultation, 

Center for Injury Prevention Policy & Practice

Freddi Segal-Gidan, PA-C, PhD, American Geriatrics Society 

William Shea, OTR/L, Fairlawn Rehabilitation Hospital

Patricia E. Sokol, RN, JD, Senior Policy Analyst, Patient Safety American Medical Association 

Esther Wagner, MA, National Highway Traffic Safety Administration

FIRST EDITION: ADVISORY PANEL

Sharon Allison-Ottey, MD, National Medical Association

Joseph D. Bloom, MD, American Psychiatric Association

Audrey Rhodes Boyd, MD, American Academy of Family Physicians

David B. Carr, MD, Washington University School of Medicine

Bonnie M. Dobbs, PhD, University of Alberta Association for the Advancement of Automotive 

Medicine

John Eberhard, PhD, National Highway Traffic Safety Administration

Laurie Flaherty, RN, MS, National Highway Traffic Safety Administration

Arthur M. Gershkoff, MD, American Academy of Physical Medicine and Rehabilitation

Brian Greenberg, MEd, American Association of Retired Persons

Lynne M. Kirk, MD, FACP, American College of Physicians – American Society of Internal 

Medicine

Marian C. Limacher, MD, FACC, FSGC, American College of Cardiology Society of Geriatric 

Cardiology

Richard Marottoli, MD, MPH, American Geriatrics Society

Lylas G. Mogk, MD, American Academy of Ophthalmology

John C. Morris, MD, American Academy of Neurology Alzheimer’s Association

James O’Hanlon, PhD, Tri-Counties Regional Center
vi

Cynthia Owsley, PhD, MSPH, University of Alabama at Birmingham

Robert Raleigh, MD, Maryland Department of Transportation

William Roccaforte, MD, American Association for Geriatric Psychiatry

Jose R. Santana Jr., MD, MPH, National Hispanic Medical Association

Melvyn L. Sterling, MD, FACP, Council on Scientific Affairs American Medical Association

Jane Stutts, PhD, University of North Carolina Highway Safety Research Center

FIRST EDITION: REVIEW COMMITTEE

Geri Adler, MSW, PhD, Minneapolis Geriatric Research Education Clinical Center

Reva Adler, MD, American Geriatrics Society 

Elizabeth Alicandri, Federal Highway Administration 

Paul J. Andreason, MD, Food and Drug Administration 

Mike Bailey, Oklahoma Department of Public Safety 

Robin Barr, PhD, National Institute on Aging

Arlene Bierman, MD, MS, Agency for Healthcare Research and Quality

Carol Bodenheimer, MD, American Academy of Physical Medicine and Rehabilitation

Jennifer Bottomley, PhD, MS, PT, American Physical Therapy Association

Thomas A. Cavalieri, DO, American Osteopathic Association

Lori Cohen, American Association of Motor Vehicle Administrators

Joseph Coughlin, PhD, Gerontological Society of America

T. Bella Dinh-Zarr, PhD, MPH, AAA

Barbara Du Bois, PhD, National Resources Center on Aging and Injury

Leonard Evans, PhD, Science Serving Society

Connie Evaschwick, ScD., FACHE, American Public Health Association

Jeff Finn, MA, American Occupational Therapy Association
vii

Jaime Fitten, MD, UCLA School of Medicine

Marshall Flax, MA, Association for the Education and Rehabilitation of the Blind and Visually

Impaired

Linda Ford, MD, Nebraska Medical Association

Barbara Freund, PhD, Eastern Virginia Medical School

Mitchell Garber, MD, MPH, MSME, National Transportation Safety Board

Andrea Gilbert, COTA/L, Rehabilitation Institute of Chicago

Claudia Grimm, MSW, Oregon Department of Transportation

Kent Higgins, PhD, Lighthouse International

Linda Hunt, PhD, OTR/L, Maryville University

Mary Janke, PhD, California Department of Motor Vehicles

Gary Kay, PhD, Washington Neuropsychological Institute

Shara Lynn Kelsey, Research and Development California Department of Motor Vehicles

Susan Kirinich, National Highway Traffic Safety Administration

Donald Kline, PhD, University of Calgary

Philip LePore, MS, New York State Office for the Aging

Sandra Lesikar, PhD, US Army Center for Health Promotion and Preventive Medicine

William Mann, OTR, PhD, University of Florida 

Dennis McCarthy, MEd, OTR/L, University of Florida 

Gerald McGwin, PhD, University of Alabama

Michael Mello, MD, FACEP, American College of Emergency Physicians

Barbara Messinger-Rapport, MD, PhD, Cleveland Clinic Foundation

Alison A. Moore, MD, MPH, David Geffen School of Medicine,

University of California 

Anne Long Morris, EdD, OTR/L, American Society on Aging

Germaine Odenheimer, MD, Center for Assessment and Rehabilitation of Elderly Drivers
viii

Eli Peli, M.Sc., OD, Schepens Eye Research Institute

Alice Pomidor, MD, MPH, Society of Teachers of Family Medicine

George Rebok, MA, PhD, Johns Hopkins School of Hygiene and Public Health 

Selma Sauls, Florida Department of Highway Safety and Motor Vehicles 

Susan Samson, Pinellas/Pasco Area Agency on Aging

Steven Schachter, MD, Epilepsy Foundation

Frank Schieber, PhD, University of South Dakota

Freddi Segal-Gidan, PA, PhD, American Geriatrics Society

Melvin Shipp, OD, MPH, DrPh, University of Alabama at Birmingham

Richard Sims, MD, American Geriatrics Society

Kristen Snyder, MD, Oregon Health & Science University School of Medicine 

Susan Standfast, MD, MPH, American College of Preventative Medicine 

Holly Stanley, MD, American Geriatrics Society

Loren Staplin, PhD, Transanalytics and Texas Transportation Institute

Wendy Stav, PhD, OTR, CDRS, American Occupational Therapy Association Cleveland State

University

Donna Stressel, OTR, CDRS, Association of Driver Rehabilitation Specialists

Cathi A. Thomas, RN, MS, Boston University Medical Center American Parkinson Disease

Association

John Tongue, MD, American Academy of Orthopedic Surgery

Patricia Waller, PhD, University of Michigan

Lisa Yagoda, MSW, ACSW, National Association of Social Workers

Patti Yanochko, MPH, San Diego State University

Richard Zorowitz, MD, National Stroke Association
ix

DISCLOSURE OF FINANCIAL INTERESTS

As an accredited provider of Continuing Medical Education, the American Geriatrics Society

continuously strives to ensure that the education activities planned and conducted by our

faculty meet generally accepted ethical standards as codified by the ACCME, the Food and Drug

Administration, and the American Medical Association’s Guide for Gifts to Physicians. To this

end, we have implemented a process wherein everyone who is in a position to control the

content of an educational activity has disclosed to us all relevant financial relationships with

any commercial interests within the past 12 months as related to the content of their

presentations and under which we work to resolve any real or apparent conflicts of interest.

Conflicts of interest in this particular CME activity have been resolved by having the

presentation content independently peer reviewed before publication by the Editorial Board

and Question Review Committee.

The following contributors have returned disclosure forms indicating that they (and/or their

spouses/partners) have no affiliation with, or financial interest in, any commercial interest that

may have direct interest in the subject matter of their chapters/questions:

David B. Carr, MD

Anne E. Dickerson, PhD, OTR/L, FAOTA

Shelly Gray, PharmD, MS

Richard Marottoli, MD

Irene Moore, MSSW, LISW-S, AGSF

Alice Pomidor, MD, MPH, AGSF

Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP

Elin Schold-Davis, OTR/L, CDRS

Carl A. Soderstrom, MD

The following contributors (and/or their spouses/partners) have reported real or apparent

conflicts of interest that have been resolved through a peer review content validation process:

Susan E. Aiello, DVM, ELS
x 

Clinician's Guide to Assessing and Counseling Older Drivers, 3rd Edition

An Update of the Physician's Guide to Assessing and Counseling Older Drivers

Introduction

Translating 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 to health care, social interaction, and nutrition through

independent mobility, interprofessional clinical team members need office-based tools to

screen for medical and functional issues which may affect driving ability, assess the risk of

driving impairment, intervene to optimize treatment and functional ability, refer appropriately

for specialized care and driving rehabilitation, and provide counseling about planning for

transitioning from driving if necessary.

The American Geriatrics Society (AGS) entered into a cooperative agreement with the U.S. 

Department of Transportation’s National Highway Traffic Safety Administration (NHTSA) to

update and expand the Physician’s Guide to Assessing and Counseling Older Drivers that was

originally developed by the American Medical Association (AMA) under a prior cooperative

agreement with NHTSA. The current title of the guide — Clinician's Guide to Assessing and

Counseling Older Drivers, 3rd Edition — reflects the interprofessional nature of the team caring

for an older adult driver.

The main goal of the guide remains helping health care practitioners prevent motor vehicle

crashes and injury to older adults. Motor vehicle injuries persist as the leading cause of injuryrelated deaths among 65- to 74-year-olds and are the second leading cause (after falls) among

75- to 84-year-olds. While traffic safety programs have had partial success in reducing crash

rates for all drivers, the fatality rate for drivers over 65 has consistently remained high.

Increased comorbidities and frailty associated with aging make it far more difficult to survive a 

crash, and the expected massive increase in the number of older adults on the road is certain to

lead to increased injuries and deaths unless we can successfully intervene to prevent harm.

Health care practitioners caring for older adults are in a leading position to address and correct

this public health concern at the individual patient and caregiver level. By providing effective

health care, clinicians can help their patients maintain a high level of fitness, enabling them to

preserve safe driving skills later in life and protecting them against serious injuries in the event

of a crash. By adopting preventive practices—including the assessment and counseling
xi

strategies outlined in this guide—clinicians can better identify older drivers at risk for crashes,

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

becomes necessary.

We wish to especially thank Brian Chodrow at NHTSA for his guidance and support for this

edition of the guide and Essie Wagner for her pioneering work with previous editions.

Our current interprofessional Editorial Board has taken great care to preserve the intent of

providing the best evidence-based recommendations from the current literature, while

recognizing the different environments of care in which members of the clinical team

encounter older adults. We hope that you will find the guide useful and welcome your

feedback as we move forward in engaging our older adults and caregivers in maintaining safe

mobility for life.

The project is supported by cooperative agreement number DTNH22-14-H-00454 from the

National Highway Traffic Safety Administration of the U.S. Department of Transportation. The 

opinions, findings, and conclusions expressed in this publication are those of the authors and 

not necessarily those of NHTSA or DOT. The United States Government assumes no liability for 

its content or use thereof. If trade or manufacturers’ names or products are mentioned, it is 

because they are considered essential to the object of the publication and should not be 

construed as an endorsement. The United States Government does not endorse products or 

manufacturers.
1 

CHAPTER 1 THE OLDER ADULT DRIVER: AN OVERVIEW

Key Points

• The number of older adult drivers is growing rapidly, and they are driving longer

distances.

• Motor vehicle crashes are far more harmful for older adults than for all other age groups.

• Driving cessation is inevitable for many and is often associated with negative outcomes.

• Many older adult drivers self-regulate their driving behavior.

• The risk of crashes for older drivers is in part related to physical, visual and/or mental

changes associated with aging and/or disease.

• Clinical team members can help older adult drivers maintain safe driving skills using the

Plan for Older Driver Safety (PODS) algorithm and may also influence older adult drivers’

decisions to modify or stop driving if they develop functional disability which affects

driving skills.

Mrs. Alvarez, a 72-year-old woman with arthritis and hypertension, mentions during a 

routine appointment that she would like an earlier time slot so she can avoid heavy traffic

and driving in the dark. She denies previous crashes or injuries but seems anxious about

her planned two-day road trip to attend her grandson’s graduation. Mrs. Alvarez admits

to feeling less confident when driving and has reduced her social and shopping activities

because of her worries. How do you address these driving concerns?

Mr. Phillips, an 82-year-old man with a history of hypertension, congestive heart failure,

atrial fibrillation, type 2 diabetes mellitus, macular degeneration, and osteoarthritis,

comes to your office for a follow-up. You notice that Mr. Phillips has a great deal of trouble

walking, uses a cane, and has difficulty reading his paperwork, even with his glasses.

During your conversation, you ask him if he still drives, and he states that he takes short

trips to run errands, get to appointments, and meet weekly with his bridge club.

What are your next steps in addressing his fitness to drive?

Older adult drivers like Mrs. Alvarez and Mr. Phillips are encountered by clinical team members

in every setting. The U.S. older adult population older than 65 reached 43 million in 2012 and is

expected to double by 2050.1,2 Approximately 86% of Americans 65 and older continue to

drive, with this cohort of 35 million older adult drivers comprising 16% of all licensed drivers in

2011. It is expected that one of every four licensed drivers will be an older adult by 2050, in

addition to driving more miles than older drivers do today.3

Common age-related changes that impact functional abilities in addition to medical conditions

can make driving difficult, potentially reducing the older adult’s independence, social contact,

and access to nutrition, health care, and other services. There are three clinical levels of care
2 

regarding driving ability in older adults (Table 1.1).

Table 1.1 Clinical Levels of Care for Prevention of Driving Disability

Level of Care Description

Primary prevention Assesses the older adult driver and intervenes

to prevent the loss of driving ability

Secondary prevention Addressesissues that have already caused the

loss of driving skills and attempts to restore

those skills through treatment and 

rehabilitation

Tertiary prevention Identifies when irreversible loss of driving

skills has occurred and includes

recommending alternatives to avoid harm to

the older adult and others when driving is no

longer an option

Assessing and managing potential driving disability can be challenging and time consuming,

especially because it is often considered a personal rather than a clinical issue. Legal and ethical

questions may also deter clinical team members from addressing driving ability in older adults.

Yet as medical conditions arise and progress with advancing age, older adult drivers and their

caregivers will increasingly turn to clinical team members for guidance on safe driving. The

challenge is in balancing the safety of older adults against their transportation needs and the

safety of society.

This guide is intended to help answer the following questions and, if necessary, help clinical

team members counsel patients about driving cessation and alternative means of

transportation.

• At what level of severity do medical conditions impair safe driving?

• What can be done to help older adults prolong their driving life expectancy (time behind

the wheel)?

Note: The information in this guide is provided to assist clinical team members in evaluating the ability of older

adults to safely operate motor vehicles as part of their everyday, personal activities. Evaluating the ability of older

adults to operate commercial vehicles or to function as professional drivers involves more stringent criteria and is

beyond the scope of this guide.

Clinical Team Members and Their Roles

All clinical team members can help identify and counsel older adults who may be at risk of

driving impairment. Clinical team members may have opportunities to interact with older

adults in varied health care settings for screening and perhaps assessment or referral to

another team member or specialist for further evaluation as needed. Although many health
3 

care professionals do not work directly with one another in the same setting, “virtual” teams

often come together during the course of care for an individual older adult. Some of the skills

and roles of potential clinical team members are described below to help identify opportunities

for interprofessional collaboration and to maximize the available support for an older adult.

Physician/Nurse Practitioner/Physician Assistant

The patient’s primary care provider, who may be a physician, nurse practitioner, or physician

assistant, performs the medical evaluation to determine if the older adult has any medical

conditions that may affect his or her ability to drive safely. This medical assessment helps to

direct further supportive interventions, referrals and potential medical treatment. Older adults

are often more likely to consider changes in their driving practices if their primary care

providers discuss the importance of safety interventions.

4

Nurse

Nurses contribute to the medical assessment by monitoring basic vital signs and evaluating

functional abilities, disease risk factors, medication adherence and adverse effects, personal

health behaviors such as alcohol use, and health literacy. This information can be used to

facilitate changes in the care plan and follow-through by the older adult and/or their caregivers. 

Home-health nurses and direct care personal assistants often have unique opportunities to

closely observe, counsel, and support older adults at home in their day-to-day activities. A nurse

may also serve as a case manager, health counselor, resource for the older adult and caregivers,

and liaison with other clinical team members if older adults or their caregivers have healthrelated questions or concerns.

Pharmacist

Pharmacists perform a thorough medication history, including use of over-the-counter drugs;

assess adherence to medication regimens; assess the potential for medications, adverse effects,

or drug interactions to affect driving ability; and counsel older adults on these issues.

Pharmacists may also make recommendationsto the clinical team for optimal pharmacologic

management of medical conditions that may impair driving, and for dosage adjustment, timing,

or therapeutic substitution of medications that may have driving-impairing effects. Some

pharmacists also directly manage the treatment of various medical conditions that may

contribute to driving impairment.

Occupational Therapist/Driving Rehabilitation Specialist

Occupational therapists assess the older adult’s functional abilities and the visual, cognitive,

perceptual, and physical capacities for those abilities. Occupational therapists provide

interventions for identified impairments to support mobility in the environment, including

driving, and may recommend strategies, therapies, and assistive devices for rehabilitation.

Occupational therapists often seek additional training to become driving rehabilitation
4 

specialists, who can perform expert special assessments and therapeutic interventions

specifically regarding fitness to drive, including on-road testing.

Social Worker

Social workers assess the older adult’s well-being and transportation needs, evaluate the level

of caregiver support available, and help access affordable training and transportation options.

Social workers may also help identify resources to overcome barriers to changing driving

patterns or eventual driving retirement (such as financial support or peer support groups).

Many tools for evaluating older adult drivers, mobility counseling, and discussing driving

retirement have been developed in the United States and other countries over the past decade

since the original development of the American Medical Association’s Physician’s Guide to

Assessing and Counseling Older Drivers. However, in part because of the complexity of the

issues involved in driving and the heterogeneity in the older adult population, there are still

relatively few well-studied strategies that reliably predict driving outcomes for each individual.

In this revision of the guide, the American Geriatrics Society is collaborating with the National

Highway Traffic Safety Administration to offer recommendations, tools, and resources for the

clinical team involved in the care of older adults, with corresponding modifications of the

previously developed assessment algorithm and recommended tests, for use in multiple care

settings as follows:

• A clinically based assessment of medical fitness to drive, presented in the algorithm Plan

for Older Drivers’ Safety (PODS) (see below in this chapter).

• A toolbox of practical, office-based functional assessment tests for driving-related skills,

the Clinical Assessment of Driving Related Skills (CADReS) (see Chapter 3). The clinical

team can choose among these tests, depending on the outcomes of screening tests and

the individual older adult’s abilities (see Chapter 2).

• Information to help navigate the legal and ethical issues regarding patient driving safety,

including information on patient reporting, with a State-by-State list of licensing agency

contact information, and additional resources for locating license renewal criteria and

reporting laws and procedures (see Chapters 7 and 8).

• A reference listing of medical conditions and medications that may affect driving, with

specific recommendations for each (see Chapter 9).

• Recommended Current Procedural Terminology (CPT) codes for assessment and

counseling procedures (see Appendix A).

• Handouts for older adults and their caregivers that include a self-screening tool for

driving safety, safe driving tips, driving alternatives, and a resource sheet for concerned

caregivers (see Appendix B). Links for accessing recommended resources from

reputable organizations are also provided.
5 

• Sample approaches in subsequent chapters for conversations about driving

assessment, rehabilitation, restriction, and cessation.

• Online access to the guide through the American Geriatrics Society’s portal of

resources (www.GeriatricsCareOnline.org) and via NHTSA’s Older Drivers website

(www.nhtsa.gov/Driving+Safety/Older+Drivers).

Key Facts About Older Adult Drivers

The number of older adult drivers is growing rapidly, and they are driving longer

distances.

Life expectancy is at an all-time high5 and the older population is rapidly increasing. By the

year 2050, the population of adults 65 and older will more than double to approximately 89

million, making up at least 20% of the total U.S. population.6 In many States, including 

Florida and California, the population of those older than 65 may reach 20% in this decade.

The fastest growing segment of the population is the 80-and-older group, which is

anticipated to increase to 8 to 10 million over the next 30 years. Similar trends are occurring

globally, with the expected worldwide population people aged 60 years or over expected to

reach 21% by 2050, when the number of older adults is projected to exceed the number of

children for the first time.

7

In addition, the United States has become a highly mobile society, and older adults drive for

volunteer activities and gainful employment, social and recreational needs, and cross-country

travel. Recent studies suggest that older adults are driving more frequently, and

transportation surveys reveal an increasing number of miles driven per year for each

successive aging cohort.3

Motor vehicle crashes are far more harmful for older adults than other age groups.

In 2012, there were 5,560 people 65 and older who were killed and 214,000 who were

injured in motor vehicle crashes.1 Unintentional injuries are the seventh leading cause of 

death among older adults, and motor vehicle crashes are the second most common cause of

injury after falls.8,9 Compared with other drivers, older adult drivers have a higher fatality rate

per mile driven than any other age group except drivers younger than 25.10On the basis of 

estimated annual travel, the fatality rate for drivers 85 and older is 9 times higher than the

rate for drivers 25 to 69 years old.11Older adult pedestrians are also more likely to be fatally

injured at crosswalks than younger adults.12

There is a disproportionately higher rate of poor outcomes in older adult drivers, due in part 

to chest and head injuries.13 There may be several reasons for this. First, some older adult

drivers are considerably more fragile. For example, older adults have an increased incidence

of osteoporosis, which can lead to fractures, and/or atherosclerosis of the aorta, which can

predispose to aortic rupture with chest trauma from an airbag or steering wheel. Fragility

begins to increase at ages 60 to 64 and increases steadily with advancing age.14 Other causes
6 

may be ownership of an older fleet of cars that is less crashworthy and/or over

representation of specific types of crashes such as left hand turns that increase vulnerability

to injury. Better countermeasures in roadway construction and vehicle protection may be

helping mitigate the risks of frailty with a gradual decrease in deaths per mile driven in the

past decade.

15 Vehicle protection for older adults may improve as future cohorts of aging

drivers purchase newer vehicles with better design features (information available on the

American Automobile Association website at http://seniordriving.aaa.com/).16

Driving cessation is inevitable for many and often associated with negative outcomes.

Driving is essential for performing necessary chores and maintaining social connectedness,

with the latter having strong correlates with mental and physical health.17Many older adults

continue to work past retirement age or engage in volunteer work or other organized

activities. In most cases, driving is the preferred means of transportation. In some rural or

suburban areas, driving is the only available means of transportation. Just as the driver’s 

license is a symbol of independence for adolescents, the ability to continue driving means

independent transportation and access to resources for day-to-day life for older adults and is

highly valued.18

In a survey of 2,422 adults 50 and older, 86% of participants reported that driving was their 

usual mode of transportation. Within this group, driving was the usual method of

transportation for 85% of participants 75 to 79 years old, for 78% of participants 80 to 84

years old, and for 60% of participants 85 and older.19 These data also indicate that the

probability of losing the ability to drive increases with advanced age. It is estimated that the

average man will have 6 years without the functional ability to drive a car, and the average

woman will have 10 years.20 However, many older adults may overestimate their driving life

expectancy, with more than half of drivers surveyed by the CDC reporting they would stop

driving sometime in their 90s, and 1 in 10 reporting they would never stop driving.21 Given

this outlook, it is likely that older adult drivers and caregivers will be unprepared to address

issues related to driving cessation when that time comes. Clinicians should initiate planning 

discussions for driving cessation earlier on in the process, before it becomes an urgency in the

clinician’s office.

Studies of driving cessation have noted increased social isolation, decreased out-of-home

activities,21 and increased depressive symptoms.22 These outcomes have been well

documented and represent some of the negative consequences of driving cessation. It is

important for the clinical team be supportive in the face of what may be a devastating loss of

independence, and to use available resources and professionals who can assist with

transportation to allow older adults to maintain independence. These issues will be discussed 

in subsequent chapters.
7 

Many older adult drivers self-regulate their driving behavior.

As drivers age, they may begin to feel limited by slower reaction times, chronic health

problems, and effects of medications. Although transportation surveys over the years

document that the current cohort of older adult drivers is driving farther, in later life many

reduce their mileage or stop driving altogether. According to an analysis of the 2009

National Household Travel Survey, daily travel patterns for drivers 65 and older show more

driving time, more miles driven, and more trips taken in 2009 than in 1990 with more than

75% of male drivers and 60% of female drivers older than 85 driving 5 or more days per

week.23Older drivers are more likely to wear seat belts and are less likely to drive at night,

speed, tailgate, consume alcohol before driving, or engage in other risky behaviors.24Data

also suggest that older women are more likely to self-regulate than men.25

Older drivers may reduce their mileage by eliminating long highway trips. However, local

roads often have more hazards in the form of signs, signals, traffic congestion, and confusing

intersections. Therefore, decreasing mileage may not always proportionately decrease driving

risks.26 In fact, the “low-mileage” drivers (i.e., less than 3,000 miles per year) may actually be

the group most “at risk.”27

Despite all these self-regulating measures, motor vehicle crash and fatality rates per mile

driven begin to increase significantly at age 70.10On a case-by-case level, the risk of a crash

depends on whether each individual driver’s decreased mileage and behavior modifications

are sufficient to counterbalance any decline in driving ability. In some cases, decline may

occur so insidiously (e.g., peripheral vision loss) that the older driver is not aware of it until he

or she experiences a crash. In fact, a recent study indicated that some older adults do not

restrict their driving despite having significant visual deficits.28 Reliance on driving as the only

available means of transportation can result in an unfortunate choice between poor options.

In the case of dementia, older adult drivers may lack the insight to realize they are unsafe to

drive.

In a series of focus groups conducted with older adults who had stopped driving within the

past 5 years, about 40% of the participants knew someone older than 65 who had problems 

with driving but was still behind the wheel.29Clearly, some older drivers require outside

assessment and interventions when it comes to driving safety. This is well recognized by older

adults themselves, with more than 7 in 10 of 1,700 adults 65 and older surveyed supporting

both mandating in-person license renewals and medical screenings for drivers older than 75.3

The risk of crashes for older drivers is in part related to physical, visual, and/or 

mental changes associated with aging and/or disease.

Compared with younger drivers whose car crashes are often due to inexperience or risky

behaviors,30,31 crashes of older adult drivers tend to be related to inattention or slowed speed

of visual processing.32 Crashes involving older adult drivers are often multiple-vehicle events
8 

that occur at intersections and involve left-hand turns.33 The crash is usually caused by the

older driver’s failure to heed signs and grant the right-of-way, which may be related to

difficulties judging the speed of other vehicles and the space available. At intersections with

traffic signals, left-hand turns are a particular problem for older adult drivers. At stop-signcontrolled intersections, older adult drivers may not know when to turn.33

These driving behaviors indicate that visual, cognitive, and/or motor factors may affect

driving ability in older adults. Research has not yet determined what percentage of car

crashes involving older adults are due to driving errors that are also common among middleaged drivers, age-related changes in function (e.g., delayed reaction time), or age-related

medical illnesses. However, it is believed that further improvements in traffic safety will

likely result from improving driving performance or modifying driving behavior.34 The

identification and management of medical conditions, functional impairments, and

potentially driving-impairing medications may maintain or improve driving abilities and road

safety.

Clinical team members can influence older adult drivers’ decisions to modify or stop

driving, as well as help older adult drivers maintain safe driving skills.

Although older adult drivers believe they should be the ones to make the final decision about

driving,

35 they also agree that their primary care providers should advise them. In a series of

focus groups conducted with older adults who had stopped driving, all agreed that clinicians

should talk to older adults about driving, if a need exists. Although family advice had limited

influence on the participants, most agreed if their physicians advised them to stop driving

and their family concurred, they would certainly do so.29,36 This is consistent with a recent

focus group study with caregivers of drivers with dementia, who stated that physicians

should be involved in this important decision-making process.4 The clinical team together can

provide the most complete information and advice for older adults and caregivers when

arriving at decisions regarding driving.

In addition to helping determine ability to drive safely, the members of the clinical team can

assist at-risk older adult drivers to maintain safe mobility in multiple ways, including

recommending effective treatment and preventive health care measures, playing a role in

determining the ability of older adults to drive safely, counseling older adults and caregivers,

and helping access alternative transportation resources.

In many cases, clinical team members can help older adult drivers to stay on the road longer

by identifying and managing medical conditions, such as cataracts and arthritis, or by 

discontinuing driving-impairing medications. Driving abilities share many attributes necessary 

for successful ambulation, such as adequate visual, cognitive, and motor function. In fact, a 

history of falls has been associated with an increased risk of motor vehicle crash.37 Clinical

team members can reduce future risk of falls and fractures by advising on fall prevention and

addressing certain extrinsic (environmental) and intrinsic factors.38
9 

There is an assumption that clinical team members can and do make a difference by

evaluating older adults for their fitness to drive. However, there is a crucial need for

systematic study of this hypothesis.

39 Research and clinical reviews on the assessment of

older adult drivers have focused on screening methods to identify unsafe drivers and restrict

older drivers. Efforts to evaluate the efficacy of driving rehabilitation strategies have been

recently reviewed and updated by the occupational therapy community,4 but other clinical

interventions have not been similarly studied in the United States. Clinical team members

are in positions to identify older adults at risk of unsafe driving or self-imposed driving 

cessation because of functional impairments, and to help address and manage these issues 

so that older adults can continue to drive safely for as long as possible.

The final determination of an individual’s ability to drive lies with the State licensing

authority; however, clinical team members can assist with this determination. Driver licensing

regulations and reporting laws vary greatly by State, and some State laws are vague and open

to interpretation. Therefore, it is important for clinical team members to be aware of their

State reporting laws and their responsibilitiesfor reporting unsafe drivers to the local driver 

licensing authority. For more information on State laws, see Chapter 8.

Thus, clinical team members can play a more active role in preventing motor vehicle crashes

by assessing and counseling older adult drivers regarding their fitness to drive,

recommending safe driving practices, referring older adults to driver rehabilitation specialists,

advising or recommending driving restrictions, and referring older adults to State licensing 

authorities when appropriate. To achieve these ends, clinical team members can follow the

general principles below and recommendations in the algorithm Plan for Older Drivers’ Safety

(PODS) (see below in this chapter):

• Screen for red flags such as medical conditions, potentially driving-impairing

medications, and recent adverse driving events or behaviors (see Am I a Safe Driver

and How to Help the Older Driver in the appendices) (see Chapter 2).

• Assess driving-related functional skills in those older adults at increased risk of unsafe

driving. For the toolbox of functional assessments, see the Clinical Assessment of

Driving Related Skills (CADReS) in Chapter 3.

• Evaluate and Treat the at-risk older driver for medical conditions and other causes

that may be impairing functional skills related to driving and intervene to:

o Optimize the treatment of underlying medical and functional contributors to

driving impairment within the clinical team member’s scope of practice or

through to another clinical team member or medical subspecialist (see Chapter

4).

o Refer older adult drivers with persistent deficits despite optimal medical

treatment, when appropriate, to a driving rehabilitation specialist for further 

driving evaluation and/or training in use of adaptive equipment (see Chapter 5).
10

• At all times, discuss the maintenance of driving ability, safe driving behaviors, and

driving restrictions. When appropriate, counsel older adults and their caregivers

on potential driving cessation, and/or alternative transportation options as

needed (see Chapter 6).

• Perform interval re-evaluations and follow-up with older adults who should adjust 

their driving to determine if they have made changes, and monitor those who stop 

driving for signs of depression and social isolation. Older driver abilities are not static 

and may either improve or decline as their conditions change. For example, an older 

adult may benefit from physical therapy after a stroke or surgery and regain functional 

abilities permitting them to return to driving. Older adults may therefore re-enter the 

PODS algorithm for reevaluation and/or treatment at any step along the way.

Although primary care providers may have access to the most resources to perform the

PODS, other clinicians also have a responsibility to discuss driving with older adults. In

addition, specialists in the fields of cardiology, ophthalmology, neurology, psychiatry,

psychology, rehabilitation, orthopedics, emergency/urgent care, trauma, and others all

encounter older adults with conditions that may have an impact on driving skills. When

advising older adults, clinical team members may wish to consult the reference list of

medical conditions in Chapter 9.
11

References

1. National Center for Statistics and Analysis. (2014, May, revised). Older Population. 

(Traffic Safety Facts 2012 Data Report No. DOT HS 812 005). Washington, DC: National

Highway Traffic Safety Administration. Available at wwwnrd.nhtsa.dot.gov/Pubs/812005.pdf

2. U.S. Census Bureau. (2012). Statistical Abstract of the United States. Washington, DC: 

Author. 

3. Mizenko, A. J., Tefft, B. C., Arnold, L. S., & Grabowski, J. (2014, November). Older 

American Drivers and Traffic Safety Culture: A LongROAD Study. Washington, DC: 

AAA Foundation for Traffic Safety.

4. Perkinson, M. A., Berg-Weger, M. L., Carr, D. B., Meuser, T.M., Palmer, J. L., Buckles, V. 

D., ... Morris, J. C. (2005, October). Driving and dementia of the alzheimer type: beliefs 

and cessation strategies among stakeholders. Gerontologist, 45(5), 676-85.

5. National Center for Health Statistics. (2014). Table 18. Life expectancy at birth, at age 

65, and at age 75, by sex, race, and Hispanic origin: United States, selected years 1900-

2010. Health, United States, 2013: With Special Feature on Prescription Drugs. 

Hyattsville, MD: Author.

6. Centers for Disease Control and Prevention. The State of Aging and Health in 

American 2013. Atlanta, GA: Author. Available at www.cdc.gov/aging/pdf/StateAging-Health-in-America-2013.pdf 

7. United Nations, Department of Economic and Social Affairs, Population Division. 

(2013). World Population Ageing 2013 (Report No. ST/ESA/SER.A/348). New York: 

Author. Retrieved from the U.N. website at 

www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulat

ionAgeing2013.pdf

8. Staats, D. O. (2008). Preventing injury in older adults. Geriatrics, 63, 12–17.

9. CDC. (2007). 10 Leading Causes of Injury Deaths, United States, 1999-2007, All Races,

Both Sexes. Office of Statistics and Programming, National Center for Injury Prevention

and Control. Atlanta, GA: Author.

10. Insurance Institute for Highway Safety. (2014, March). Older drivers. Retrieved from 

the IIHS website at www.iihs.org/iihs/topics/t/older-drivers/fatalityfacts/older-people

11. Evans, L. (2000). Risks older drivers face themselves and threats they pose to other 

road users. International Journal of Epidemiology, 29, 315–322.
12

12. Nabors, D., Schneider, R., Leven, D., Lieberman, K., & Mitchell, C. (2008). Pedestrian 

Safety Guide for Transit Agencies. Washington, DC: Federal Highway Administration. 

Retrieved from the FHWA website at 

http://safety.fhwa.dot.gov/ped_bike/ped_transit/ped_transguide/intro.cfm

13. Bauza, G., Lamorte, W. W., Burke, P., & Hirsch, E. F. (2008). High mortality in elderly 

drivers is associated with distinct injury patterns: Analysis of 187,869 drivers. Journal of 

Trauma Injury, Infectection and Critical Care, 64(2), 304–310.

14. Li, G., Braver, E., & Chen, L-H. (2003). Fragility versus excessive crash involvement as 

determinants of high death rates per vehicle mile of travel for older drivers. Accident 

Analysis & Prevention, 35(2), 227– 235.

15. Cicchino, J. B. (2015). Why have fatality rates among older drivers declined? The relative 

contributions of changes in survivability and crash involvement. Accident Analysis & 

Prevention, 83:67-73. doi: 10.1016/j.aap.2015.06.012

16. American Automobile Association. (2011). Finding the right vehicle for you. Retrieved 

from the AAA website at http://seniordriving.aaa.com/maintain-mobilityindependence/car-buying-maintenance-assistive-accessories/find-right-vehicle-you. 

17. Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). From social integration to 

health: Durkheim in the new millennium. Social Science & Medicine, 51(6), 843–857.

18. Dickerson, A. E., Reistetter, T., & Gaudy, J. R. (2011). The perception of meaningfulness 

and performance of instrumental activities of daily living from the perspectives of the 

medically at-risk older adults and their caregivers. Journal of Applied Gerontology, 32(6), 

749–764.

19. Ritter, A. S., Straight, A., & Evans, E. (2002). Understanding Senior Transportation: Report 

and Analysis of a Survey of Consumers Age 50+. Washington, DC: American Association 

for Retired Persons. Available at 

http://assets.aarp.org/rgcenter/il/2002_04_transport.pdf

20. Foley, D. J., Heimovitz, H. K., Guralnik, J., & Brock, D. B. (2002). Driving life expectancy of 

persons aged 70 years and older in the United States. American Journal of Public Health, 

92(8), 1284–1289.

21. Naumann, R. B., West, B. A., & Sauber-Schatz, E. K. At what age do you think you will 

stop driving? View of older US adults. Journal of the American Geriatric Society, 62(10), 

1999–2001.

22. Ragland, D. R., Satariano, W. A., & MacLeod, K. E. (2005). Driving cessation and increased 

depressive symptoms. Journal of Gerontology, Series A: Biological Sciences and Medical 

Sciences, 60, 399–403.
13

23. Rosenbloom, S., & Santos, R. (2014, April). Understanding older drivers: An examination 

of medical conditions, medication use, and travel behavior. Washington, DC: AAA 

Foundation for Traffic Safety.

24. Lyman, J. M., McGwin, G., & Sims, R. V. (2001). Factors related to driving difficulty 

and habits in older drivers. Accident Analysis & Prevention, 33(3), 413–421.

25. Kostyniuk, L. P., & Molnar, L. J. (2008). Self-regulatory driving practices among older 

adults: health, age and sex effects. Accident Analysis & Prevention, 40(4), 1576–1580.

26. Janke, M. K. (1991). Accidents, mileage, and the exaggeration of risk. Accident Analysis 

& Prevention, 23, 183–188.

27. Langford, .J, Methorst, R., & Hakamies-Blomqvist, L. (2006). Older drivers do not 

have a high crash risk—a replication of low mileage bias. Accident Analysis & 

Prevention, 38(3), 574–578.

28. Okonkwo, O. C., Crowe, M., Wadley, V. G., & Ball, K. (2008). Visual attention and selfregulation of driving among older adults. International Psychogeriatrics, 20, 162–173.

29. Persson, D. The elderly driver: deciding when to stop. Gerontologist, 33(1), 88–91.

30. Preusser, D. F., Williams, A. F., Ferguson, S. A., Ulmer, R. G., & Weinstein, H. 

B. (1998). Fatal crash risk for older drivers at intersections. Accident Analysis 

& Prevention, 30(2), 151–159.

31. Williams, A. F., & Ferguson, S. A. (2002). Rationale for graduated licensing and 

the risks it should address. Injury Prevention, 8 (Suppl 2), ii9–ii16. doi: 

10.1136/ip.8.suppl_2.ii9

32. Eberhard, J. W. (1996). Safe mobility for senior citizens. International Association for 

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

33. Langford, J., & Koppel, S. (2006). Epidemiology of older driver crashes-identifying 

older driver risk factors and exposure patters. Transportation Research, Part F, 9, 

309-321.

34. Lee, J. D. (2008). Fifty years of driving safety research. Human Factors, 50(3), 521–528.

35. Choi, M., Mezuk, B., & Rebok, G. W. (2012). Voluntary and involuntary driving 

cessation in later life. Journal of Gerontological Social Work, 55(4), 367-376.

36. Betz, M. E., Schwartz, R., Valley, M., & Lowenstein, S.R. (2012). Older adult opinions 

about driving cessation: a role for advanced driving directives. Journal of Primary 

Care and Community Health, 3(3) 150-154.
14

37. Dugan, E., & Lee, C. M. (2013). Biopsychosocial risk factors for driving cessation:

findings from the health and retirement study. Journal of Aging Health, 25(8),

1313–1328.

38. Gillespie, L. D., Robertson, M. C., Gillespie, W. J, Lamb, S. E., Gates, S., Cumming, R.

G., & Rowe, B. H. (2012). Interventions for preventing falls in older people living in

the community. Cochrane Database System Review, 9, CD007146.

39. Meuser, T.M., Carr, D. B., & Ulfarsson, G. F. (2009, March). Motor-vehicle crash

history and licensing outcomes for older drivers reported as medically impaired in

Missouri. Accident Analysis & Prevention, 41(2), 246-52. doi:

10.1016/j.aap.2008.11.003.
Plan for Older Drivers’ Safety (PODS)

SCREENING EVALUATION RESULTS

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?

Older adult/caregiver concerns?

Not At Risk: Minimal to No 

Positive Risk Factors Identified

Discuss transportation plans and 

health maintenance

At Risk: Positive Risk Factors Identified

Step 2: Use Clinical Assessment of Driving Related Skills

(CADReS) to Identify Impairments and Seek Remediation

General:

Driving History, IADLs

Questionnaire,

Medication Change

Vision:

Fields, Acuity,

Contrast

Cognitive:

MoCA, Trails B,

Clock Drawing,

Maze

Motor/Sensory:

Range of Motion,

Proprioception, Get Up

and Go, Rapid Pace

Walk

Step 3: Analysis of Screen and CADreS Not At Risk

At Risk

Clinical Specialist Evaluation and Intervention* Driving Rehabilitation Specialist Evaluation

Medical Conditions

Uncompensated

or In Recovery Phase

Medical

Conditions

Optimized

Rehab/Intervention

Needed:

Refer to a Specialist

Vehicle Adaptation/

Training Needed:

Refer to Available

Resources

Step 4: Driving Deficit Results

Driving Deficit Identified No Significant Driving Deficit Identified: Fit To Drive

Discuss transportation plans and health maintenance

Fit to Drive with

Restrictions:

Perform Interval

Re-evaluations

Cessation of Driving:

Counsel on

Alternative Modes of

Transportation; 

Call for Family Meeting

No Driving Yet:

Refer for Recovery

Plan to Revisit Driving

Repeat Step 3

IADLs Instrumental Activities of Daily Living

MoCA Montreal Cognitive Assessment

Pathway step may be repeated if progressive assessment necessary

Clinical specialists may include medicine, nursing, rehabilitation, pharmacy

and social work, or others, depending on the clinical setting

Time Lapse

*

15
16

CHAPTER 2 IS THE OLDER ADULT AT INCREASED RISK OF UNSAFE DRIVING?

Key Points

• When taking the patient’s history and reviewing the medical record, be alert to “red

flags,” which include any medical conditions, visual, cognitive, or motor changes,

medications, functional decline, or symptoms or signs that can affect driving skills and

safety.

• Do not make assumptions about whether an older adult is driving. Always be sure to ask

about this key instrumental activity of daily living.

• Age alone is not a red flag for driving safety. The media often emphasizes age when an

older driver is involved in an injurious crash, but this is ageism and not evidenced-based.

• Health care providers should take the approach of optimizing safe driving rather than

simply stopping older adults from driving.

Mr. Phillips, an 82-year-old man with a history of hypertension, congestive heart failure,

atrial fibrillation, type 2 diabetes mellitus, macular degeneration, and osteoarthritis, comes

to your office for a routine check-up. Mr. Phillips ambulates with a wide-based ataxic gait,

uses a walker, and has impaired standing balance. He is unable to stand from the exam chair

without multiple attempts and use of his arms, and he reports feeling temporarily

lightheaded on standing. He is no longer able to read newspaper print and tells you he avoids

driving at night and only goes short distances to run errands, get to appointments, and meet 

weekly with his bridge club.

Mrs. Bales, a 90-year-old woman, lives in a continuing care retirement community with her

92-year-old husband for whom she is the primary caregiver because of his Parkinson’s

disease. Her past medical history includes degenerative joint disease and hypertension. She

has decreased range of motion in her neck and walks without an assistive device but with a 

wide-based gait. She drinks a moderate amount of alcohol daily and was recently started on

oxycodone for chronic pain.

This chapter discusses the first steps of the Plan for Older Drivers’ Safety (PODS) and, in

particular, provides a strategy for answering the question “Is the older adult at increased risk of

unsafe driving?” This part of the evaluation process includes clinical observation of the older

adult, identifying red flags such as medical conditions and medications that may impair safe

driving and inquiring about new-onset driving behaviors that may indicate declining traffic skills.

The goal of the assessment is to facilitate driving safety among older adults and assure that those

who can drive safely are helped to do so.
17

Steps To Answer this Question

Observe the older adult throughout the encounter.

Careful observation is often an important step in diagnosis. Clinicians should observe the

older adult and be alert to:

• Sensory deprivation such as impaired vision, hearing or decreased sensation in the

extremities

• Inattention or loss of insight regarding personal care (e.g., poor hygiene and grooming)

• Impaired ambulation (e.g., difficulty walking or getting into and out of chairs)

• Difficulty with way finding (e.g., getting to or out of the office)

• Impaired attention, memory, language expression, or comprehension

• Difficulties or lack of insight related to managing medical encounters, such as missed

appointments, repeated phone calls for the same issues, or appearing on the wrong day.

In the example above, Mr. Phillips has difficulty with balance and strength as revealed by his

inability to get up from the chair without multiple tries and his wide-based gait. Moreover, he

has visual changes such that he cannot read print of typical size. This raises a question as to

whether he can operate vehicle foot pedals properly or see well enough to both drive and find

his way safely. His physical limitations may not preclude driving, but they may be indicators that

more assessment isindicated.

Be alert to conditions in the older adult’s medical history, examine the current list of

medications, and perform a comprehensive review of systems.

During an interview of the older driver, clinicians should be alert to “red flags,” i.e., any

medical condition, medication, or symptom that can affect driving skills, either through acute

effects or chronic functional deficits (see Chapter 9). For example, Mr. Phillips (introduced in

previous chapter) presents with lightheadedness associated with atrial fibrillation. Symptoms

of dizziness should be considered as a red flag, and Mr. Phillips should be counseled to cease

driving until his symptoms are diagnosed, treated and resolved. Significant pain and associated

limitations in function seen with degenerative joint disease, such as those noted with Mrs.

Bales, should also be considered “red flags.” Other conditions may impact safety and/or require

training to use compensatory techniques when driving, e.g., limited range of motion in the

neck. Acute or chronic pain can also be distracting and make it unsafe for older adults to drive. 

Many factors can put individuals at risk of unsafe driving and should be explored during office

visits (Table 2.1).
18

Table 2.1 Clinical Risk Factors for Impaired Driving

Risk Factor Signs and Symptoms

Physical capabilities History of falls

Impaired ambulation

Vision and/or hearing impairment 

Functional impairment with regard to use of gas or brake pedals 

Decreased ability to turn the head to fully visualize an area

l l d Cognitive ability Decreased short-term memory

Decreased or impaired way finding 

Easily distracted

Inability to learn new information quickly 

Inability to recognize unsafe situations 

Driving ability Not using turn signals appropriately

Difficulty turning the wheel and making turns 

Difficulty staying in the correct driving lane

Difficulty judging the space between cars or upcoming exits

Hitting curbs when parking or backing up

Stopping in traffic inappropriately

Not following stop signs, yield signs, traffic lights, etc.

Not noticing workmen or activity on side of the road

Inappropriate speeds for the weather/driving conditions

History of traffic violations, minor crashes, or warnings

Most older adults have at least one chronic medical condition and many have multiple

conditions, the most common including arthritis, hypertension, hearing impairments, heart

disease, cataracts, dizziness, orthopedic impairments, and diabetes.1 The impact of multiple

comorbidities is not well-known. Some of these conditions have been associated with driving

impairment by virtue of both their symptoms and their treatments (e.g., medications and

medication adverse effects) that can influence driving safety. These conditions will be discussed

in more detail in subsequent chapters, including a reference list of medical conditions and

medications that may affect driving in Chapter 9, with some of the more common chronic

conditions noted below in Table 2.3.

Older adults generally take more medications than their younger counterparts and are more

susceptible to adverse effects. The Beers Criteria for potentially inappropriate medication use in

older adults is a useful tool for screening medication lists.2 Whenever medication is prescribed

or the dosage of a current medication is changed, it is important to inform the older adult of

potential effects or drug-drug interactions that might affect driving safety. Adverse effects, such

as drowsiness, confusion, dizziness, or nausea, can impact the ability to concentrate and drive

safely. Concern may be heightened in the face of already-present underlying concerns about

visuospatial processing speed, cognition, or functional changes (e.g., the Trails B test [see

Chapters 3 and 4]), slow response time, and decreased attention.
19

The review of systems can reveal symptoms that may interfere with driving ability. For

example, loss of consciousness, confusion, falling asleep while driving, feelings of faintness,

memory loss, visual impairment, numbness or tingling in extremities, and muscle weakness all

have the potential to affect driving safety.

The clinical team should not make assumptions about whether an older adult is driving and

should always be sure to ask about this important activity of daily living. Sometimes, older

drivers themselves or caregivers may raise concerns. If the older adult or his or her caregiver

asks your opinion about whether the individual is safe to drive, any concerns that have been

noted should be explored. Has the older adult had any recent accidents, near-accidents,

citations or crashes? Is he or she feeling uncomfortable or unsafe driving? A list of specific

driving behaviors that could indicate concerns for safety are found in the Fitness to Drive

measure freely available online.3 Clinicians should encourage caregivers to monitor and observe

skills of the older adult driver in real-world traffic situations, with full disclosure and permission

from the older driver. Concern should be noted if caregivers will not drive with the individual or

let others drive with him or her. If the older adult is living in a retirement community (or

continuing care retirement community, assisted living, etc.), it may be helpful to explore with

staff if they have noticed any driving behaviors that might indicate unsafe driving (e.g.,

inappropriate speeds, not stopping at stop signs, not slowing over curb bumps, bumping

into/scraping other cars).

Age alone is not a red flag! Unfortunately, the media often emphasizes age when an older

driver is involved in an injurious crash. This “ageism” is a well-known phenomenon in U.S.

society.4 Although many people experience a decline in vision, cognition, or motor skills as

they get older, these changes occur at different rates, and older adults experience functional

changes to different degrees. The focus should be on functional abilities and medical fitness

to drive versus on age per se. The clinical team should take the approach of optimizing safe

driving rather than simply stopping the individual from driving.5

Inquire about driving during the social history and health risk assessment.

A health risk assessment is a series of questions intended to identify potential health and safety

hazards in the older adult’s behaviors, lifestyle, and living environment (Table 2.2). The health

risk assessment is tailored to the older adult and generally focuses on physical activity, falls,

drinking (alcohol), medication management, and driving. Questions about driving should be

integrated into the health risk assessment.
20

Table 2.2 Questions About Driving

ExploratoryQuestions Health Risk Assessment Questions

How did you get here today?

Do you drive?

How much do you drive?

Do you drive to the store? hairdresser? bank?

Do you drive at night?

Have you lost any confidence in your ability to be a 

safe driver?

Have others expressed concern about your driving?

Physical activity and diet history

Daily alcohol intake

Daily medication management

concerns or use of sedating

medications

History of falls 

Use of seat belts

What would you do if you had to stop driving?

Are comfortable when seated in your car?

Tell me about your ability to see signs when driving?

To manage the steering wheel? To manage the

foot pedals? To visualize the street signs? To

visualize the traffic lights and signs?

Do you often get lost while driving?

Have you received any traffic violations or warnings

in the past 2 years?

Have you had any accidents or near-accidents in the

past 2 years?

Questions for caregiversif concerns are raised:

How often do you believe drives?

Have you had the opportunity to ride with

 in the past month?

Do you feel safe in the car when riding with

 ? 

Do you have any concerns about driving ability?

If a patient presents a form from the licensing

agency, the clinician should ask why they are being

asked to submit the form.

If the older adult drives, then his or her driving safety should be addressed if red flags are

raised. In addition, whenever there is any change in a medical condition or medication that

could impact driving, the impact on driving safety should be considered. For example, Mrs.

Bales should be cautioned regarding driving because of her use of a new narcotic and to

consider a short driving-free period while she evaluates its impact on her driving skills.

In contrast, for chronic medical conditions, driving safety is addressed by formally assessing the

functions important for driving (see Chapter 3). Chronic medical conditions, such as

degenerative joint disease or congestive heart failure should be considered when evaluating
21

driving ability and safety. For example, an older adult with congestive heart failure may have an

acute exacerbation, resulting in the need for increased use of diuretics and, therefore, risk of

dizziness, fatigue, or electrolyte imbalance. This individual might not be safe to drive and should

be counseled to avoid driving until the symptoms of heart failure, including fluid buildup, have

resolved, the heart failure is compensated, and she has resumed maintenance treatment.

Ongoing evaluation after stabilization is needed. The clinician should also recommend formal

assessment of function as described in chapters 3 and 4 if the older adult shows any signs of

chronic functional decline. (For more complete recommendations on medical conditions (e.g.,

diabetes) and medications that may affect driving, see Chapter 9.)

If the older adult does not currently drive, ask if he or she ever drove and what was the reason

for stopping. If the older adult voluntarily stopped driving because of medical reasons that are

potentially treatable, it may be possible to help him or her return to safe driving. In this case,

formal assessment of function can be performed to identify specific areas of concern and serve

as a baseline to monitor the individual’s improvement with treatment. Referral to a driver

rehabilitation specialist in these cases is strongly encouraged (see Chapter 5).

When exploring driving ability, it is very useful to also speak with a caregiver to confirm what

the older adult has stated. As noted above, if the older adult lives in a retirement community or

continuing care retirement community, the staff may also be able to provide invaluable

information with permission because they have the opportunity to observe the individual’s

driving activities, techniques, and safety.

If caregivers are particularly concerned, it may be helpful to have them review some driving

simulations with the older adult; these are available on the AARP webpage

(www.aarp.org/home-family/getting-around/driving-resource-center/info-08- 

2013/interactive-driving-simulations.html). These simulations include situations such as 

making left-hand turns, hazard detection, and lane changes. In addition, older adults can be

encouraged to review the AARP’s “My Driving Plan,” which is a guide to help older adults

continue to drive safely as they age.

Understand the older adult’s mobility needs.

Asking about the older adult’s mobility needs and encouraging him or her to begin exploring

alternative transportation options before it becomes imperative to stop driving is advised.

When a diagnosis is encountered that may lead to the need for adaptive equipment or driving

cessation, the clinician should advise the older adult of the potential impact on driving. For

example, an older adult with multiple sclerosis could be advised that hand controls might be

necessary in the future. Without ongoing discussion, older adults who have not planned for any

forms of alternative transportation may feel that they have no choice but to continue driving,

increasing their likelihood of continuing to drive after they may have lost the capacity to do so.

Even if alternative transportation options are not needed at this point, it is wise for older adults to

plan ahead in case it becomes necessary.
22

Some questions to use to initiate this conversation using the Hartford “We Need to Talk”

discussion materials6 include:

• How do you usually get around?

• If your car ever broke down, how would you get around? Is there anyone who can give

you a ride? Can you use public transportation, such as a bus or train? Does your

community offer a shuttle service or volunteer driver service?

It can also be useful to explore the cost/benefit of driving (such as car maintenance and insurance)

versus using a cab service, Uber, Lyft, or other type of public or community transportation.

Older adults should be encouraged to plan a safety net of transportation options. It can be helpful 

to link independent mobility to clinical concern for the older adult’s well-being with phrases such

as “Mobility is very important for physical and emotional health. If you were ever unable to drive 

for any reason, I’d want to be certain that you could still make it to your appointments, pick up 

your medications, go grocery shopping, and visit your friends.”

Sources of educational materials on alternatives to driving are listed in Appendix B and include the 

National Center on Senior Transportation’s material.7 Other resources are available through AARP

(www.aarp.org/home-family/getting-around/driving-resource-center/driving-resource-centergetting-started2/) and the University of Michigan Transportation Research Institute

(www.umtri.umich.edu/critical-issues/senior-mobility).

8 If an older driver must stop driving, the

transition will be less traumatic if he or she has already created a transportation plan. In addition, 

the handout Getting By Without Driving, or Transportation Options for Older Adults can help the

older adult get started (Appendix B).

Counseling Older Adult Driversin the Inpatient Setting

When caring for older adults in the acute hospital setting, it is critical to use this opportunity to

consider driving and if the individual is currently safe to do so.9 Counseling may include

recommendationsfor temporary or permanent driving cessation or for driving assessment and

rehabilitation when the individual’s condition has stabilized. Such recommendations are intended 

to promote safety and, if possible, help the older adult regain his or her ability to drive. Case

managers may be able to assist with supporting older adults when this recommendation is

necessary. This recommendation should be included within the discharge summary that goes to

the rehabilitation/subacute setting and/or to the older adult’s primary care provider.
23

Red Flagsfor Further Assessment

Older Adult Driver’s or Caregiver’s Concern

Regardless of the setting of care, older adult drivers and their caregivers may express concerns

about driving safety. If so, the cause of concern should be investigated, specifically if there have

been recent motor vehicle crashes, near-crashes, traffic tickets, instances of becoming lost, poor

night vision, forgetfulness, or confusion. Function should be evaluated using the Clinical

Assessment of Driving Related Skills (CADReS) tests (Chapters 3 and 4).

Acute Events

Any acute event, whether requiring hospitalization or not, is a red flag for immediate assessment of

driving safety. If the older adult has been hospitalized, it is particularly important to counsel him or

her as well as caregivers on driving safety issues. Acute disease exacerbations can serve as an

opportunity to address, or re-address driving concerns. As a general recommendation, older adults

should cease driving until cleared to drive by their primary care provider in the event of any of the

following common acute events. 

• Acute myocardial infarction

• Acute stroke or other traumatic brain injury

• Arrhythmia (e.g., atrial fibrillation, bradycardia)

• Lightheadedness, dizziness

• Orthostatic Hypotension

• Syncope or presyncope

• Vertigo

• Seizure

• Surgery

• Delirium from any cause

• New sedating medications or those that can cause confusion or dizziness

Chronic Medical Conditions

Older adults may require focused assessments to determine the impact of the following

chronic medical conditions on their level of function (detailed information in chapter 9):
24

Table 2.3 Chronic Medical Conditions that May Impact Driving

Medical Condition Examples

Diseases/conditions affecting vision Cataracts

Diabetic retinopathy

Macular degeneration

Glaucoma

Retinitis pigmentosa

Field cuts

Low visual acuity even after correction

Cardiovascular disease, especially when

associated with presyncope, syncope, or

cognitive deficits

Unstable coronary syndrome

Arrhythmias

Palpitations

Congestive heart failure

Hypertrophic obstructive cardiomyopathy

Valvular disease

Neurologic disease Dementia

Multiple sclerosis

Parkinson disease

Peripheral neuropathy

Brain injury

Spinal cord injury

Psychiatric disease Mood disorders

Depression

Anxiety disorders

Psychotic illness

Personality disorders

Alcohol or other substance abuse

Metabolic disease Type 1 and type 2 diabetes mellitus

(especially with hypoglycemic attacks or

severe swings in blood glucose)

Hypothyroidism

Musculoskeletal disabilities Arthritis and foot abnormalities

Contractures and decreased range of

motion

Inflammation 

Pain

Respiratory disease Chronic obstructive pulmonary disease

Obstructive sleep apnea

Chronic renal failure

Cancer and chemotherapy
25

Medications

Many nonprescription and prescription medications have the potential to impair driving ability,

either by themselves or in combination with other drugs. Combinations of drugs may affect

drug metabolism and excretion, and dosages may need to be adjusted accordingly. In addition,

clinicians should always ask about alcohol use and timing of intake (for more information on

each medication class that may affect driving, see Chapter 9). Medications with strong

potential to affect driving ability include:

• Anticholinergics, 

• Anticonvulsants, 

• Antidepressants, 

• Antiemetics, 

• Antihistamines, 

• Antihypertensives, 

• Antiparkinsonian agents, 

• Antipsychotics, 

• Benzodiazepines and other sedatives/anxiolytics, 

• Muscle relaxants, 

• Narcotic analgesics, 

• Stimulants, 

• Hypnotics, and

• Other agents with anticholinergic side effects. 

Review of Systems

The review of systems can reveal symptoms or conditions that may impair driving

performance. Symptoms associated with acute and chronic medical problems are critically

important red flags and should be carefully explored.
26

Table 2.4 Organ Systems and Symptoms

Organ System “Red Flag” Symptoms

General Fatigue

Weakness

Dizziness

Head, ears, eyes, nose, throat (HEENT) Headache

Head trauma

Double vision

Visual changes

Vertigo

Change in ability to read

Change in visual acuity

Respiratory Shortness of breath

Use of oxygen

Cardiac Chest pain Dyspnea

on exertion

Palpitations

Sudden loss of consciousness

Increased swelling in the legs

Musculoskeletal Muscle weakness

Pain

Joint stiffness or pain

Decreased range of motion

Neurologic Loss of consciousness

Neurologic Loss of consciousness

Faintness 

Seizures 

Weakness

Paralysis

Tremors

Loss of sensation

Numbness

Tingling

Psychiatric Depression

Anxiety

Changes in memory and ability to recall

recent events, confusion, psychosis, mania,

or difficulty with word finding, way finding,

decision making, or concentration
27

Assessment and Plan

Clinicians should consider screening at-risk older adults using red flags and identifying common

signs, symptoms and medical conditions associated with impairment of driving safety in every

clinical setting where older adults are encountered. When formulating a diagnosis and

treatment plan for older adults, driving safety should be addressed whenever needed.

Identification of risk early on may facilitate primary prevention and interventions to prevent the

loss of driving ability. Ongoing monitoring of chronic illness may facilitate secondary prevention 

efforts to rehabilitate the loss of driving skills and attempts to restore those skills.

Red flag indicators and acute events may signal that irreversible loss of driving skills has

occurred and tertiary prevention should include recommending alternatives to driving to avoid

harm to the older adult and others. It is also critically important to recognize that some older

adults may have impaired insight with regard to their driving safety, and self-reports should be

confirmed with caregivers or others who may be familiar with the older adult’s driving ability.10

In summary, assessment of driving safety can and should be routinely integrated into the care

plan when:

• A new diagnosis or change occurs in any condition that has been associated with

impaired driving; 

• A new medication is prescribed, or the dosage of a current medication is changed; 

• A change in functional abilities is reported; or

• As part of an annual wellness visit. 
28

References

1. Dickerson A. E., Meuel D. B., Ridenour C. D., & Cooper, K. (2014, November-December). 

Assessment tools predicting fitness to drive in older adults: A systematic review.

American Journal of Occupational Therapy, 68(6), 670–680.

2. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (2015, November). 

American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate 

medication use in older adults. Journal of the American Geriatrics Society, 63(11), 2227-46. 

doi: 10.1111/jgs.13702

3. University of Florida Institute for Mobility, Activity and Participation. (2013). Fitnessto-drive screening measure online (Web Page). Retrieved from the University of 

Florida website at http://fitnesstodrive.phhp.ufl.edu/

4. Nelson, T. (2002). Ageism: Stereotyping and Prejudice Against Older Persons. Cambridge, 

MA: MIT Press.

5. Golisz, 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.

6. The Hartford Financial Services Group, Inc. (2015, July).Family Conversations with Older

Drivers. Available at: www.thehartford.com/sites/thehartford/files/we-need-to-talk2012.pdf

7. National Center on Senior Transportation. Transportation options for older adults. 

Retrieved from the NCST website at 

www.seniortransportation.net/Portals/0/Cache/Pages/Resources/Trans_Options_Panels.pdf

8. University of Michigan Transportation Research Institute. (2007). Senior Mobility (Web 

page). Retrieved from the UMTRI website at www.umtri.umich.edu/critical-issues/seniormobility

9. Baker, A., Bruce, C., & Unsworth, C. (2014). Fitness-to-Drive for acute care and ADHD.

Occupational Therapy Practitioner, 19(10), 7–10.

10. 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.
29

CHAPTER 3 SCREENING AND ASSESSMENT OF FUNCTIONAL ABILITIES FOR

DRIVING

Key Points

• An assessment of underlying functional abilities important for safe driving (e.g.,

vision, cognition, motor) should determine the need for further evaluation and

subsequent intervention, and/or for a more specialized driving evaluation.

• Significant functional impairment may necessitate cessation of driving with assistance in

developing a plan for alternative methods of transportation.

• Older adults with visual and/or physical impairments have a greater potential for

continuing safe driving than those with cognitive impairment, since adaptive equipment

and compensatory strategies are available.

• No single assessment can accurately predict fitness to drive; an array of assessment tools

should be used to determine risk in older adults.

• The Clinical Assessment of Driving Related Skills (CADReS) is a toolbox of evidence-based

practical, office-based functional assessment tools in the key areas of vision, cognition,

and motor/sensory function related to driving.

• Self-report or self-assessment has not been shown to be an adequate measure of fitnessto-drive largely because of the overlearned skill set of driving combined with the intense

desire to remain driving independently.

Mr. Phillips (introduced in previous chapters) has been accompanied to the clinic by his son, who

is in the examination room with him. Mr. Phillips tells you that he is a safe driver. You request

and obtain permission to interview the son, who voices his concern. Four months ago, Mr.

Phillips was involved in a minor car crash, which was his fault. He has also had several nearcrashes in the past 2 years. He has never been lost while driving.

In discussing Mr. Phillips’ transportation options, you learn that he drove himself to this

appointment. Driving is Mr. Phillips’ main mode of transportation, and he drives almost every

day. Although Mr. Phillips is certain—and his son confirms—that family members and neighbors

would be willing to drive him wherever he needs to go, he has never asked for rides. “Why

should I ask for rides when I can just drive myself? Besides, I don’t want to impose on my family

or friends.”

Increasing longevity in the U.S. population means that, because of comorbid conditions, many

older adults may outlive their ability to drive safely. Men are projected to live approximately 6

years and women 10 years longer than their ability to drive.1 This chapter focuses on the

functional abilities needed for driving. It is important to distinguish between screening older
30

adults for functional disability that may impair driving and conducting a more detailed

assessment that identifies at-risk drivers who may benefit from intervention strategies. The

goal is to optimize the ability of older adults to continue to drive safely for as long as possible.

The clinical team may detect problems that (1) allow early intervention and may prevent

disability and prolong driving ability, (2) identify impairments that can be remediated, (3)

identify strategies to compensate for a medical condition, and (4) plan for the timely transition

to alternative means of transportation.

Primary prevention addresses issues to prevent the loss of driving ability and includes starting

the conversation about transitions and planning for driving retirement. This is helpful for all

older adults, especially those with chronic medical conditions that may eventually affect driving

(e.g., diabetes, dementia, Parkinson disease). For example, when counseling an older adult with

diabetes, in addition to explaining how to manage blood sugar levels, it may be helpful to

explain how to help minimize peripheral nerve damage to prolong the ability to drive

independently. This potentially is a highly motivating and important way to optimize adherence.

Chapter 2 outlined what factors or “red flags” to observe if driving is of concern to the older

adult, caregiver, or clinical team member. This chapter goes beyond the initial screening

process for those older adults recognized to have a possible safety risk who need further

exploration of their fitness to drive.

Secondary prevention attempts to remediate any loss of driving skills that have already

occurred as well as to prevent further loss of driving ability.

Screening Versus Assessment

Screening

Screening for unsafe driving requires the use of simple tools to identify the possibility of risk.

The goal is to identify all older adults drivers who might be “at risk” of unsafe driving, with the

understanding that some individuals who are not at risk will also be incorrectly identified.

Assessment

Assessment requires more in-depth evaluation to distinguish between individuals who are truly

at risk and those who are not. It is important to note that screening and assessment tool scores

do not by themselves predict crash risk for many reasons, including the relatively low

occurrence of crashes and because older adults are often low-risk individuals compared to the

general population. It is the clinical skill, expertise, and reasoning of the health care provider

during assessment of the older adult that allows a judgment about probable driving outcome.

The Transportation Research Board Committee for Safe Mobility for Older Persons2 has

developed definitions for screening, assessment, and evaluation (Table 3.1).
31

Table 3.1 Screening, Assessment, and Evaluation Terminology

Term Definition

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

Proxy screening An individual obtains and reviews data to determine the need for

evaluation for another person

Evaluatorscreening 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 triggered 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 evaluation Obtaining and interpreting data and documenting results to

determine fitness to drive through assessment of

sensory/perceptual, cognitive, and/or psychomotor functional 

abilities using specific tools or instruments

Comprehensive driving

evaluation

A complete evaluation of an individual’s driving knowledge, skills,

and abilities that includes (1) medical and driving history; 

(2) clinical assessment ofsensory/perceptual, cognitive, or

psychomotor functional abilities; (3) on-road assessment, as

appropriate; (4) an outcome summary; and (5) recommendations

for an inclusive mobility plan, including transportation options
32

Multiple assessment tools are used for screening and assessment of driving.3 However,

except for on-road assessment, there is no single tool at present that should be used to

determine fitness to drive.4-9 Older adults have typically been driving for 30 to 50 years and

may have overlearned skills and abilities that compensate for deficits detected with officebased tools. Computer-based screening or assessment tools for someone who may not use

technology frequently may result in test failure because of lack of familiarity with the

technology rather than because of deficits in driving ability.

Clinical team members may perform screening, assessment, and clinical driving evaluation,

which may then permit health care and community interventions. Team members can then

determine whether to refer the older adult to a driver rehabilitation specialist for a 

comprehensive driving evaluation or whether to facilitate a decision about cessation of 

driving.

Health care providers are in the best position to determine if the at-risk older adult requires a 

referral to another health care provider (e.g., ophthalmologist, occupational therapist, driver

rehabilitation specialist) for an evaluation for a specific deficit. Although cut-off scores might

be provided, it is important to remember that the assessment tools discussed below

demonstrate only the presence of a problem, not its cause.

Clinical team members must function within their scope of practice and use clinical judgment

regardless of test scores to make decisions about fitness-to-drive of older adults. All available

information, including driving and medical history, should be considered. The specific tools

discussed here were selected for their applicability and feasibility in an office setting, along

with their correlates with impaired driving outcomes, but they cannot cover every important

function needed for driving.

Broaching the Issue of a Driving Screening or Assessment With the Older Adult

The primary message should be one of concern and assistance, balancing the older adult’s or

caregiver’s concern about the safety of the older adult and/or the public and the older

adult’s need for transportation. Care should be taken to avoid an adversarial position,

because this may prompt an unproductive reaction of defensiveness. The conversation

should begin with a commitment to explore all reasonable options for keeping the older 

adult mobile in his or her community. Points to emphasize include that screening and

assessment are necessary to identify ways to help the older adult continue to drive safely as

long as possible, and that current technology, roadways, and rehabilitation offer many

helpful interventionsto do 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

licensing agency has that type of legal authority (see Chapter 7).
33 

“Mr. Phillips, I’m concerned about how your condition is affecting your driving. Your son tells me

that you were recently in a car crash and that you’ve had several near-crashes in the past 2

years. Although you have managed your medical condition, I believe it may have progressed to

the point that it may be affecting your driving skills and ability. I am going to ask you to do a 

few simple tests that can measure functional abilities needed for safe driving, such as walking

down the hall while I time you. This will help us find out if there are areas we need to look into

further.

“Based on your health condition and the results of the tests, we’ll do our best to treat or reverse

any problems we find. For example, if you’re not seeing as well as you should, we’ll see what we

can do to improve your vision. If you have difficulty turning your head, a referral to a physical

therapist may be in order. If there’s something we can’t improve, then we may consult a driving

rehabilitation specialist to explore all possible solutions. This type of specialist, typically an

occupational therapist, will offer you further testing and then go out on the road with you to see

how you’re driving. The driving rehabilitation specialist can develop a plan that will include, if at

all possible and safe, recommendations, strategies, and maybe adaptive equipment for you to

consider. Whenever possible, the driving rehabilitation specialist will recommend ways to make

your driving safer. Our goal is to keep you on the road for as long as you are safe to drive.”

Functional Areas Assessed for Driving

Three key functional areas are considered as the foundation for fitness to drive: vision,

cognition, and motor/somatosensory function. Any impairment in these areas has the potential

to increase the older adult’s risk of being involved in a crash. Once these areas are assessed, the

health care provider can determine if more information is required in one or all areas or if

referral to a specific specialist for further evaluation or intervention is needed (e.g.,

ophthalmologist, neuropsychologist, driver rehabilitation specialist).

Vision

A vision assessment includes assessment of visual acuity, visual fields, and contrast sensitivity.

Vision is the primary sense used in driving and is responsible for most of the driving-related

sensory input.10 In most States, vision testing is required to obtain a driver’s license. Several

States also require vision testing at the time of license renewal. For information on these

laws, see Chapter 8.

Visual Acuity: Visual acuity commonly declines with age, although no consensus exists on the

rate of decline or decade of onset. Decline in acuity is related to physiologic changes of the eye

that occur with age and the increased incidence of diseases such as cataracts, glaucoma,

diabetic retinopathy, and age-related macular degeneration (ARMD).11Although distance visual

acuity appears to be crucial to many driving-related tasks, declines in near visual acuity may be
34

associated with difficulty seeing/reading maps or gauges and controls inside the vehicle.

Most research studies show that visual acuity is not linked to crash risk,8, 12-14 which may be

because of the variability in visual requirements by State licensing agencies. There is some

evidence that visual screening laws are associated with decreased motor vehicle crash fatality

rates.

15 Cataracts are another major concern associated with vision and driving. The gradual

development of cataracts results in a slow change in vision, which the older adult may not

recognize. Identification and removal of cataracts can effectively improve driving safety.16-18

General visual acuity can be easily measured in the office setting using readily available tools

such as a Snellen chart www.provisu.ch/Age/Snellenchart_en.pdf). Near visual acuity can be

assessed by the Rosenbaum pocket chart and there are several free apps available for

smartphones. Some States license low-vision drivers; in this case, driver rehabilitation programs

may offer specialized services that include the training and provision of specially designed

adaptive devices. For the cognitively intact driver, these specialized programs may offer options

for continued driving.

Visual Field: Visual fields may decline as a result of natural aging changes such as ptosis, a 

drooping of the eyelid most commonly found in the older population. Most visual field cuts,

however, are the consequence of medical conditions such as glaucoma, optic neuritis, detached

retina, and stroke/traumatic brain injury. Drivers with loss of peripheral vision may have trouble

noticing traffic signs or cars and pedestrians about to cross their path. The evidence examining

the relationship between visual field loss and driving performance is still evolving,19 Visual fields

are measured through confrontation testing.

Contrast Sensitivity: Older adults require about three times more contrast than young adults to

distinguish a target against its background. Low light levels exacerbate this deficit. Thus, older

adult drivers may have problems distinguishing cars or pedestrians against the driving

background; this may be much worse at night or during storms.20 Impairment should be

addressed by offering strategies that include avoiding driving during dawn and dusk hours, in

foggy conditions, or during storms. Because impaired contrast sensitivity is a valid predictor of

crash risk among older adult drivers,19 it could be included in routine eye examinations by

primary care providers. Contrast sensitivity can be evaluated with specially printed cards. More

research is needed to produce standardized, validated cut-off points for contrast sensitivity and

the level at which impairment resultsin decreased driving safety. These tests are rarely

performed outside ophthalmology practice settings.

Several other visual functions are important in driving (light adaptation, accommodation,

dynamic visual acuity, color perception), but office-based measures that can be used for

screening and assessment are neither easily available nor linked to crash risk. Therefore, they

are not discussed here.
35

Cognition

Cognitive assessment includes functional assessments of memory, visual perception/processing,

attention, executive function, language, and insight.

Driving requires timely visual and cognitive processing to make appropriate decisions in a 

dynamic and complex environment. The best assessment tools integrate several cognitive

processes (e.g., divided attention and visual processing) to test high-level cognitive processes,

such as executive functioning.21 At the clinical team level of screening, specific cognitive

abilities and skills can be assessed for deficits indicative of risk. Because these functions are the

building blocks of more complex abilities, if an older adult has a significant issue with any basic

cognitive skills, it will likely affect driving.

Memory: To drive safely, drivers need to remember their destination, how to navigate to the

destination, how to operate the vehicle, and to obey traffic rules and regulations.22 In addition,

drivers must be able to retain certain information while simultaneously processing other

information, using the skill of working memory. Working memory (and the other cognitive skills

to which it contributes) tends to decline with age.23

Visual Perception/Processing: Visual perception and processing as well as visuospatial skills are

necessary for drivers to organize visual stimuli into recognizable forms and understand where

they exist in space. Without these skills, drivers would be unable to recognize another vehicle

and determine its distance ahead to maintain speed, slow, or stop in relation to that vehicle. In

general, visual processing may slow20 and complex visuospatial skills may decline with age,

while visual perception remains stable.24

Attention: Because of the dynamic and changing environment, demands on attention can be

significant, especially in areas of high traffic or during rush hour traffic. Drivers must possess

selective attention (i.e., the ability to prioritize stimuli and focus on only the most important) to

attend to critical stimuli (e.g., traffic lights, other vehicles, pedestrians) without being 

distracted by irrelevant ones (e.g., billboards, city sights). In addition, drivers must possess

divided attention to focus on the multiple stimuli required by most driving tasks. For example,

the driver must be able to attend to vehicles surrounding him or her while changing lanes for a 

turn, maintaining a safe speed, and activating the turn signal in the correct direction.

Attentional functioning may decline with age,25 with divided attention showing more

pronounced changes than selective attention.26 However, regardless of age, the divided

attention from using cell phones is clearly a significant safety risk. Older adults should be

advised to avoid using cell phones while driving because of the possibility of decreased working

memory and attention reserves.
36

Executive Function: Executive function is an umbrella term that refers to the coordination of

several cognitive subprocesses to achieve a particular goal.27 Executive function acts as a 

supervisor of all cognitive processes28 and includes initiation of a task, problem solving,

planning, sequencing, flexibility in thinking, and impulsivity. Executive skills allow drivers to

make the decision to stop at a red light or when the light is green if a pedestrian is in the path

of the vehicle. Although the capacity for this kind of logical analysis tends to decline with age,26

it is with brain injury that the problems with executive functions become more evident in

driving. Because of the overlearned ability of driving, many drivers with executive function

deficits can drive familiar routes without a problem. However, if an unexpected event occurs

(e.g., a child running onto the street, a familiar road is closed because of construction), older

adult drivers with poor executive functioning may put themselves or others at risk.

Insight: Insight is the awareness that a person has about himself or herself, including abilities

and limitations. It is important to determine the older adult’s understanding of how his or her

physical and/or mental limitations may affect fitness to drive. For example, the individual with

glaucoma should understand and agree that he or she should refrain from driving at night but

may drive without significant risk during daylight and non-rush hours. Individuals with dementia

may not have adequate insight, believing they are fit to drive when they are not.

Motor and Somatosensory Function

Motor and somatosensory function assessment includes functional assessments of functional

range of motion, proprioception, and endurance.

Driving requires motor and somatosensory abilities. Driver rehabilitation excels at the

prescription of and training in the use of strategies, devices, or vehicle modifications to

compensate for a wide range of physical and somatosensory impairments. Because of

improvements in technology (e.g., antilock braking systems, power seats, power steering,

keyless ignition, traction control systems, backing cameras), driving has become much less

physically demanding. Thus, physically frail older adults may not have limitations in continuing

to operate a motor vehicle. The amount of muscle strength and range of motion necessary to

physically operate a vehicle has decreased, although basic motor skills and abilities are still

needed.

Endurance: Before the act of driving, motor abilities are needed to enter the car safely and

fasten the seat belt. The natural process of aging may involve a decline in muscle strength and

endurance, flexibility, and joint stability. In addition, osteoarthritis and other musculoskeletal

problems are common in older adults. Individuals who suffer pain and limitations from these

conditions may not only experience direct effects on their driving ability but also decrease their

physical activity, causing further decline in motor function. Fatigue can be an issue for older

adults who are driving a long distance, have undiagnosed sleep apnea, or advanced functional

loss from severe end organ disease.
37

Functional Range of Motion: Drivers must be able to steer, use the accelerator and brake

pedals, and use the primary and secondary controls of the vehicle (e.g., turn signal, headlights,

wipers, climate controls). Range of motion in the neck is essential so that the driver can turn his

or her head quickly to check the blind spot; however, resources are available to compensate for

this functional limitation (e.g., backing cameras, fisheye mirrors, panoramic mirrors). Although

muscle strength is less of an issue with newer vehicles, older adult drivers should have

functional range of motion that permits reaching for pedals and the steering wheel with little or

no pain.

Proprioception: Drivers must have the ability to know whether their foot is on the brake or

accelerator pedal. The underlying issues with “pedal confusion” are not clear. For older adult

drivers, the problem may possibly be with proprioception. It would be easy for a driver to

become confused if he or she had to “look” to see where his or her foot was in order to drive.

Clearly, older adult drivers with sensory issues such as diabetic neuropathy would benefit from

a test of leg and foot proprioception.

Refusal of Assessment

Older adult drivers and their caregivers may express fear, resistance, or refusal to participate in

screening or assessment of functional abilities. The three most common reasons are the older

adult’s belief that he or she is a good driver, there is fear the outcome may put the older adult’s

license at risk, and/or the older adult and/or caregiver has impaired insight. Caregivers may

have conflicting priorities when trying to balance their respect for the older driver’s wishes,

level of risk, and the caregiver burden that cessation of driving can create, including

responsibility in time or money for transporting the older adult to appointments and activities.

In these situations, it may be helpful to assure the older adult that the concern and focus is on

prevention and optimizing driving ability and not on removing the ability to drive. Health care

providers, considering clinical observations and using best judgment, may decide there is cause

for concern but not an immediate risk. The goal might be to initiate a conversation with the

older adult and ideally with the caregiver about driving safety. It will be important to discuss,

with permission, the medical condition(s) of the older adult and the potential impact these can

have on driving safety. The first steps may focus on increasing self-awareness and a shared

understanding of driving risk for self and others. In addition, providers should ensure that the

older adult understands that the goal is to work together to find solutions for him or her to

continue driving if at all possible. It is well established that most older adults, regardless of age,

intend to continue driving until they decide “I have become an unsafe driver.”29 Older adults

who live in rural communities may realize they are at risk but do not feel they have any other

option. Focusing on counseling and referral on alternative transportation options first may

allow older adults to consider assessment at a later point in time.

For some older adults, it may be evident that further evaluation is necessary. In these cases,

professional ethics should be used to guide the decision. Maybe the clinical team member can
38

work with the older adult to follow a course of stopping driving now until “we better

understand your situation, gain the information required through evaluation, and then

determine the appropriate plan of care.” This message is about safety and support, both

offering the older adult and the family time to consider the consequences and prepare them for

next steps. If the older adult appears to have deficits in the functional areas and he or she or

caregivers report problems in other complex tasks (e.g., finances, cooking, shopping), referral to

an occupational therapist may be more appropriate. As a service usually covered by medical

insurance plans, a full assessment of underlying functions as well as other complex tasks can

lead to interventions that may improve function before a specialized assessment of driving.

Alternatively, if the older adult appears to have problems only in regard to driving, and not with

other areas of daily living, a referral to a driver rehabilitation specialist is prudent (see Chapter

5). The driver rehabilitation specialist will conduct a comprehensive driving evaluation that

includes a complete clinical assessment covering the areas of vision, perception, cognition, and

motor as well as an on-road assessment, if warranted.

Some older adults will absolutely refuse to consider evaluation and are intent on continuing to

drive. For these individuals, insight into deficits may be a problem. A discussion with a caregiver

may offer more information as well as provide additional support for pursuing an evaluation.

Actions should be guided by professional ethics, and it may be necessary to report the older

adult to the appropriate driving licensing agency (see Chapters 7 and 8).

Self-Assessment Tools

Many self-screening and caregiver rating tools are available to assist in building awareness of

the changes associated with aging as well as the symptoms of conditions that affect driving.

Following up with the older driver after use of these tools may improve their willingness to be

formally assessed by the clinical team. Regardless, it is important to understand that use of

these tools do not replace screening performed by professionals.

• Am I a Safe Driver? (a one-page handout, see Appendix B)

• The Driving Decisions Workbook, developed by the University of Michigan

Transportation Research Institute, is a free self-assessment tool with evidence that the

workbook scores are positively correlated with on-road driving scores and several

clinical tests of functional ability. Both online and print versions are available.

Individualized feedback is provided to respondents based on how they answer

questions. The workbook can be downloaded at

http://deepblue.lib.umich.edu/bitstream/handle/2027.42/1321/94135.0001.001.pdf?se

quence=2&isAllowed=y. 

• The Fitness to Drive Screening Measure, developed by the University of Florida, is a free

web-based tool for caregivers of older adults to identify at-risk older drivers. The user

needs to have driven with the driver in the last 3 months and then rates the driver on 54
39

driving skills. A rating profile of the driver is available and includes a classification of the

driver into one of three categories (at-risk driver, routine driver, or accomplished driver)

with recommendations given as follow-up steps. Research has shown that feedback

from the web site correlates positively with driving risk. This tool is available at

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

• The SAFER Driving Survey, developed at the University of Michigan Transportation

Research Institute, is a web-based tool (available at http://um-saferdriving.org) that 

asks users about the severity of health concerns they are experiencing due to medical

conditions and medications. The website then calculates the effects of these health

concerns on critical driving skills and gives users individualized feedback on (1) how their

driving may be declining, (2) what to do to continue driving safely given these declines,

and (3) possible recommendations for more in-depth assessment. Research has shown

that feedback from the web site correlates positively with on-road driving scores and an

assessment from an occupational therapist. Users also report that the site is easy to use,

the information is helpful, and that they discovered declines in themselves of which they

were not previously aware.30

• Roadwise Review is an online assessment (available at www.aaafoundation.org/-

roadwise-review-online; CD also available) from the American Automobile Association

that instructs older adults in real time on the completion of several tests of important

functional abilities for driving. It then provides feedback on the presence of

impairment. Roadwise Review requires the older adult to use a computer and

presence of an assistant during the assessment.

Clinical Team Assessment Tools

Assessments range from simple paper and pencil tools performed by clinicians in their offices to

complex assessments that may be only in the scope of practice of neuropsychologist (e.g., Rey

Figure) or driver rehabilitation specialist (e.g., comprehensive driving evaluation with on-road

assessment).

For the clinical team member who is screening or assessing an older driver, the following

summary describes a toolbox of practical, office-based functional assessment tools in the major

areas of vision, cognition, and motor/sensory function related to driving, the Clinical

Assessment of Driving Related Skills (CADReS). Clinical team members should choose the tool in

each area that best fits the practice setting in which they care for older adults and document

their encounters.

In the case of cognitive assessments, it is not always necessary to do all the tests. Depending

on the outcome of the easiest tests, it may be unnecessary to progress further.
40

General

• Driving history: A brief driving history can be useful as an initial screen to identify the

older adult’s perception of his or her driving as well that of a caregiver if available.

Recent traffic violations, crashes (including unreported), or near misses are all red flags

for concern (see Chapter 2). The Driving Habits Questionnaire is available31 but is

lengthy. A modified version is available in Appendix C.

• IADLs questionnaire: A checklist of other IADLs can also be used as an initial screen to

identify if the older adult is having difficulties with other complex tasks of daily living. As

an IADL, driving uses underlying functions (e.g., visual processing, executive functioning,

memory), similar to financial management, shopping, or cooking. If the older adult is

having difficulty with those tasks, further screening or assessment is warranted. A report

from a caregiver may also be helpful when the older adult appears to have cognitive

impairment.

• Medication change: Certain medications clearly affect driving, and new or changing

doses may affect assessment findings, perhaps triggering red flags that are temporary.

Vision

• Visual acuity: Measured by vision charts, visual acuity should be measured because it is

the legal criteria for most State licensing agencies. The Snellen chart is described below

and provided in Appendix C.

• Visual fields: Using a uniform manner of testing as described below, visual fields can be

assessed.

• Contrast sensitivity: Many charts are commercially available (e.g., Pelli-Robson

contrast sensitivity chart) to test the ability to perceive objects in contrast to the

environment.

Cognitive

• Montreal Cognitive Assessment (MoCA [www.mocatest.org/]): The MoCA is a brief

cognitive test designed to assist health care professionals in detecting mild cognitive

impairment. It may be administered by anyone, but the results should only be

interpreted by an individual with expertise in the cognitive field.32 It rates cognitive

performance, is available in multiple languages, and has been validated for adults 55 to 

85 years old. It tests memory, attention, language, abstract, recall, orientation, as well

as visuospatial skills by incorporating a shorter Trails B and a clock-making task.

• Trails B: This test of general cognitive function also specifically assesses working

memory, visual processing, visuospatial skills, selective and divided attention, and

psychomotor coordination. Numerous studies have demonstrated an association

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

performance33 (see below for directions and form). Neuropsychologists often

recommend giving the Trails A test (connecting just numbers) before giving the Trails B
41

test. The rationale is two-fold: The Trails A provides an appropriate warm-up to Trails 

B, and allows the older adult some practice on a simpler concept, and, in many of the

driving studies that validated Trails B, the Trails A was given first.

• Clock-Drawing Test: Thistest may assess long-term memory, short-term memory, visual

perception, visuospatialskills, selective attention, abstract thinking, and executive skills.

Preliminary research indicates an association between specific scoring elements of the

clock-drawing test and poor driving performance.34

• Maze test: There are several versions of maze testing, including online versions.

Depending on the type of test, it assesses visual perception, visuospatial skills, abstract

thinking, and executive skills. The Snellgrove maze35 is a one-page cognitive screen for

driving competence that was validated with older adults with mild cognitive impairment

or early dementia.

Motor/Sensory

• Rapid Pace Walk and Get Up and Go: These tests are measures of lower limb strength,

endurance, range of motion, and balance. The Rapid Pace Walk has been linked with

driving outcomes,9,36 whereas Get Up and Go37 has been more closely linked with falls

and future disability and long term care placement. Because falls have been associated

with poor driving outcomes, either of these tests would be appropriate measures for

assessing overall motor abilities. For directions, see below.

• Range of Motion: Performing a functional range of motion test is important for

examining if and how the motor vehicle can be adapted to meet limitations of the older

adult. Mirrors and education/training can accommodate limitations of the neck.

Limitations in any of the extremities can be accommodated by adaptive equipment

recommended by driver rehabilitation specialists. For directions for a functional range of

motion test, see below.

The Evolution of Computer-Based Tools

Three computer-based assessment tools are commercially available. The cost of these tools is

presently not covered by most insurance products. In general, more research is needed on

these computer-based assessments before they can be used as tools for making licensing

decisions. The use of interactive driving simulators is also being studied, with emerging

evidence supportive for their use as a potential assessment tool.

• Useful Field of View: This is the most widely studied instrument for detection of

impairment in processing speed, divided attention, and selective attention that has

been moderately correlated with crash risk in older adult drivers. The strongest

evidence is for the Subtest 2, which tests processing speed,9,14,35,38 but not all studies

supported the predictive validity of this instrument.8,39 This assessment tool is

available for purchase (information is available on the Visual Awareness web site

(www.visualawareness.com/Pages/whatis.html).40 Cost, time, and ability to bill, as well
42

as limited studies in a primary care setting, might be potential barriers to utilization.

• Driving Health Inventory (DHI).41 This computerized set of tests that assess key

functional abilities for driving was developed using data from individual assessments in

the Maryland Pilot Older Driver Study. It is intended for use by health care professionals

to assess older adults,36 but individual users may download single-use licenses for

personal use. Because each component was studied separately and the older adults

studied were a low-risk general population low risk, there is not strong evidence for the

DHI as a whole, linking the final version of the DHI with fitness to drive. The DHI did

appear to discriminate between drivers with a history of a crash and those without

crashes in a small cohort of drivers. In addition, this battery of tests appears feasible and

acceptable to older drivers as a screen for functional impairments.39 This assessment

tool is available for purchase (information is available on the DrivingHealth website

http://drivinghealth.com/screeningassessment.html). Again, cost, time, and ability to 

bill are potential barriers to utilization.

• DriveABLE: This assessment is only of cognitive abilities for driving; it is computer-based

and electronically scored (available at www.driveable.com/). Based on the performance

of the older adult, results are generated from a computer algorithm that returns a score

between 1 and 99 and reflects the “Predicted Probability of Failing an On-Road

Evaluation,” with 1 being least likely and 99 being most likely to fail. The computer

program designates upper and lower areas of risk. The developers of the program

maintain that computer knowledge or familiarity with a computer does not affect

performance and that the computer presentation of the tasks enables precision

measurements and objectivity and removes testing bias. However, there is minimal

independent research evidence using DriveABLE that supports the claims of predicting

driving risk accurately and this approach does not provide the clinician with information

which can be used to identify clinical solutions for potential problems. Older adults who

score in the middle of the range may require further evaluation such as on-road

assessment, reliance on caregiver information, recent driving history, or further in-office

testing.

Assessment Tool Performance Instructions

Snellen E chart

The Snellen chart is used to test far visual acuity. The standard chart measures 9” x 23” and is

printed on a durable, tear-resistant latex sheet, with eyelets for easy hanging. Letters are

printed on one side, and tumbling “E” symbols are printed on the reverse.

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

of 20 feet.
43

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

his or her usual glasses or contact lenses, the individual reads the smallest line possible with

both eyes open. Visual acuity is based on the lowest full row that he or she successfully reads,

and the process is repeated for each eye individually. However, if the best the individual can

see in either eye is 20/40, then his or her acuity is considered to be 20/40 in both eyes.

Far visual acuity can also be measured using another chart per the clinician’s preference, such

as the Snellen chart for a 10-foot distance or the Sloan low-vision letter chart for 6 meters (20

feet).42

Near visual acuity can be tested with commercially available charts and should be considered

whenever an older adult complains of difficulty seeing/reading maps or gauges and controls

within the vehicle. This can be checked using a Rosenbaum pocket chart.

Some limitations have been noted in testing using the Snellen chart. These include, but are not

limited to, the different number of letters per line, different spacing between lines, the specific

use of letters, and the spacing between letters.43 A trend in the field of eye care has been to

use a newer chart called the Early Treatment Diabetic Retinopathy Study (ETDRS) that in some

studies of eye diseases appears to be more accurate.44 The ETDRS chart improves on the

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

letters.

Visual Fields

The examiner sits or stands 3 feet in front of the patient, at the individual’s eye level. The

patient is asked to close his or her right eye, while the examiner closes his or her left eye. Each

fixes on the other’s nose.

The examiner then holds up a hand in each visual field simultaneously, with a random number

(usually one or two) of fingers in each of the four quadrants, and asks the patient to state the

total number of fingers. With the fingers held slightly closer to the examiner, the patient has a 

wider field of view than the examiner. Provided that the examiner’s visual fields are within

normal limits, if the examiner can see the fingers, then the patient should be able to see them

unless he or she has a visual field defect.

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

The examiner indicates any visual field defects by shading in the area of defect on a visual field

representation.
44

Rapid Pace Walk

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

path, turn around, and walk back to the starting point as quickly as possible. If the older adult

normally walks with a walker or cane, he or she may use it during this test. The total walking

distance is 20 feet.

The examiner begins timing the individual when he or she picks up the first foot, and stops

timing when the last foot crosses the finish mark. This test is scored by the total number of

seconds it takes for the older adult to walk 10 feet and back.42

In addition, the examiner should indicate on the scoring sheet whether the older adult used a 

walker or cane. Scores longer than 9 seconds are associated with an increased risk of at-fault

motor vehicle tasks.33

Get Up and Go

Instructions37

Ask the patient to perform the following series of maneuvers. 

1. Sit comfortably in a straight-backed chair.

2. Rise from the chair.

3. Stand still momentarily.

4. Walk a short distance (approximately 10 feet/3 meters).

5. Turn around.

6. Walk back to the chair.

7. Turn around.

8. Sit down in the chair.

Scoring

Observe the patient's movements for any deviation from a confident, normal performance. Use

the following scale. 

1 = Normal

2 = Very slightly abnormal

3 = Mildly abnormal

4 = Moderately abnormal 

5 = Severely abnormal

"Normal" indicates that the patient gave no evidence of being at risk of falling during the test or

at any other time. "Severely abnormal" indicates that the patient appeared at risk of falling

during the test. Intermediate grades reflect the presence of any of the following as indicators of

the possibility of falling: undue slowness, hesitancy, abnormal movements of the trunk or upper

limbs, staggering, or stumbling.
45

A patient with a score of 3 or more on the Get Up and Go Test is at risk of falling.

Functional Range of Motion

To test the functional range of motion for an older adult, ask him or her to perform the below

listed motions bilaterally.

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

same thing for the other side.”

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

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

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

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

other foot.”

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

The test is scored by evaluating the motion as either within normal limits or not within normal

limits. The latter means that range of motion is done with excessive hesitation, pain, or very

limited range of motion.

Maze Test

The Maze Test was developed as a pencil and paper test of attention, visuoconstructional

ability, and executive functions of planning and foresight. The participants compete a simple

demonstration maze first in order to establish the rule set, then complete the Maze Task.

Performance is measured in time (in seconds), using a stop watch, and the total number of

errors. Errors are determined by the number of times the participant enters a dead-end or fails

to stay in the lines. Time to administer is 1–4 minutes. The Maze Test is in Appendix C; it should

be printed on an 8 × 11” paper with the Maze Test at least 5.5” square and the practice 4.5”.

The Maze Test is placed in front of the participant, and the examiner states, “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 of the maze (point to the exit). Draw a line representing the

route from the start to the exit of the maze. Don’t run into any dead ends (point to a dead end)

or cross any solid lines (point to a solid line). Go!” The instructions can be repeated, and the

administrator should correct any rule breaks. There is a limit of 3 minutes for the Maze Test. If

the maze has not been completed in this time, discontinue.

Montreal Cognitive Assessment (MoCA)

The MoCA is designed as a rapid screening tool that measures attention and concentration,

executive functions, memory, language, visuoconstructional skills, conceptual thinking,

calculations, and orientation. Time to administrator is about 10 minutes.
46

The highest possible score is 30, with a score of 26 or above considered normal. One point

should be added for individuals with 12 years or fewer of formal education. A score of 18 or less

should raise concerns about driving safety.

The original version and directions are in Appendix C.

Trail-Making Test, Part B

This test of general cognitive function specifically assesses working memory, visual processing,

visuospatial skills, selective and divided attention, and psychomotor coordination. In addition,

numerous studies have demonstrated an association between poor performance on the TrailMaking Test, Part B, and poor driving performance.36

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

(A–L) randomly arranged on a page. This test is scored by overall time (seconds) required to

complete the connections accurately. The examiner points out and corrects mistakes as they

occur; the effect of mistakes, then, is to increase the time required to complete the test. This

test usually takes 3–4 minutes to administer.

The examiner administers the test to the individual, stating, “Now I will give you a paper and

pencil. The numbers 1 through 13 and the letters A through L are scattered across the page.

Starting with 1, draw a line to A, then to 2, then to B, and so on, alternating back and forth

between numbers and letters until you finish with the number 13. I’ll time how fast you can do

this. Are you ready? Go.” The examiner records the time to complete.42

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).
47

Test Sequence

Although these tests may be administered in any order, the following sequence is

recommended: (Note that the MoCA incorporates the Trail-Making Part B, and Clock Drawing).

1. Visual fields by confrontation testing

2. Snellen E Chart

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.
48

References

1. Foley, D. J., Heimovitz, H. K., Guralnik, J. M., & Brock, D. B. (2002, August). Driving 

life expectancy of persons aged 70 years and older in the United States. 

American Journal of Public Health, 92, 8, 1282-9.

2. Transportation Research Board. (in press). A Taxonomy and Terms for 

Stakeholders in Senior Mobility. Washington, DC: Author.

3. Dickerson, A. E. (2013). Driving assessment tools used by driver rehabilitation 

specialists: survey of use and implications for practice. American Journal of 

Occupational Therapy, 67, 564–573.

4. Dickerson, A. E., Brown, D., Ridenour, C. (2014). The predictive validity of 

screening and assessment tools for driving: a systematic review. American 

Journal of Occupational Therapy, 68, 670–680.

5. Bédard, M., & Dickerson, A. E. National Highway Traffic Safety Administration, & 

American Occupational Therapy Association. (2014). Consensus statements for 

screening and assessment tools. Occupational Therapy Health Care, 28(2), 127–

131. doi: 10.3109/07380577.2014.903017.

6. Bédard, M., Weaver, B., Darzins, P., & Porter, M. M. (2008). Predicting driving 

performance in older adults: We are not there yet! Traffic Injury Prevention, 9(4), 

336–341.

7. Baldock, M.R. J., Mathias J., McLean J., & Berndt, A. (2007). Visual attention

as a predictor of on-road driving performance of older drivers. Australian 

Journal of Psychology, 59, 159–168.

8. Carr, D. B., Barco P. P., Wallendorf, M., J., et al. (2011). Predicting road test

performance in drivers with dementia. Journal of the American Geriatrics Society,

59, 2112–2117.

9. Classen, S., Witter D. P., Lanford D. N., Okun, M. S., Rodriguez, R. L., Romrell, J., ..., 

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.

10. Shinar, D., & Schieber, F. (1991). Visual requirements for safety and mobility of 

older drivers. Human Factors, 33(5), 507–519.

11. Carr, D. B. (1993). Assessing older drivers for physical and cognitive

impairment. Geriatrics, 48(5), 46–51.
49

12. Munro, C. A., Jefferys, J., Gower, E. W., Munoz, B. E., Lyketsos, C. G., Keay, L., ... 

Bandeen-Roche, K. (2010). Predictors of lane-change errors in older drivers. Journal 

of the American Geriatrics Society, 58, 457–464.

13. Uc, E. Y., Rizzo. M., Johnson, A., . M., Dastrup, E., Anderson, S. W., & Dawson, J. D. 

(2009). Road safety in drivers with Parkinson disease. Neurology, 73, 2112–2119.

14. Wood, J. M., Anstey, K., J., Kerr, G. K., Lacherez, P. F., & Lord, S. (2008). A 

multidomain approach for predicting older driver safety under in-traffic road

conditions. Journal of the American Geriatrics Society, 56, 986–993.

15. McGwin, G. Jr., Sarrels, S. A., Griffin, R., Owsley, C., & Rue, L. W. 3rd. (2008, 

November). The impact of a vision screening law on older driver fatality rates.

Archives of Ophthalmology, 126(11), 1544-7 

16. Mennemeyer, S. T., Owsley, C., & McGwin, G. Jr. (2013). Reducing older driver 

motor vehicle collisions via earlier cataract surgery. Accident Analysis & 

Prevention, 61, 203–211.

17. Wood, J. M., & Carberry, T. P. (2006). Bilateral cataract surgery and driving 

performance. British Journal of Ophthalmology, 90(10), 1277-1280.

18. Owsley, C., McGwin, G. Jr., Sloane, M., Wells, J., Stalvey, B. T., & Gauthreaux, S. 

(2002). Impact of cataract surgery on motor vehicle crash involvement by older 

adults. Journal of the American Medical Association, 288(7), 841-289.

19. Dobbs, B. M. (2002, February). Medical Conditions and Driving: Current Knowledge.

(NHTSA Contract Number DTNH22-94-G-05297) . Barrington, IL: Association for the 

Advancement of Automotive Medicine. 

20. Owsley, C., & Ball, K. (1993). Assessing visual function in the older driver.

Clinics in Geriatric Medicine, 9(2), 389–401.

21. Classen, S., Dickerson, A. E., & Justiss, M. (2012). Occupational Therapy Driving 

Evaluation: Using Evidence-Based Screening and Assessment Tools. In: M. J. 

Maguire & E. Schold Davis (eds.), Driving and Community Mobility: Occupational

Therapy Strategies Across the Lifespan. Bethesda, MD: AOTA Press. 

22. Colsher, P. L., & Wallace, R. B. (1993). Geriatric assessment and driver 

functioning. Clinics in Geriatric Medicine, 9(2), 365–375.

23. Goetz, C. G. (1999). Textbook of Clinical Neurology, 1st ed. Philadelphia: W. B. 

Saunders Company. 
50

24. Beers, M. H., & Berkow, R. (eds). (2000). Aging and mental health. In: The Merck

Manual of Geriatrics. Whitehouse Station, NJ: Merck & Co., Inc. 

25. Hartley, A. A. (1992). Attention. In F. I. M. Craik & T. A. Salthouse (eds). The 

Handbook of Aging and Cognition. Hillsdale, NJ: Erlbaum. 

26. Madden D. J., Turkington T. G., Provenzale, J. M., Hawk, T. C., Hoffman, J. M., & 

Coleman, R. E. (1997). Selective and divided visual attention: age-related

changes in regional cerebral blood flow measured by H215O PET. Human Brain 

Mapping, 5, 389–409.

27. Elliot, R. (2003). Executive functioning and their disorders. British Medical Bulletin,

65, 49–59.

28. Barkley, R. A. (2012). Executive Functions: What They Are, How They Work,

and Why They Evolved. New York: Guilford Publications, Inc.

29. D’Ambrosio, L. A., Coughlin, J. F., Pratt, M. R., & Mohyde, M. (2012). The 

continuing and growing importance of mobility. In: J. Coughlin & L. A. D’Ambrosio, 

(eds.), Aging America and Transportation: Personal Choices and Public Policy. New 

York: Springer Publishing Co. 

30. Eby, D. W., Molnar, L. J., Shope J. T., & Dellinger, A. M. (2007). Development 

and pilot testing of an assessment battery for older drivers. Journal of Safety 

Research, 38,535–543.

31. Owsley, C., Stalvey, B., Wells, J., & Sloane, M. E. (1999). Older drivers and

cataracts: Driving habits and crash risk. The Journals of Gerontology, Series A: 

Biological Science and Medical Science, 54A, M203–M211.

32. Nasredinne, Z. (2007). Frequently Asked Questions. (Web page). Retrieved from the 

MOCA web site at www.mocatest.org/faq/

33. Staplin, L., Gish, K., . W., & Wagner, E., K. (2003). MaryPODS revisited: updated 

crash analysis and implications for screening program implementation. Journal 

of Safety Research, 34, 389–397

34. Freund, B., Gravenstein, S., & Ferris, R. (2002). Use of the clock drawing test as a 

screen for driving competency in older adults. Presented at the American

Geriatrics Society Annual Meeting, Washington, DC, May 9, 2002.

35. 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. 
51

36. 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.

37. Mathias, S., Nayak, U. S. L., & Isaacs, B. (1986). Balance in elderly patients: the “getup and go” test. Archives of Physical Medicine and Rehabilitation, 67, 387-389.

38. Classen, S., McCarthy D. P., Shechtman, O., Awadzi, K. D., Lanford, D. N., Okun, M. S., 

... Fernandez, H. H. (2009). Useful field of view as a reliable screening measure of 

driving performance in people with Parkinson's disease: results of a pilot study. 

Traffic Injury Prevention, 10, 593–598.

39. Weaver, B., Bédard. M., McAuliffe, J., & Parkkari, M. (2009). Using the

Attention Network Test to predict driving test scores. Accident Analysis & 

Prevention, 41, 76–83.

40. Visual Awareness Research Group, Inc. What Is UFOV? A Breakthrough In Cognitive 

Assessment and Rehabilitation (Web page). Retrieved from the Visual Awareness 

website at www.visualawareness.com/Pages/whatis.html

41. TransAnalytics Health & Safety Services. (2015). [Driving Health Inventory] and UFOV 

(Web page). Retrieved from the TransAnalytics website at 

http://drivinghealth.com/screeningassessment.html

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

Older People Notebook (Report No. DOT HS 808 853). Washington, DC: National

Highway Traffic Safety Administration. 

43. VectorVision. (2015). ETDRS Acuity (Web page). Retrieved from the 

VectorVision website at

www.vectorvision.com/html/educationETDRSAcuity.html 

44. Falkenstein, I. A., Cochran, D. E., Azen, S. P., Dustin, L., Tammewar, A.M., Kozak, I., & 

Freeman, W. R. Comparison of visual acuity in macular degeneration patients 

measured with Snellen and early treatment diabetic retinopathy study charts. 

Ophthalmology, 115(2), 319–323.
52

CHAPTER 4 CLINICAL INTERVENTIONS

Key Points

• The goal of clinical evaluation is to identify, correct, or stabilize any functional deficits that

may impair the older adult’s driving performance and to consider referral to a driver

rehabilitation specialist (DRS), if appropriate

• Screening for visual field cuts is important, because most older adults with visual field loss

are unaware of the deficit until it becomes quite significant.

• Failure to pass any measure of cognition in the Clinical Assessment of Driver-Related Skills

(CADreS) toolbox should elicit a referral to provide opportunities for older adults to

optimize cognitive function and perhaps explore their potential to continue to drive safely.

Local resources will vary and may include occupational therapy, speech-language

pathologists, neuropsychologists, driving rehabilitation specialists, or other medical

specialists.

• If the only problems are with motor and/or somatosensory areas, these individuals should

be referred to a DRS to take advantage of advancements in technology and possible

adaptive equipment for the vehicle.

Despite encouragement, Mr. Phillips (introduced in previous chapters) hesitates to go through

the assessment tools you recommend from the Clinical Assessment of Driver Related Skills

(CADReS) toolbox. He states, “I don’t see the need for it.” You discuss your concerns for his

safety and explain how to access NHTSA’s Driving Safely While Aging Gracefully online selfassessment as well as provide a copy of the Am I a Safe Driver? handout to take home

(www.nhtsa.gov/people/injury/olddrive/Driving%20Safely%20Aging%20Web/index.html). You

also counsel Mr. Phillips using The Hartford’s We Need to Talk brochure

(www.thehartford.com/mature-market-excellence/family-conversations-with-older-drivers). 

Mr. Phillips agrees to allow his son to observe his driving, and you advise the son on how to

access the online Fitness-to-Drive screening measure (http://ftds.phhp.ufl.edu/) as well as a 

print copy of NHTSA’s How to Understand & Influence Older Drivers (or the How to Assist the

Older Driver handout (see Appendix B).

You document all of this in Mr. Phillips’ record and schedule a follow-up appointment. At Mr.

Phillips’ next visit, you ask him if he has had a chance to review the materials provided on his

last visit. He admits that he had another close call while driving, and his son states he observed

several driving errors, including turning left in front of an oncoming vehicle. These events have

motivated Mr. Phillips to complete the self-assessment. He believes the self-assessment

recommendation for further evaluation is a reasonable idea and is now willing to be assessed.

From the CADReS toolbox, Mr. Phillips takes 11 seconds to perform the Rapid Pace Walk. His

visual acuity is 20/50 on the right and 20/70 on the left. He has limited range of motion on neck

rotation, but his ankle plantar flexion and dorsiflexion are within normal limits. It takes him 182
53

seconds to complete the Trail-Making Test, Part B, and his clock-drawing test is scored as

“normal” for all seven criteria.

Now that Mr. Phillips has been assessed, what does his performance indicate? This chapter

provides information to support interpretation of CADReS assessment outcomes. However,

recommendations stated here are subject to individual State reporting laws and State licensing

agency requirements. Links to individual State requirements are provided in chapter 8.

Examples of interventions that may help manage and treat any functional deficits identified

through CADReS are also provided.

Remember that the goal of clinical evaluation is to identify, correct, or stabilize any functional

deficits that may impair the older adult’s driving performance and to refer to a DRS, if

appropriate (see Chapter 5). Contributing medical conditions, and potential medication effects

as discussed in the Beers criteria1 are discussed further in chapter 9.

The Clinical Assessment of Driver-Related Skills(CADReS)

Motor and sensory ability, vision and cognition are all important for driving. However, they may

not be equally important for a particular older adult. Depending on the older adult’s medical

conditions, one area of function may warrant greater attention than another. Depending on the

assessment outcome in each area, the outcome action may be different.

Vision

Screening for visual field cuts is important, because most older adults with visual field loss are

unaware of the deficit until it becomes quite significant, especially if their medical condition

warrants examination (e.g., stroke, macular degeneration). In most cases, referral to an eye

specialist is the best outcome if there is any cause for concern.

Contrast sensitivity is a good screen for all older adults, followed by providing appropriate

education and information to the older adult driver and caregiver on how to compensate for a 

deficit. A problem solely with contrast sensitivity does not merit a report to the State licensing

agency.

Visual Acuity: Although many States currently require far visual acuity of 20/40 for an

unrestricted license, there is little evidence that links static visual acuity to crash risk. In fact,

studies undertaken in some States have demonstrated that there is no increased crash risk

between 20/40 and 20/70, resulting in several new State requirements.2 However, some

studies have found that States that require visual testing for license renewal for older adults

have lower crash rates.3,4

General recommendations on visual acuity and driving are given below, but note that they are

subject to each State’s licensing requirements.

For corrected visual acuity worse than 20/40 (i.e., more impaired), the clinical team member

should:
54

• Refer to a vision specialist (ophthalmologist or optometrist) for diagnosis and treatment (if

possible) of the underlying cause of vision loss. The older adult should obtain and use the

appropriate glasses or contact lenses. If the older adult is not currently under the care of a 

specialist, referral is recommended.

• Recommend that the older adult reduce the impact of decreased visual acuity by

restricting travel to low-risk areas and conditions (e.g., familiar surroundings, non-rush

hour traffic, low speed areas, daytime, and good weather conditions). We recognize that

the evidenced-based literature on restriction is equivocal, but still believe this to be good

practice.

• Be aware that the older adult may require more frequent (e.g., yearly) assessment of

visual acuity to detect further visual decline caused by chronic, progressive diseases such

as age- related macular degeneration and glaucoma.

For corrected visual acuity worse than 20/100 (i.e., more impaired), the clinical team member

should:

• Follow the recommendations above.

• Recommend that 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. Check to

see if low-vision driving rehabilitation is available in your area.

Visual Fields and Contrast Sensitivity: Research shows that visual field loss can significantly

affect driving safety. In a study of 10,000 volunteer California license applicants, visual fields

deteriorated significantly among drivers >60 years old. In addition, drivers with binocular visual

field loss had driving crash and conviction rates more than twice as high as age- and gendermatched drivers with normal visual fields.5 In another study, most drivers with moderate

binocular visual field loss (i.e., horizontal field ranging from 78 to 165 degrees) displayed

acceptable on-road driving skills.6 Recently, in studies focused on a more homogeneous group

of older adults with a specific condition known to impair visual fields (e.g., glaucoma),

increased crash risk was correlated with moderate to severe field defects.7,8

Although an adequate visual field is important for safe driving, there is no conclusive evidence

to define “adequate.” Most likely, this varies widely from person to person and may depend on

the presence of other comorbidities. For example, a driver with a restricted visual field but

excellent scanning ability may drive as safely as a driver with an unrestricted visual field but

poor neck rotation.9 Screening for visual field cuts is important, because most older adults with

visual field loss are unaware of the deficit until it becomes quite significant, especially if their

medical condition warrants examination (e.g., stroke, macular degeneration).

General recommendations on visual field and driving are stated below. Physicians and other

clinical team members should be aware of and adhere to their States’ specific visual field

requirements.
55

For visual field defects noted on confrontation testing, the clinical team member should:

• Refer to a vision specialist (ophthalmologist or optometrist) for diagnosis and

treatment (if possible) of the underlying cause of vision loss. In addition, automated

visual field testing may help define the extent of the defect; ophthalmologists have a 

number of useful instruments for measuring visual fields.

• For older adults with a binocular visual field of questionable adequacy (as deemed

by clinical judgment), strongly recommend an on-road assessment performed by a 

DRS. Through driving rehabilitation, the older adult may learn how to compensate

for decreased visual fields. In addition, the DRS may prescribe equipment such as

enlarged side- and rear-view mirrors and train the older adult in their use.

• Consider contrast sensitivity testing, which is a good screen for all older adults,

followed by providing education and information to both the older adult driver and

caregivers on how to compensate for a deficit by minimizing low-light driving

conditions (at night, in bad weather). Vision specialist referral is desirable, but a 

problem solely with contrast sensitivity does not merit a report to the State licensing

board.

Visual fields may need to be retested in the future for visual field defects caused by chronic,

progressive diseases.

Cognition

Screening for cognitive deficits is essential, along with careful interpretation of the findings.

There is clear evidence that the Mini–Mental State Exam is not related to outcomes in crashes

or driving abilities.10,11However, the tools recommended in the CADreS have been particularly

chosen to provide reasonable information in the office-based setting on skills known to be

related to driving. Any cognitive screen that clearly demonstrates the older adult has moderate

or severe cognitive impairment is sufficient evidence for a provider to recommend driving

cessation.12 No further referral is necessary for evaluation of driving performance. A referral to

a general practice occupational therapist for further evaluation of IADLs or to a 

neuropsychologist for appropriate testing and diagnosis is warranted and may be an important

resource for improving or extending quality of life and safe mobility.

For older adults with mild cognitive impairment or early dementia (with or without motor

impairment), more information should be obtained to explore the reversibility of the cognitive

impairment, the etiology and the potential and strategies for compensation, if memory loss is

not severe. Failure to pass any measure of cognition in the Clinical Assessment of DriverRelated Skills (CADreS) toolbox should elicit a referral to provide opportunities for older adults

to optimize cognitive function and perhaps explore their potential to continue to drive safely.

Local resources will vary and may include occupational therapy, speech-language pathologists,

neuropsychologists, driving rehabilitation specialists, or other medical specialists. Although the

following cognitive tests are scored separately, interventions are recommended if the older

adult reaches designated cut-off values (as described below) on any of them. Potential
56

interventions will vary depending on the area of cognitive impairment demonstrated

(impulsiveness, judgment, memory, visuospatial, etc.).

Montreal Cognitive Assessment (MoCA): The 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. 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. One point is added for any individual who has 12 years or fewer of formal

education.13 In individuals with cognitive impairment, there was a significant relationship

between MoCA score and on-road outcome. Specifically, an individual was 1.36 times as likely

to fail the road test with each 1-point decrease in MoCA score, with a score of 18 or less of

concern regarding driving safety.14 The MoCA is free for public use as it is not copyrighted, and

is widely available in multiple languages via their website.

Trail-Making Test, Part B (TMT-B): A time for completion of >3 minutes (>180 seconds) indicates

a need for intervention,15 such as a review of causes for the abnormal result (e.g., dementia,

sedating medication, depression), and/or referral to a DRS. Numerous studies have

demonstrated an association between performance on the TMT-B and cognitive function

and/or driving performance. In a study of 1,700 drivers ≥65 years old who were applying for

renewal of their North Carolina driver’s licenses, TMT-B test results were strongly associated

with recent prior crash involvement.16 A study of 105 drivers in Nebraska 65 to 88 years old

showed that on-road driving performance significantly correlated to TMT-B performance

(correlation coefficient –0.42).17 Further data from the Maryland Pilot Older Driver Study18

demonstrated a significant correlation between TMT-B performance and future at-fault crash in

the license renewal sample.

Clock-Drawing Test, Freund Clock Scoring for Driving Competency: Any incorrect or missing

element on the Freund Clock Scoring criteria signals a need for intervention, such as a review of

causes for the abnormal result (e.g., dementia) and/or referral to a DRS.

Clock-drawing tests have been found to correlate significantly with traditional cognitive

measures and in some studies discriminate healthy individuals from those with dementia.19 Of

all the measures that have been correlated with impaired driving performance in older adults

with dementia, tests of visuospatial skill ability have had the highest predictive value.20 Several

versions of the clock-drawing test are available, each varying slightly in the method of

administration and scoring.21 The Freund Clock Scoring is based on seven “principal

components” (as outlined on the CADReS Score Sheet in Appendix C) that were derived by

analyzing the clock drawings of 88 drivers ≥65 years old against their performance on a driving

simulator.22 Errors on these principal components correlated significantly with specific

hazardous driving errors, signaling the need for formal driving evaluation.

Maze Test: The Snellgrove Maze Test measures only those skills required for safe driving:

attention, visuoconstructional skills, and executive functions of planning and foresight. In a 

sample of older adults with mild cognitive impairment or early dementia, the Maze Test time
57

and error scores predicted on-road driving competence with high sensitivity, specificity, and

overall accuracy.23

Again, these tests should not be the sole determinant as to whether an older adult should

drive.24 However, impairments on these tests are associated with increased risk, and referral

for further evaluation, such as performance-based road testing, should be considered. In

addition, it is unlikely that future fitness-to-drive evaluations will rely on one test but likely will

use a battery of tests such as are currently being tested as part of the CANDRIVE II/Ozcandrive

multicenter prospective cohort study or the Rockwood Battery.25,26

If the older adult’s performance warrants interventions, the clinician should:

• Gather (or refer for) more information to include detailed history and examination of

cognitive and functional abilities, as needed.

• Identify or interview a reliable informant (e.g., family member or caregiver) who

can assist with the evaluation.

• Work with the older adult’s clinical team for further diagnostic evaluation aimed at

identifying the cause of the cognitive decline.

• Evaluate for reversible causes of cognitive decline. Based on history, examination, and

cognitive testing, order laboratory tests as needed, including CBC for anemia or

infection, comprehensive metabolic profile for electrolyte imbalance and renal function,

finger stick for blood sugar, pulse oximetry for hypoxia, TSH for hypothyroidism, liver

function tests, vitamin B12 and folate for vitamin deficiency, and based on prior

probability, noncontrast CT or MRI scan.

• Screen for depression and treat if positive.27

• Review the older adult’s medication regimen and the adverse effects of the

medications, and ask the older adult and caregivers about the onset of cognitive decline

as related to new medications or dosage changes. Older adults may be unaware of the

potential effects of polypharmacy on cognitive ability and driving.

• If possible, treat the underlying disorder and/or adjust the medication regimen as

needed. Remember, it is critical that every older adult have a complete evaluation to

identify the underlying cause(s) and receive proper treatment.

• If needed, refer the older adult to a neurologist, psychiatrist, or neuropsychologist for

additional diagnosis or treatment as needed.

• Recommend a comprehensive driving evaluation performed by a DRS to assess the older

adult’s performance in the actual driving task. An initial comprehensive on-road

assessment with retesting at regular intervals is particularly useful for those with

progressive dementing illnesses.

• Strongly recommend that the older adult begin exploring alternative forms of

transportation now, and encourage him or her to involve caregivers in these discussions.

See the Plan for Older Drivers’ Safety (PODS) diagram on the next page.
Plan for Older Drivers’ Safety (PODS)

SCREENING EVALUATION RESULTS

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?

Older adult/caregiver concerns?

Not At Risk: Minimal to No 

Positive Risk Factors Identified

Discuss transportation plans and 

health maintenance

At Risk: Positive Risk Factors Identified

Step 2: Use Clinical Assessment of Driving Related Skills

(CADReS) to Identify Impairments and Seek Remediation

General:

Driving History, IADLs

Questionnaire,

Medication Change

Vision:

Fields, Acuity,

Contrast

Cognitive:

MoCA, Trails B,

Clock Drawing,

Maze

Motor/Sensory:

Range of Motion,

Proprioception, Get Up

and Go, Rapid Pace

Walk

Step 3: Analysis of Screen and CADreS Not At Risk

At Risk

Clinical Specialist Evaluation and Intervention* Driving Rehabilitation Specialist Evaluation

Medical Conditions

Uncompensated

or In Recovery Phase

Medical

Conditions

Optimized

Rehab/Intervention

Needed:

Refer to a Specialist

Vehicle Adaptation/

Training Needed:

Refer to Available

Resources

Step 4: Driving Deficit Results

Driving Deficit Identified No Significant Driving Deficit Identified: Fit To Drive

Discuss transportation plans and health maintenance

Fit to Drive with

Restrictions:

Perform Interval

Re-evaluations

Cessation of Driving:

Counsel on

Alternative Modes of

Transportation; 

Call for Family Meeting

No Driving Yet:

Refer for Recovery

Plan to Revisit Driving

Repeat Step 3

IADLs Instrumental Activities of Daily Living

MoCA Montreal Cognitive Assessment

Pathway step may be repeated if progressive assessment necessary

Clinical specialists may include medicine, nursing, rehabilitation, pharmacy

and social work, or others, depending on the clinical setting

Time Lapse

*

58
59

Motor Ability

If the only problems are with motor and/or somatosensory areas, these individuals should

be referred to a DRS to take advantage of advancements in technology (see Chapter 5). For

older adult drivers who are cognitively intact, learning to compensate for motor and/or

somatosensory deficits warrants getting expert advice on strategies, available vehicle

adaptations or devices, the type best suited for individual issues, and the training to use

them for continued driving. Although the following tests are scored separately, interventions 

are recommended if the older adult shows significant difficulty as described below on any of

the individual tests.

Rapid Pace Walk or the Get Up and Go: Because each of these measure overall lower

extremity strength, coordination, and proprioception in a functional task, they also serve to

screen how well an older adult can function despite individual motor or range of motion

deficits. Older adults with a history of falls have been noted to be at increased risk of motor

vehicle crashes.28A Rapid Pace Walk score >9 seconds should trigger a referral to physical

therapy for evaluation and treatment, as well as further evaluation by the clinical team for

potential causes and treatments. A score of ≥3 on the Get Up and Go test should similarly be

considered an indication for referral and treatment. If functional disability is quite severe, it

may be wise for the older adult to refrain from driving until such time as their condition can

be optimized or adaptive devices (e.g., hand controls) can be installed and the older adult can

be trained in their use.

The clinical team member should also be aware that the amount of strength required for safe

driving may depend on what vehicle is being driven. For example, an older adult who drives 

an older car that does not have power steering or who operates a large vehicle (e.g., an RV,

which is not uncommon for retirees) may require greater strength to safely drive the vehicle.

Functional Range of Motion: If the older adult’s range of motion is not within normal limits 

(i.e., range of motion is very limited, or good only with excessive hesitation or pain), this may

signal the need for intervention. The inability to recognize an object presented directly 

behind an older adult (e.g., impaired cervical range of motion) has been correlated with

increased risk of a motor vehicle crash.18

Scoring for range of motion is based on simple dichotomous outcomes (normal versus

impaired) for several reasons:

• Most clinicians are neither trained in use of goniometers nor have the devices in

the office setting.

• Range-of-motion requirements vary with automobile design, and thus it is difficult

to specify exact requirements. Vehicle adaptation to compensate is also possible.

• The impact of limited range of motion on driving safety also depends on other

functions (as discussed in the visual fields section).
60

• As with all the other tests from the CADReS toolbox, an older adult’s poor

performance should be a stimulus for optimization of function rather than for

immediate driving restrictions.

If the older adult’s performance on this test is not within normal limits, the clinician should be

certain to elicit the reason: Do these movements cause muscle or joint pain? Does the older

adult complain of tight muscles or stiff joints? Do these movements cause a loss of balance?

Knowing the answers to these questions will help in management of the older adult’s physical

limitations.

If the older adult’s performance warrants interventions, the clinical team member should:

• Encourage the older adult to drive a vehicle with power steering and automatic

transmission, if he or she does not already do so.

• Recommend that the older adult maintain or begin a consistent regimen of general

physical activity, including cardiovascular exercise, strengthening exercises, and

stretching. Excellent resources are available through the Go4Life program sponsored by

the National Institute on Aging (https://go4life.nia.nih.gov/).

• Refer the older adult to a physical therapist as needed for training and exercises to

improve strength and/or range of motion, or to an occupational therapist if impairment

is affecting daily tasks.

• Check with the older adult’s primary care provider on providing effective pain control if

pain is limiting range of motion or mobility. This may include prescribing analgesics or

medications that treat the underlying disorder (e.g., a urate-lowering drug for gout or Ldopa for Parkinson’s disease), or changing the time that the older adult takes pain

medications so that relief is achieved before driving. Note that while many analgesics

may improve driving through symptom relief, others (including narcotics and skeletal

muscle relaxants) have the potential to impair driving ability and may be more

deleterious to driving performance than the instigating symptoms. These medications

should be avoided, if possible, or prescribed at the lowest effective dose. Older adults

should be advised to refrain from driving when first taking these medications until they

know whether the medications are tolerated well. Nonsedating and nonpharmacologic

strategies for pain management are preferred whenever possible.

• Refer the older adult to a specialist for management of any joint disease, podiatry

issues, or neuromuscular problems. Individuals who have had a stroke may have

residual deficits that interfere with their handling of car controls and should also be

referred.
61

• Recommend an comprehensive driving assessment (including an on-road assessment)

performed by a DRS. A comprehensive on-road assessment is particularly useful for

assessing the impact of physical fatigue, flexibility, and pain on the older adult’s driving

skills. The DRS may prescribe adaptive devices as needed (e.g., a spinner knob on the

steering wheel to compensate for poor hand grip or an extended gear shift lever to

compensate for reduced reach) and train the older adult in their use.

Next Course of Action

After administering CADReS assessment tools, three courses of action are possible (see also

Plan for Older Drivers’ Safety, Chapter 1):

• If the older adult performs well in all three areasfrom the CADReS toolbox, he or she

can be advised that there are no medical contraindications to safe driving and offered

counseling regarding health maintenance and future transportation plans. Older adults

should be counseled on health maintenance by providing information such as Ten Tips

for Aging Well and Tips for Safe Driving handouts, and the clinician should periodically

follow-up on the older adult’s driving safety. However, if there is evidence of a new

onset of impaired driving behaviors (e.g., a decline from baseline) as described by the

older adult and/or caregiver, further evaluation may be warranted despite a normal

score.

• If the older adult performs poorly on any area of CADReS, but on clinical specialist

evaluation the causes of poor performance are medically correctable, medical

treatment and intervention should be pursued until the older adult’s function has been

optimized. The older adult may need to be counseled to limit driving as treatment

proceeds. The level of improvement should be assessed with repeat administration of

CADReS tools. Once the older adult performs well in all areas, he or she should be

counseled on health maintenance (as above).

• If the poor performance on the CADReS toolkit cannot be medically corrected, or if no

further potential for improvement with medical interventions is anticipated, the older

adult should be referred to a DRS.

The CADReS toolbox is useful when supporting an in-office assessment, but it does not

evaluate the older adult’s performance in the actual driving task. Results, even if abnormal,

are not sufficient to recommend driving cessation, except for vision and moderate/severe

cognitive impairment. In this case, comprehensive driving evaluation with an on-road

assessment performed by a DRS is needed. The DRS can more specifically determine the

older adult’s level of driving safety and potentially correct his or her functional impairments,

if possible, through adaptive techniques or devices (see Chapter 5 and Appendix C).

State licensing policies are evolving, with each State establishing guidelines for issuing and

revoking driver’s licenses. Health care providers must be aware of the guidelines in their State

and ideally other States in which the older adult drives, as available through chapter 8. The

first responsibility, regardless of the State processes, is the identification of drivers who
62

exhibit a level of impairment potentially incompatible with continued driving. For those

individuals, the message must be clear that driving must stop until further information is

obtained. If the concern is medical (e.g., seizures, confusion), the individual must not drive

until medical reports meet the State requirements for continued driving. If function on the

road is in question, a comprehensive driving evaluation by a DRS provides the necessary

evaluation data and intervention plan.

The recommendation for further evaluation is typically the result of a series of steps (as

described in this chapter). Therefore, the driver should be informed both verbally and in

writing that declining recommendations for further evaluation may put the patient and/or the

public at risk for a crash or injury and could possibly start the State process for license 

revocation, including potential reporting to the State’s Medical Review Board.

There will be cases when, in his or her best ethical judgment, the health care provider

believes that the risk is very high and that the older adult will continue to drive despite the

recommendation to stop driving. Clinicians must follow State laws for reporting to State

licensing agencies and program/facility guidelines for informing the older driver and/or

caregivers. Depending on the State’s reporting laws, clinicians may be legally responsible for

reporting “unsafe” drivers to the State licensing agency (for descriptions of legal and ethical

responsibilities, see Chapters 7 and 8). In terms of best practice, the older adult should also

be informed about this report.

The Copilot Phenomenon

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

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

adults with cognitive impairment may rely on passengers to tell them where to drive and

how to respond to driving situations, whereas older adults with vision deficits may ask

passengers to alert them to traffic signs and signals.

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

older men with dementia, about 10% of the 59 subjects who were still driving relied on

copilots.29 Older adults should be advised to not continue driving unless they are capable of

driving safely without the use of a copilot. In many traffic situations, there is insufficient time

for the copilot to detect a hazard and alert the driver, and for the driver to then respond

quickly enough to avoid a crash. In such situations, the driver places not only himself or 

herself in danger but also the copilot and other passengers. Furthermore, the use of copilots

to meet standards for licensure raises questions of who, exactly, is licensed to drive; how the

presence of the copilot can be ensured; and what standards for medical fitness-to-drive

should be applied to the copilot.30
63

Older adults who are not safe to drive should be recommended to stop driving, regardless of

their need or use of a copilot. Copilots should not be recommended to unsafe drivers as a 

means to continue driving. Instead, efforts should focus on helping older adults find

alternative transportation for themselves and others who may depend on them. Conversely,

some safe drivers feel more comfortable driving with a passenger who provides company

and help with navigation. Although using a passenger to assist as a navigator is an acceptable

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

As long as older adult drivers have the ability to drive safely on their own, passenger assistance

in navigation is an acceptable and advisable practice.

References

1. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (2015, November). 

American Geriatrics Society updated Beers Criteria for potentially inappropriate 

medication use in older adults. Journal of the American Geriatrics Society, 63(11), 2227-

46.

2. National Highway Traffic Safety Administration. (2009, September). Driver fitness 

medical guidelines (Report No. DOT HS 811 210). Washington, DC: Author. Available at 

http://ntl.bts.gov/lib/31000/31100/31148/6061_MedicalReviewGuide_10-1_v2a.pdf

3. McGwin, G., Sarrels S. A., Griffin, R., Owsley, C., & Rue, L. W. 3rd. (2008). The impact of 

a vision screening law on older driver fatality rates. Archives of Ophthalmology,

126(11), 1544–1547.

4. Shipp, M. D. (1998). Potential human economic cost-savings attributable to vision

testing policies for driver license renewal, 1989–1991. Optometry & Vision Science, 75, 

103–118.

5. Johnson, C. A., & Keltner, J. L. (1983). Incidence of visual field loss in 20,000 eyes and

its relationship to driving performance. Archives of Ophthalmology, 101, 371–375.

6. Bowers, A., Peli, E., Elgin, J., McGwin, G. Jr., & Owsley, C. (2005). On-road driving with

moderate visual field loss. Optometry & Vision Science, 82, 657–667.

7. Szlyk, J. P., Mahler, C. L., Seiple, W., Edward, D. P., & Wilensky, J. T. (2005). Driving

performance of glaucoma patients correlates with peripheral visual field loss. Journal 

of Glaucoma, 14, 145–150.

8. McGwin, G. Jr, Xie, A., Mays, A., Joiner, W., DeCarlo, D. K., Hall, T. A., & Owsley, C. 

(2005). Visual field defects and the risk of motor vehicle collisions among patients 

with glaucoma. Investigative Ophthalmology & Visual Science, 46(12), 4437– 4441.
64

9. American Academy of Ophthalmology. (2006, March). Vision Requirements for Driving

(Policy statement, revised and approved by Board of Trustees). Washington, DC: 

Author.

10. Wheatley, D. J., Carr, D. B., & Marottoli, R. A. (2014). Consensus statements on driving 

for persons with dementia. Occupational Therapy in Health Care, 28, 132-139.

11. Carr, D. B., Duchek, J. M., Meuser, T. M., & Morris, J. C. (2006). Older adult drivers 

with cognitive impairment. American Family Physician, 73, 1029–1034. 

12. Iverson, D. J., Gronseth, G. . S., Reger, M. A., Classen, S., Dubinsky, R. . M., & Rizzo, M. 

(2010). Practice parameter update: Evaluation and management of driving risk in 

dementia (Report of the quality standards subcommittee of the American Academy of 

Neurology). Neurology, 74, 1316-1324. 

13. Nasreddine, Z. (2010). Montreal Cognitive Assessment Administration and

Scoring Instructions. Retrieved from the MOCA website at www.mocatest.org

14. Hollis, A., . M., Cuncanson, H., Kapust, L., . R., Xi, P. M., & O’Connor, M. G. (2015). Validity 

of the Mini–Mental State Examination and the Montreal Cognitive Assessment in the

prediction of driving test outcome. Journal of the American Geriatrics Society, 63(5), 

998–992.

15. Staplin, L., Gish, K. W., & Sifrit, K. J. Using cognitive status to predict crash risk: Blazing 

new trails? Journal of Safety Research, 48, 19–25.

16. Stutts, J. C., Stewart, J. R., & Martell, C. (1998). Cognitive test performance and

crash risk in an older driver population. Accident Analysis & Prevention, 30(3), 

337–346.

17. Tarawneh, M., S., McCoy, P. T., Bishu, R. R., & Ballard, J. L. (1993). Factors associated

with driving performance of older drivers. Transportation Research Record, 1405, 64–

71.

18. Ball, K. K., Roenker, D. L., Wadley, V. G., Edwards, J. D., Roth, D. L., McGwin, G. Jr., ... 

Dube, T. (2006). Can high-risk older drivers be identified through performance-based 

measures in a Department of Motor Vehicles setting? Journal of the American Geriatrics 

Society, 54, 77–84.

19. Royall, D. R., Cordes, J. A., Polk, M. J. (1998). Clox: An executive clock drawing task.

Journal of Neurology, Neurosurgery, and Psychiatry, 64, 588–594.
65

20. Reger, M. A., Welsh R. K., Watson G. S., Cholerton, B., Baker, L. D., & Craft, S. (2004). The 

relationship between neuropsychological functioning and driving ability in dementia: a 

meta-analysis. Neuropsychology, 18, 85–93.

21. Royall, D. R., Mulroy, A. R., Chiodo, L. K., & Polk, M. J. (1999). Clock drawing is 

sensitive to executive control: a comparison of six methods. Journals of Gerontology. 

Series B: Psychological Sciences and Social Sciences, 54B(5), 328–333.

22. Freund, B., Gravenstein, S., Ferris, R., Burke, B. L., & Shaheen, E. (2005). Drawing clocks

and driving cars. Journal of General Internal Medicine, 20, 240–244.

23. Snellgrove, C. (2005). Cognitive screening for the safe driving competence of older people 

with mild cognitive impairment or early dementia. Retrieved from the ATBS website 

atwww.atsb.gov.au/publications/2005/pdf/cog_screen_old.pdf.

24. Langford, J. (2008). Usefulness of off-road screening tests to licensing authorities when

assessing older driver fitness to drive. Traffic Injury Prevention, 9, 328–335.Eby D. W.,

& Molnar, L., J. (2010). Driving fitness and cognitive impairment: issues for physicians. 

Journal of the American Medical Association, 303(16), 1642–1643.

25. Stav W B., Justiss, M. D., & McCarthy D. P., (2008). Predictability of clinical assessments

for driving performance. Journal of Safety Research, 39, 1–7.

26. Knopman, D. S. (2001). Practice parameter: diagnosis of dementia (an evidence-based 

review). Report of the Quality Standards Subcommittee of the American Academy of

Neurology. Neurology, 56(9), 1143–1153.

27. Dugan, E., & Lee, C. M. (2013). Biopsychosocial risk factors of driving cessation findings 

from the health and retirement study. Journal of Aging Health, 25(8), 1313–1328.

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

dementia. Journal of the American Geriatrics Society, 48(8), 928–930.

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

independence and public safety. Medical Journal of Australia, 167, 406–407.
66

CHAPTER 5 THE DRIVER REHABILITATION SPECIALIST

Key Points

• A driver rehabilitation specialist (DRS) is a health care professional who is best

qualified to make a fitness-to-drive decision when the at-risk older adult has

functional impairments in physical, visual, or cognitive abilities.

• A comprehensive driving evaluation is completed by a DRS and includes clinical

assessment of underlying component abilities, a medical and driving history, an

on- road evaluation, and an alternative transportation plan if needed.

• Older adult driving programs vary in terms of typical providers, costs, availability,

required knowledge, services provided, and according to the level of complexity of

adaptive vehicles (i.e., basic, low tech, high tech), types of programs, and

outcomes.

• Not all older adults require the specialized services of a driving rehabilitation

specialist. Screening and assessment by appropriate clinical team members can

collect necessary information for evidenced-based decisions.

• Before referring to a DRS, advise the older adult about the reason for the referral, the

goals of the assessment and rehabilitation, the evaluation and tests that will be

done, and the expected out-of-pocket cost for these services. 

After scoring Mr. Phillips’ (introduced in previous chapters) performance on the CADReS toolbox

assessments, you discuss the results with him. You assure him that he scored well on the

cognitive tests, but that his performance on the visual and motor tasks indicates a need for

further evaluation and treatment. You recommend that Mr. Phillips make an appointment with

his ophthalmologist, whom he has not seen for over a year. You also recommend that he begin

exercising regularly by walking for 10-minute intervals, three times a day, and stretching gently

afterward. His son, who is present at the clinic visit, offers to exercise with him several times a 

week.

When Mr. Phillips arrives for his follow-up appointment, he is wearing new glasses. His vision

with the new glasses is 20/40 in both eyes. You retest his motor skills, and he is now able to

complete the Rapid Pace Walk in 8.0 seconds. His range of motion on finger curl and neck

rotation, however, remains restricted and his Trails B test has not improved. With Mr.

Phillips’ agreement, you refer him to a driver rehabilitation specialist (DRS) for an evaluation

and adaptive equipment, if necessary.

Although there may be improvement in visual, cognitive, or physical abilities, older adults may

still demonstrate functional impairments that affect their driving performance. In these cases, a 

driver rehabilitation specialist (DRS) is an excellent resource to explore solutions supporting

continued driving. A DRS can perform a comprehensive driving evaluation that includes indepth clinical assessment of functional abilities plus an on-road driving assessment. Based on
67

the older adult’s performance, a DRS develops a summary of the evaluation results and an

individualized plan for safe mobility. This plan may include any of the following:

• A recommendation for continued driving with or without restrictions (e.g., no

night driving, no highways)

• An “interval recommendation” for reevaluation because of progressive conditions

(e.g., early dementia, Parkinson disease). This may include a driving cessation plan

(see Appendix C).

• Intervention to restore abilities (e.g., improve range of motion, strength, or flexibility)

• Adaptive techniques or the use of devices to compensate for functional deficits 

(e.g., hand controls, left foot accelerator)

• A recommendation for the older adult driver to cease driving

This last, difficult recommendation typically is followed by a plan to explore resources,

alternative forms of transportation, and the supports the older adult requires (e.g., escort,

curb- to-curb, or door–to-door). An example may be found in Appendix C. For those unwilling

or unable to understand the cessation recommendation, caregivers should be provided with

strategies to prevent access to the car and to manage ongoing resistance and arguments

demanding access to the car. Other clinical team members may also be helpful when

supporting older adults and caregivers who lack insight.

This chapter provides information about driver rehabilitation, the clinical specialty that offers

comprehensive driving evaluation and planning, and what data is required to respond to the

question, “Can drive?” For the clinical team, this question may follow an interaction with

the older adult driver or a request from his or her caregiver. Physicians and nurse practitioners

in particular may be asked to respond if the older driver receives a letter from a Medical Review

Board, vehicle licensing agency, or law enforcement. An example may be found in Appendix C.

Health care providers may be asked to complete a State medical reporting form such as the

example found at http://dor.mo.gov/forms/1528.pdf.

The Driver Rehabilitation Specialist Defined

DRSs “provide clinical driving evaluations and driving mobility equipment evaluations and

intervention to develop or restore driving skills and abilities.”1

DRSs are often occupational therapists who have additional training in driver rehabilitation. In

addition, DRSs with underlying degrees in medical fields may come from backgrounds such as

physical therapy, kinesiotherapy, or psychology. Those with nonmedical backgrounds tend to

come from transportation and community mobility backgrounds, such as driving school

instructors.

Two national associations offer certification in driver rehabilitation. The Association for Driver

Rehabilitation Specialists (formerly Association of Driver Educators for the Disabled, still known

as ADED) requires education and experience qualifications and passing a certification

examination (www.aded.net/?page=215). Persons of varied backgrounds may apply for
68

certification through ADED. ADED also requires that the certified driver rehabilitation

specialists (CDRSs) renew their certification every 3 years by fulfilling a minimum amount of

contact hours. The American Occupational Therapy Association (AOTA) offers Specialty

Certification in Driving and Community Mobility (SCDCM) (www.aota.org/EducationCareers/Advance-Career/Board-Specialty-Certifications/Driving-Community-Mobility.aspx).This

portfolio-based professional certification is awarded on approved application by a credentialing

body at AOTA. The SCDCM includes a development plan and must be renewed, via application,

every 5 years. Only occupational therapists may apply through AOTA for certification for this

advanced level of achievement. Although many DRSs either hold certification or are in the

process of obtaining the necessary education and experience to sit for the examination, in most

States certification is not required to practice driver rehabilitation.

Functions of Driver Rehabilitation Specialists

DRSs evaluate the sensory (vision, proprioception), cognitive, and motor functional abilities

which support driving skills, and 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 impairment. 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 to support ongoing driving. Although driver 

rehabilitation programs vary, most typically consist of a comprehensive driving evaluation that

includes the following elements:

Clinical Driving Evaluation

• Clinical assessment, including review of driving history, driving needs, and license status;

review of medical history and medications; functional assessments of vision/perception;

physical abilities (may include range of motion, motor strength, coordination, sensation,

and/or reaction time); and cognition.

• On-road evaluation to determine degree of safety risk for driving, including assessment

of vehicle ingress/egress, mobility aid management (e.g., ability to transport a

wheelchair or scooter), vehicle preparation, vehicle control, adherence to traffic rules

and regulations, environmental awareness and interpretation, and consistent use of

compensatory strategies for visual, cognitive, physical, and behavioral impairments.

• Communication of assessment results and recommendations to the older adult, the

caregivers, and/or referring health care provider/agency. Although this is the most

frequent model, the process for communication of results may vary by program model

and local referral agreement. Variations include sending driving evaluation results to the

clinical team to relay to the older adult driver and caregivers:
69

o Return to driving with adaptive driving equipment and instruction after

installation and/or driver retraining using a vehicle equipped to match the older

adult’s individual needs.

o Recommendations consistent with State laws for continued driving with

restrictions. Some States do not offer restrictions, whereas others may limit

geographic areas (e.g., 5-mile radiusfrom residence or local routes) or

conditions (e.g., no night or highway driving) in which the older adult drives. 

(Note: Recommendations are informal, but “Restrictions” describe a licensing

action associated with the license similarly to how listing a required vision

correction is part of licensure.)

o Return to driving after education or refresher, including self-study, classroom, or

on-road. It is important to specify if the intention of seeking on-road driving

lessons is to establish/maintain defensive driving skills.

o Interval” reevaluation is indicated when an older adult demonstrates adequate

skills to drive at present but has a progressive disorder that may cause future

decline (e.g., dementia, Parkinson disease).

o Temporary driving cessation, noting potential for improvement and driving in

future. Recommend intervention to improve deficits in vision, perception, 

motor and/or cognition. This is advised when the older adult has medical

condition(s) that can improve over time (e.g., stroke, heart attack, traumatic

brain injury) and can return for reevaluation.

o Permanent driving cessation. This is advised when an older adult does not

demonstrate the necessary skills to compensate for visual, perceptual, or

cognitive deficits to safely resume driving, and the potential for improvement,

even with intervention, is poor. In these cases, the message is that all options

were explored and considered. Alternative transportation options and a

support network should be addressed with the older adult.

Passenger Vehicle Evaluation

• Assessment of vehicle, vehicle modifications, and equipment needed for the older

adult’s safe transport as a passenger or driver.

• Needs of caregivers as drivers or passengers should also be considered (e.g., inability to

assist with transfer due to arthritis, limitations in stowing mobility devices, transporting

scooter). In these cases, certain lifts or tie-down systems may be recommended because

of a caregiver’s physical limitations.

Treatment and Intervention

• Adaptive driving instruction or driver retraining, with or without vehicle modifications.

• Coordination of vehicle modifications:
70

o Vehicle consultation: The DRS serves as a consultant to older adults who are

purchasing a new vehicle to ensure that the vehicle will accommodate the

necessary mobility limitations (door opening or seat height to optimize ease in

transfer, ease in applying adaptive equipment now or in the future).

o Vehicle modification recommendations: The DRS provides written

recommendations for all vehicle/equipment needs to the older adult driver,

third-party payer, and vehicle/equipment dealer.

o Adaptive Equipment/Vehicle modification inspection: The DRS is involved with

the older adult and adaptive equipment dealer in a final fitting to ensure optimal

functioning of the recommended vehicle/equipment.

A comprehensive driving evaluation can last 1–4 hours, depending on the older adult’s

disabilities and driving needs. After the clinical driving evaluation, the on-road evaluation is

performed if the older adult driver meets the minimum State standards for health and vision

and holds a valid driver’s license or permit. The on-road evaluation is performed in the DRS’s

vehicle equipped with dual brakes, a rear-view mirror and eye-check mirror for the DRS, and

any necessary adaptive equipment. (Note: Some programs divide the evaluation into 2 days in

consideration of fatigue or require on-road driving on two separate occasions to evaluate for

consistency).

Older adults who perform poorly on the clinical driving evaluation may or may not be offered

the on-road portion of the evaluation. If the older adult driver is deemed too impaired, the risk

to the driver and evaluator may preclude an on-the-road evaluation for safety reasons.

However, even after poor performance on the clinical driving evaluation, the DRS may still

conduct an on-road evaluation in some cases:

• Older adults who perform poorly on some individual components of the clinical driving

evaluation may still demonstrate safe driving because there is no assessment tool that

accurately predicts on-road performance as clearly as the on-road assessment and

driving is an overlearned skill.2,3,4

• Older adults and their family and caregivers may need concrete evidence of unsafe

driving. However, in the case of the older adult with cognitive impairment that lacks

insight, the on-road evaluation may in fact not change their perception.
71

Older Adult Drivers Who Can Benefit from Driver Rehabilitation Specialists

Driver evaluation and rehabilitation are appropriate for older adult drivers with a broad

spectrum of visual, physical, and/or cognitive disabilities. DRSs work with older adult drivers

who have dementia, stroke, arthritis, low vision, learning disabilities, limb amputations,

neuromuscular disorders, spinal cord injuries, mental health problems, cardiovascular diseases,

and other causes of functional deficits.

Vehicle modification can be as straightforward as providing extended gear shift levers, padded

steering wheels, or extra/larger mirrors to patients with arthritis, and training the older adult

driver in their use.

Rehabilitation can also be as complex as working with an older adult with dementia and his or

her caregivers to determine the individual’s driving needs, plan appropriate driving routes (e.g.,

avoiding left hand turns or busy intersections), supervise practice drives, and provide close and

extended follow-up.

Services of Driver Rehabilitation Specialists

Because driver rehabilitation is a multidisciplinary profession, programs are diverse and provide

services at different levels; clinical team members should recognize which level is needed when

referring an older adult driver to a DRS.

The three main levels of DRS programs can be defined as basic, low tech, and high tech (Table

1, Appendix C). The basic program is appropriate for older adult drivers with limited physical

impairments who require only very basic adaptive equipment in the vehicle. The low-tech

program can address the needs of older adult drivers who may need mechanical or low-tech

vehicle modifications or equipment (e.g., hand controls, left foot accelerator, spinning knob

for one-handed steering), including training in safe use on the road. The high-tech program is

necessary for older adults who need to drive from a wheelchair or need high-tech equipment,

such as low-effort steering.1 Upper level programs also provide basic program services.

Other services can also provide support for some older adults without specific medical conditions 

who may need help with driving. For example, if an older adult has a stroke and can no longer 

drive, and the spouse has a license, but has not driven in 10 years, referring the spouse to a 

driving school for a driver refresher course may improve confidence and safety.

Ideal programs will offer road time with a driving instructor. Conversely, if an older adult 

demonstrates clear impairments in other instrumental activities of daily living (IADLs) but is 

focused on the IADL of driving, the clinical team could consider referral to a general practice

occupational therapist who can offer a traditional professional evaluation of IADLs, including high 

level/complex IADLs. The question of driving competence may be the first clue the clinical team 

has that may lead to a general review of IADL status and intervention goals to improve quality of 

life. Through this pathway, the clinical team and/or the occupational therapist can determine 

when or if the older adult may be prepared to benefit from comprehensive driving evaluation.
72

Performing a driving evaluation too early in an older driver’s recovery may result in failure that

could be misunderstood as permanent, such as in patients with stroke who have not fully

recovered. If the older adult agrees to not drive until evaluated, delaying until after a recovery

period of 6 to 12 months, the outcome may be more favorable, preventing premature driving

cessation.

It is important to note that the services of an occupational therapist are covered by third-party

payers, Medicare, and Medicaid.

Cost of Driver Assessment and Rehabilitation

The cost of driver assessment and rehabilitation varies between programs and according to the

extent of services provided. As a general figure, the range of the private-pay model is currently

about $300 to $600 for a full assessment and $125 an hour for rehabilitation. If adaptive

equipment is required, sample costs might be approximately $70 to $100 for a spinner knob,

$400 to $500 for a left foot accelerator, and $700 to $900 for hand controls. Costs for

reduced- effort steering systems, wheelchair lifts, raised roofs, and dropped floors on vans

run in the thousands of dollars.

Two programs that have funding to cover expenses associated with comprehensive driving

evaluations, driver rehabilitation, and vehicle modifications are States workers’ compensation

and vocational rehabilitation programs. These programs focus on the disability population and

return-to-work,so many older adult drivers will not qualify for either program. Coverage from

Medicare, Medicaid, and private insurance companies is variable and depends on local

interpretation of policies (e.g., government fiscal intermediaries). The Veterans Administration

programs may also cover DRS evaluations and training for spinal cord and mobility-related

injuries, although not all States have a VA driver rehabilitation program. Many driver

rehabilitation programs choose to offer private pay only, because current reimbursement

models are inadequate to cover the expenses of this individualized and highly trained service.

Because rates and extent of insurance reimbursement vary, older adult drivers should be

encouraged to inquire about program rates, insurance coverage, and payment procedures

when they are required to pay up-front and receive reimbursement at a later time.

Of interest, a recent source of funding for DRS services has been for one automobile insurance

company to add reimbursement for a comprehensive driving evaluation to its auto insurance

plan in some regions, if performed by a DRS who is also an occupational therapist, for up to 3

years after an accident and up to $500. When balanced against the personal and global costs to

the older adult driver and the community of a crash, or services needed to support an older

adult lacking independent mobility, this may prove to be a cost-savings strategy.

Finding a Driver Rehabilitation Specialist

Driver rehabilitation programs and DRSs are located across the country, although availability is

typically in urban areas or large medical centers. DRSs can be in private practice or affiliated
73

with hospitals, rehabilitation centers, driving schools, and State departments of motor vehicles.

DRS services may also be accessed through area agencies on aging, universities, and area

departments of education. Before referring older adults to driving rehabilitation services, it is

important to ensure the appropriate level of service needed is available. The credentials and

knowledge level of the provider, typical services provided, and expected outcome should match

the needs of the older adult driver and caregivers. A background in driver education alone is

likely insufficient for appropriate assessment of medically impaired drivers and correct

interpretation of the assessment.

To find a DRS in the local area, calling the occupational therapy departments in local hospitals

or rehabilitation centers is a good place to start. The local chapters of subspecialty

organizations such as the Alzheimer Association may keep up to date driving evaluation

program information on their websites. The ADED’s online directory is a good source of

information (http://aded.site-ym.com/search/custom.asp?id=1984) and lists DRS services by

State and type of program. The AOTA website is another source to locate a DRS by State

(http://myaota.aota.org/driver_search/index.aspx). Many local chapters of the Alzheimer’s

Association (www.alz.org/care/alzheimers-dementia-and-driving.asp) also provide lists of

area driving evaluation programs.

When selecting a DRS or driver rehabilitation program, the older adult driver and/or caregivers

may wish to inquire:

• How many years of experience does the DRS (or program) and what types of clients do

they serve? In many cases, experience may be a more important indicator of quality

than certification alone. There are many well-qualified DRSs who are not certified.

• Does the DRS provide a comprehensive driving evaluation that includes both clinical and

on-road assessments? A DRS who provides both components of the evaluation (or a 

program whose team of specialists perform both components) is ideal. Referral to two

separate specialists or centers is inconvenient for the older adult and the clinical team

member and often presents a greater insurance reimbursement challenge. In addition,

some programs use a driving simulator program, which should not be used to replace

the on-road component. Simulators have the advantages of reliability and safety, but

they are not standardized and have limited validity when compared to the performance

based road test. In addition, in older adults they may induce motion sickness, which can

limit the findings.

• Does the DRS provide rehabilitation and training? A comprehensive DRS provider and/or

program should ideally be experienced in both evaluation and rehabilitation. If the older

adult driver will likely need any adaptive devices or vehicle modifications, he or she and

their caregivers should go to a “low tech” or “high tech” program (see Appendix C) that

has the appropriate equipment to evaluate and train the driver in their use.

• How much can the older adult driver expect to pay out-of-pocket for assessment,

rehabilitation, and adaptive equipment?

• Who will receive a report of the assessment outcome? Most of the time, reports are
74

sent to the older adult driver and to the referring clinical team member and/or referring

agency (e.g., workers’ compensation or office of retirement services) Some DRSs also

send reports to caregivers, at the request of the caregiver and with the older adult’s

consent. Whether or not the DRS reports to the State licensing agency is variable and

should be clearly stated before the evaluation is initiated. In States with mandatory

reporting laws, the DRS and/or physician may send a report to the State licensing

agency; even if reporting is not legally required, some DRSs will still send a report in the

interest of public safety and ethical responsibility.

• If the older adult receives recommendations to cease driving, does the DRS

provide any counseling or aid in identifying alternative forms of transportation?

Note that DRS counseling does not preclude the need for follow-up by the

clinical team. Many times, the older adult and caregivers may be too distressed

at the time of DRS counseling to deal with additional information. Mobility

counseling is crucial for reinforcing this information and providing continued

mobility in the community, as well as demonstrating the health care provider’s

involvement and support.

Making the Referral

Before making the referral, advise the older adult about the reason for the referral, the goals of

the assessment and rehabilitation, the evaluation and tests that will be done, and the expected

out-of-pocket cost for these services.
75

“Mr. Phillips, I’m pleased that you can see better with your new glasses and that your physical

fitness has improved with your walking. I’d like you to keep up the good work. However, I’m

still concerned about slowed processing and ability to move your neck. I’m worried that you

can’t see around you well enough to drive safely. I’d like to send you to someone who can

assist us with your driving abilities. Consider this a kind of “driving check-up” to be sure you

are fit to drive.

“A person called a driver rehabilitation specialist will ask you some questions about your

medical history and test your vision, strength, range of motion, and thinking skills—similar to

what we did the last time you were here. He or she will also take you out on the road and

watch your driving. He or she might recommend some accessories or modifications for your

car, such as extra mirrors, and show you how to use them.

“The cost of these assessments ranges anywhere from $300 to $400, and there may be

additional costs for accessories or rehabilitation training. However, it is possible that insurance

may pay for part of the assessment and training. I know this sounds like a lot of money, but I

think this is important for your safety. If you were in a serious car crash, your medical bills or

the costs for someone you injured could end up costing you more money. We should try to

prevent that from happening.”

Some programs require a written physician prescription, others may not. Understanding your

local requirements or clinic policies are important to appropriately and efficiently referring the

older adult. A driving evaluation prescription should list specific reasons and needs that justify

the evaluation and/or rehabilitation. For example, “OT driver evaluation for hand weakness

such as poor finger flexion or for limited neck rotation secondary to arthritis,” “DRS evaluation

for hemianopsia secondary to stroke,” or “DRS evaluation for cognitive impairments 

secondary to Alzheimer disease” provide guidance for the DRS and are more likely to be

reimbursed by insurance. (Most DRS programs will also send the physician a referral form that

includes space for a list of current diagnoses and medications.) In contrast, vague orders for

“an older adult,” “debilitated,” or “frail” older adult do not provide adequate guidance to the

DRS and can complicate insurance reimbursement. 

If appropriate and feasible in the clinical team setting, a follow-up appointment should be

scheduled for after the driving evaluation. If the older adult is safe to drive (with or without

restrictions, adaptive devices, and/or rehabilitation), recommendations made by the DRS

should be reinforced. When applicable, caregivers should be informed of these

recommendations. Also remember that older adult drivers should be counseled on health

maintenance and safe driving behaviors, and encouraged to start planning alternative forms

of transportation in case they ever become necessary. If the older adult is not considered fit

to drive, then mobility access should be ensured and followed up with services that support

driving cessation (see Chapter 6).
76

Special mention is made of other rehabilitation specialists who may help address impairments

that are not uncommon in older adults. For instance, physical therapists may be able to 

improve muscle weakness, range of motion, or physical frailty. Visual rehabilitation may be

available in some specialized centers. Neurophthalmologists or optometrists may provide

vision training, especially for older adults with neurologic insults that affect convergence,

alignment, nystagmus, eye apraxia, and/or visual neglect from stroke, head injury, brain

tumors, and trauma.

When Driver Assessment Is Not Option

Unfortunately, driver evaluation and rehabilitation services may not always be readily available

in the local area. Even if a DRS is available, the older adult may refuse further assessment or be

unable to afford it. However, some patients and caregivers in DRS shortage areas may be willing

to travel to have this type of evaluation, particularly if the chances are good that the evaluation

may result in prolonging driving life expectancy and safety.

It is important to distinguish whether this is an elective recommendation or essential to

ongoing driving. If the latter, steps for stopping driving until assessment is done must be

clearly communicated to the older adult driver and caregivers and, if necessary, also to the

State licensing authority. Older adults who refuse on the basis of cost should be reminded that

operating a motor vehicle is expensive and that this type of assessment is critical for safety

and important when considered against the cost of a motor vehicle crash. It is the clinician’s

ethical duty to report to the licensing authorities, if there are clear indications that the older 

adult is demonstrating unsafe driving practices with resulting risk to themselves and the

public.

If comprehensive driving evaluation through a DRS is not available, there are several options:

• Advocacy efforts can be undertaken to inform local rehabilitation providers that the

clinical team is seeking local driving rehabilitation services for older adults. Rehabilitation

providers must know of local interest to recognize the need for program growth.

• Most occupational therapists are “generalists” who can provide an occupational therapy

evaluation of IADLs. (These are typically provided services reimbursed by Medicare and

Medicaid as occupational therapy services). Because driving is an IADL, these assessments

can be used to determine driving risk and potential for risk. Occupational therapists in

general practice may also be able to perform specific assessments that provide results

correlated to driving risk as well as mobility counseling. Referral to these types of health

professionals may actually be a more widely available option in many communities.

• Driving education specialists are often based at high schools or affiliated with programs for

novice drivers. Some of these specialists have developed experience in assessing and

counseling older adult drivers. Certain instructors may also be affiliated with a medical

facility and provide the on-road component of the comprehensive driving evaluation.
77

• Private driving schools and driving education programs may be available in the local

area. However, they may not have expertise in evaluating older adults with medical

impairments.

• Further evaluation by another health professional such as a geriatrician, neurologist,

psychiatrist, or neuropsychologist can be considered for an older adult who has a 

chronic condition such as Alzheimer disease or an episodic acute illness (e.g. seizure

disorder).

• If changes in driving behavior are likely to improve the older adult’s driving safety (e.g.,

avoiding driving at night, rush hour, adverse weather conditions, etc.), the clinical team

member can make recommendations. However, officially, State policies vary in the area of

restrictions. Strict adherence to these policies can be made a condition for licensing

through the State licensing agency or Medical Review Board. State policies should be

checked before 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 towards 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 in writing. This may place the clinical team member in a difficult

position. Many States require physicians to fill out forms that require medical information

and vision testing results and to provide an opinion on whether the driver should undergo 

visual and/or on-road testing.

• If the older adult has no medical contraindications to continued driving, he or she should

be offered education and handouts such as the Ten Tips for Aging Well and Safe

Driving Tips (available in this guide). All older adults should be encouraged to develop a 

driving plan, and to become familiar with and able to successfully access alternative

forms of transportation. Planning ahead is invaluable to support aging in place while

bridging short- or long-term disruptions in the most common and familiar form of

transportation—the personal vehicle.
78

References

1. Transportation Research Board (in press). A Taxonomy and Terms for Stakeholders in 

Senior Mobility. Washington, DC: Author.

2. Dickerson, A. E. (2013). Driving assessment tools used by driver rehabilitation specialists: 

Survey of use and implications for practice. American Journal of Occupational Therapy, 67, 

564–573.

3. Classen, S., Dickerson, A. E., & Justiss, M. (2012). Occupational Therapy Driving 

Evaluation: Using Evidence-Based Screening and Assessment Tools. In J. Maguire & E. S. 

Davis (eds.). Driving and Community Mobility: Occupational Therapy Strategies Across

the Lifespan. Bethesda, MD: AOTA Publishing. 

4. Eby, D. W., Molnar, L. J., & Kartje, P. S. (2009). Maintaining safe mobility in an aging

society. London: CRC Press. 
79

CHAPTER 6 ADVISING THE OLDER ADULT ABOUT TRANSITIONING FROM

DRIVING

Key Points

• Health care providers should proactively/annually screen frail older adults for driving

safety and consider referral for comprehensive driving evaluation by a driving

rehabilitation specialist/occupational therapist.

• Health professionals should encourage discussion of a driving retirement plan prior to

the patient losing their privilege to drive.

• When an older adult is unsafe to drive, they and their caregivers should review the

assessment and conclusions and discuss alternative transportation options; this should

be documented in the older adult’s health record.

• If an older adult who is unsafe to drive continues driving, caregiver responsibility and

intervention (when available) is important to document. A “do not drive” prescription

that is provided to the older driver and if appropriate, the caregiver, should be

considered if the patient is medically unfit to drive. The clinician should also consider,

sending a formal letter to the older adult recommending driving cessation and notifying

the State licensing agency.

• Clinicians should know referral sources in the community that can provide mobility

counseling and information on local transportation alternatives such as gerontological

care managers, social workers CDRS’s, and local Agencies on Aging.

Mr. Phillips returns for a follow-up visit after undergoing driver assessment. The driver

rehabilitation specialist (DRS) recommended that wide-angle rearview mirrors be fitted on Mr.

Phillips’ car. Mr. Phillips states that he is driving more comfortably with this adaptive device. You

counsel him on the Tips for Safe Driving and Ten Tips for Aging Well, advise him to continue

walking, and encourage him to start planning alternative transportation options. His daughter is

recruited to assist Mr. Phillips and his son with these discussions and interventions.

You continue to provide care for Mr. Phillips’ chronic conditions and follow up on his driving

safety. Three years later, Mr. Phillips has a right middle cerebral artery stroke and deficits of

left-sided weakness and hemispatial inattention. His health has declined to the extent that you

believe it is no longer safe for him to drive. You also feel that because of the fixed nature of his

deficits (longer than 6 months since the event), driver rehabilitation is unlikely to improve his

driving safety. Mr. Phillips has decreased his driving over the years, and you now tell him that it

is time to stop driving completely. Mr. Phillips replies, “We’ve talked about this before, and I

figured it was coming sooner or later.” He believes that rides from family and friends and the

senior citizen shuttle in his community will be adequate for his transportation needs, and he

plans to give his car to his granddaughter.
80

For most of us, driving is a symbol of independence and a source of self-esteem. When we

retire from driving, we lose not only a form of transportation but also all the emotional and

social benefits derived from driving. In primary preventive care, the transition to cessation

of driving may be discussed during the Medicare Annual Wellness Visit. The Medicare

Learning Network (detailed on www.cms.gov/Outreach-and-Education/MedicareLearning- Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf) provides

educational products and information to proactively address health conditions that may

adversely affect driving ability.

Advance planning for driving cessation ideally will be reviewed along with other standard

instrumental activities of daily living in primary prevention. In secondary prevention, referral

to the clinical team can assist with anticipation of and preparation for driving cessation1, 

rather than responding abruptly in an acute need.

For various reasons, clinical team members may be reluctant to discuss driving cessation

with older adults. Clinicians may fear delivering bad news or be concerned that the older 

adult will lose mobility and all its benefits. Clinicians may also avoid discussions of driving

altogether, because they believe that an individual will not heed their advice or become

angry. Clinicians may be concerned about losing an individual to another practice.

These concerns are all valid. However, clinical team members have an ethical responsibility

to protect the safety of the older adult, as well as that of the public, through assessing 

driving- related functions, exploring medical and rehabilitation options to improve driving

safety, and when all other options have been exhausted, providing recommendations for

restriction or cessation of driving. Within the clinical team, the physician is often

considered key for driver licensing and assessment referral. The development of a universal

State licensing agency fitness-to-drive form would assist with clear, objective medical

documentation,2 along with consistent guidelines across States.

In tertiary preventive care, when it is clear to the clinical team that an older adult driver must

stop driving, the team must manage such challenging cases, including encouraging the older

adult driver to involve caregivers in creating a transportation plan and obtaining the older

adult driver’s permission when involving his or her support system.

Useful Stepsin Counseling Older Adults to Stop Driving

Begin with the older adult’s perspective

An initial assessment of the older adult’s perception of his or her driving ability often directly

impacts the process in which a person redefines not only personal mobility but also public 

risk. Reviewing the self-perceived driving skills of the older adult is critical in any discussion

regarding driving cessation. Interviews of older adult drivers demonstrate the critical

attitudes combined with social pressure impacting driving conduct.3 The older adult’s

individual epiphany, self-determination, confidence, autonomy, and relatedness to social
81

activity require understanding by the clinical team.

When drivers 65 and older were studied regarding when they would terminate driving,

responses were extremely varied. Responses included the following: cessation at a definite

age (half stated during their 90s), at the onset of vision decline, at no time would they

terminate driving (1 in 10), or cessation when they believed they became a hazard on the

road.4

Assess family/caregiver readiness for mobility transition.

Whenever available, there is no substitute for caregiver support in developing plans for

driving cessation. It is important early on to determine whether or not the older adult has

any caregivers who can support their transition. Caregivers often wish the clinical team

would intervene and recommend driving cessation for the older adult.5 For a planned

transition from driving by the clinical team to be successful, the caregivers’ buy-in to a 

unified position and support is critical. It is very difficult to successfully counsel older adults

to stop driving if their caregivers wish them to continue operating a motor vehicle or

disagree among themselves.

Remember that if there is an involved caregiver, they are the one constant and consistent

member of the “team.” Education of the caregivers may increase informed decision-making

and prevent plan-of-care errors.6 When no caregiver support is available, it is very important

to engage local resources through community agencies such as Area Agencies on Aging to

provide additionalservices.

Utilize a clinical team.

Clinical teams require skill sets, assessment instruments, and an appreciation of age-related

driving retirement challenges. Because driving cessation involves so many aspects of the

older adult’s coping style and physical and mental health, the availability of social support

and a clinical team sensitive to age-related mobility change is critical to address multiple

needs and direct an intervention plan.7

Develop clinical team communication.

Clinical teams concur that concise communication is both fundamental and one of the most

challenging aspects of good care during a transition process. Cultural heritage must be

acknowledged and respected in decision making, because a lack of understanding may

prevent the older adult from requesting clarification. Older adults with compromised

health literacy may agree with the clinician in an effort to maintain their dignity, even when

they do not fully understand medical terminology.8

Explain the Importance of Driving Cessation

If the older adult driver has undergone the CADReS toolbox assessments (see Chapters 3 and

4) or assessment by a driver rehabilitation specialist, results in simple language should be

provided to the older adult driver and his or her caregivers to share and discuss. Results
82

should be clearly explained, including what they indicate about the older adult driver’s level

of function and why this function is important for driving. The potential risks of driving should

be stated, ending with the recommendation that the older adult stop driving. This might be a 

good time to discuss the older adult driver’s thoughts or feelings, especially if he or she were

to cause a vehicle crash. If the older adult should not drive, you might discuss issues related

to injury, public safety, and/or financial liability. This discussion should be put in writing with

copies given to the older adult driver. If the older driver lacks decision-making capacity, a 

copy should be given to a family member or caregiver.

“Mr. Phillips, the results of your eye exam show that your vision isn’t as good as it used to

be. Good vision is important for driving because you need to be able to see the road, other

cars, pedestrians, and traffic signs. With your reduced vision and now that you’ve had a 

stroke, I’m concerned you’ll be in a car crash. Because your visual deficits from your stroke

cannot be corrected to a level safe for driving, for your own safety and the safety of others,

it’s time for you to retire from driving. In addition, there are legal requirements for vision

that, unfortunately, you no longer meet.“

Older adult drivers may become upset or angry at the clinical team’s recommendation to

curtail driving. These feelings should be acknowledged, and although clinicians should be

sensitive to the practical and emotional implications of driving cessation, it is necessary to

remain firm with the recommendation. Engaging in disputes or long explanations should be 

avoided. Instead, the focus should be on making certain the older adult understands the

recommendation and that it was made for his or her safety. If the older adult driver is

mentally competent and willing to allow a caregiver to be present at the visit, this may be

helpful when communicating this sensitive information. All discussions should be

documented in the health record. It is critical for the clinical team to reinforce, reinterpret,

and follow up with the older adult driver and caregiver during this transition.

Discuss TransportationOptions

Once a driving cessation has been recommended, possible transportation alternatives need

to be explored and discussed with the older adult. Unfortunately, driving cessation has 

been associated with a decrease in social engagement, depression, anxiety, and long-term

care placement.9 Older adults should be encouraged to take control of their future by

creating a transportation plan. (If the individual does not have the cognitive capability for

these tasks, see the section on those who lack decision-making capacity later in this

chapter.)

Providing the older adult resources to explore options (e.g., handouts in Appendix B) will

help empower him or her to formulate a personal plan for transportation. Special mention

is made of The Hartford’s (The Hartford Center for Mature Market Excellence) educational
83

guidebooks: We Need to Talk: Family Conversations with Older Drivers (available at

www.thehartford.com/mature-market-excellence/family-conversations-with-older-drivers),

At the Crossroads: Family Conversations about Alzheimer’s Disease, Dementia & Driving

(available at www.thehartford.com/sites/thehartford/files/crossroads-kit- intro.pdf), and

You and Your Car: A Guide to Driving Wellness (available at

http://hartfordauto.thehartford.com/UI/Downloads/You_and_Your_Car.pdf).10 Using

alternative transportation options, such as buses, trains, cabs, or even walking, offers older

adults independence from having to rely on others. However, these may not be reasonable

alternatives for those with physical frailty and/or dementia. It may be useful to use the

Beverly Foundation’s dementia friendliness calculator (based on the 5 A’s of

transportation: availability, acceptability, accessibility, adaptability and affordability) when

searching for services11. 

A discussion of driving alternatives can begin by asking if the older adult has made plans to

stop driving or how he or she currently finds rides when driving is not an option. Alternative

transportation methods (Table 6.1) should be explored, as well as any barriers the older adult

foresees (e.g., financial constraints, limited service and destinations, required physical skills

for accessibility).

The older adult may need assistance to identify his or her most feasible transportation

options, because certain cognitive and physical skills are often necessary to use particular

transportation alternatives. The importance of planning ahead for social activities, which

contribute to quality of life, should be stressed. Older adults in driving retirement should be

encouraged to contact the Area Agency on Aging and/or Alzheimer’s Association for

information on local resources such as taxis, public transportation services, and seniorspecific transportation services. For connection to senior services nationwide, The Eldercare

Locator (800-677-1116 or at www.eldercare.gov/; be prepared to provide the relevant city

and State) can provide connections to senior services nationwide. This might be a good time

to refer to clinical teams, including a social worker, nurse, or a gerontologic care manager.

The team may be aware of alternative modes of transportation and/or may deal with the

older adult’s feelings of social isolation or depression.

Older adults should be encouraged to involve caregivers and supportive friends and to form a 

team in creating a transportation plan. The older adult’s permission should always be 

obtained when involving others, who should be encouraged to offer rides and formulate a 

weekly schedule for running errands. However, the older adult should not be ignored when

caregivers are included in the discussion. Help in arranging for delivery of prescriptions, 

newspapers, groceries, and other services may also be considered (see Table 6.2).

ReinforceDriving Cessation

When the message to cease driving is essential for ensuring the older adult’s safety, this also

places a significant demand on the adult to change his or her current behavior. Therefore, the
84

clinical team will need to ensure the older adult understands the reasons (legal, health, and

safety) for the driving cessation recommendation. In many cases, older adults may become

argumentative or emotional during the office visit. They may not fully comprehend the

recommendations or remember all the information provided. Messages can be reinforced by

the following: 

• Make open-ended statements, such as “Please share with me your concerns

regarding the assessment and recommendations.” Reassure the older adult that

you and the clinical team are available if he or she has questions or needs further

assistance.

• Use a teach-back technique by requesting the older adult to repeat why he or she

must not drive. Stress that this recommendation is for his or her personal safety and

the safety of others on the road.

• The older adult driver may benefit from visual reinforcement of a prescription with

the words “Do Not Drive.” Ensuring that the older adult understands why he or she

is receiving this prescription may help avoid feelings of anxiety or anger. See Table

6.3 for further reinforcementtips.

• Send the older adult a letter that recommends driving cessation (see Table 6.6 for a 

template). Place a copy of this letter in the health record as both documentation and

another visual tool for reinforcement. The letter should be written in simple language

to ensure the older adult understands the clinical team’s recommendation.

• The clinical team must understand each State’s reporting requirements and explain

this requirement to the older adult driver and caregivers (see Chapters 7 and 8 for

more details). State regulations, in the case of mandatory reporting laws, dictate 

that older adult drivers and possibly by proxy, their caregivers,) must inform the

local State licensing agency of medical conditions that could affect the older adult’s

safe operation of a vehicle. The older adult should be informed that the State

licensing agency will follow up and what to expect as part of this evaluation (i.e., a 

review of the driving record, a medical statement, potentially on-road testing).

• In States with voluntary laws, a referral to the licensing agency could still be

appropriate, and older adults may be informed that they will be reported, if they

drive against medical advice.

• Help facilitate caregiver assistance in encouraging driving cessation, and if

necessary, encourage the older adult to self-report his or her impairment to the

State licensing agency. It may be helpful to enlist other trusted allies, such as

clergy, friends, or the family attorney.

• Request the older adult driver return in 1 month for a follow-up assessment (see

next section).
85

Follow-Up with the Older Adult

At the older adult’s follow-up appointment, clinicians should assess:

• The older adult’s ability to comply with the driving cessation recommendation

• Transportation resources the older adult identified and has or has not used, 

evaluating the viability of the chosen options

• Signs of isolation or depression

The assessment should begin by asking the older adult how he or she got to the

appointment that day. This will help determine whether the older adult has been able to

plan for and schedule transportation to and from necessary appointments. Ensure that the

older adult has secured reliable and sufficient transportation resources to meet his or her

needs.

Utilize the clinical team; refer to a social worker or gerontologic care manager.

Clinician: I’m pleased to see you for your follow-up appointment today. How were you able

to get to the office?

Mr. Phillips: Oh, my son dropped me off.

Clinician: I see. Has he been driving you lately?

Mr. Phillips: Yes, ever since I stopped driving, he and his wife have been taking me where I 

need to go. He’s going to pick me up in 15 minutes.

Clinician: How has that been working for you?

Mr. Phillips: It’s worked quite well.

Clinician: I have a prescription for you to refill your medicines after our appointment. Will

your son be able to take you to the pharmacy?

Mr. Phillips: Yes, that won’t be a problem.

Clinician: It’s wonderful that your son and daughter-in-law are a reliable source of rides for

you. What do you do when they are unable to drive you where you need to go?

Mr. Phillips: I am stuck at home.

Frailty symptoms (weakness, slow gait speed) combined with depression yield the

consequence of higher mortality in older adults.12 In all levels of care, clinicians should be alert

to signs of depression, neglect, and social isolation (see Tables 6.4 and 6.5). It is important to

continue to monitor older adults for any signs of worsening mental or physical health and to

ask how they are managing without driving. Caregivers should be educated on signs of 

depression and asked if they have any concerns. Clinicians should consider using formal
86

assessments for depression such as the Geriatric Depression Scale or the PHQ-9.

The older adult’s functional or cognitive impairments should continue to be assessed and treated. 

If the older adult improves to the extent that he or she is safe to drive again, the individual should 

be notified and given the resource sheet on Tips for Safe Driving (see Appendix B).

Situations That Require Additional Counseling

Additional counseling may be needed to encourage driving retirement or to help older adults

cope with this loss. Potential situations that may arise with individuals who have difficulty

coping or adhering to the recommendation to stop driving are described below.

The Resistant Older Adult Driver

If the older adult becomes belligerent or refuses to stop driving, it is important to

understand why. Knowing the reason will help to address the individual’s concerns.

Be sure to listen and use supportive statements when addressing the older adult’s

concerns. Let the individual know you are an advocate for his or her health and safety.

Remember that driving cessation can have severe emotional and practical implications, and

older adults may have a difficult time adjusting.

Asking the older adult driver to define when a person would be unfit to drive may help the

individual better recognize impairment in his or her own driving capabilities, as well as

provide an opportunity to assess his or her judgment and insight. In addition, it might open

up discussion to reach some common ground.

Many older adult drivers are able to identify peers whose driving they consider unsafe, yet

may not have the insight to recognize their own unsafe driving habits. It can be helpful to

ask older adults if they have friends with whom they are afraid to drive and why.

It’s important to encourage older adult drivers to begin to think about what to expect when

their driving abilities begin to decline and to let them know that many people make the

decision to restrict or stop driving when safety becomes a concern. Older adult drivers 

should be encouraged to obtain a second opinion if the results were borderline or

questionable and they feel additional consultation would be helpful.

• Help the older adult driver identify support systems. Ask him or her to list family

members, faith communities , neighbors, etc., who are able and willing to help

with transportation. This may help the older adult driver become aware of a 

supportive network and feel more at ease when searching for alternative

transportation. Some communities may now have more affordable 

transportation than taxis such as Uber and Lyft.

• Assist the older adult driver to consider the positives of this decision—an opportunity

to assert control over a limitation. Often, discussion of relinquishing driving privileges

tends to focus on the negative aspects of driving cessation, such as “losing

independence” or “giving up freedom.” Help the older adult driver view this as a step
87

in health promotion and safety for themselves and others. Use phrases such as “it’s

time to retire from driving” and point out that older adults can still stay connected by

requesting rides from caregivers and using community services. It may be helpful to

point out that the older driver has quite likely been giving rides to others throughout

their driving career, and they may now allow others to return the favor. Another

positive is that expenses will be lower without the financial responsibility of

maintaining a vehicle.

• Refer the older adult driver to a social worker or clinical team member. Older adult

drivers may need additional help in securing resources and transitioning to a life

without driving. Social workers often provide supportive counseling to older adults

and caregivers, assess the individual’s psychosocial needs, assist in locating and

coordinating community services and transportation, and enable older adults to

maintain independence and safety while preserving quality of life. The National

Association of Social Workers Register of Clinical Social Workers is a valuable

resource for finding local social workers who have met national, verified,

professional standards for education, experience, and supervision. Information can

be ordered and the online register accessed at www.helpstartshere.org/find-asocial-worker. Local hospitals are another resource for social workers, and referral

sources include the Area Agency on Aging or the Alzheimer’s Association.

The Older Adult Driver with Symptoms of Depression

Depression may result from a combination of factors such as diminished health, social

isolation, or feelings of loss. An older adult driver suspected of being depressed (see 

Table 6.4) should have a full assessment to determine the most appropriate treatment.

Older adults and caregivers should be educated about symptoms of depression and

available treatment options. Referring the older adult to individual or group therapy,

and/or to social/recreational activities may be considered. Pharmacologic treatment or

referral to a mental health professional may also be appropriate. It is important to

acknowledge that the older adult has suffered a loss and recognize that this may be an

especially difficult time for him or her.

The Older Adult Driver who Lacks Decision-Making Capacity

When the older adult driver has significant cognitive impairment and/or lacks insight or

decision-making capacity (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 adult to stop driving and to help the 

individual find alternatives. 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 adult. In turn,

the guardian may forfeit the older adult’s car and license on behalf of the individual’s safety.

These actions should be taken only as a last resort. From a practical standpoint, hiding,
88

donating, dismantling, or selling the car may also be useful in these difficult situations.

The Older Adult Driver Shows Signs of Self-Neglect or Neglect

Older adults may be unable to secure resources for themselves and may be isolated, lacking

sufficient support from family, friends, or an appointed caregiver. If the older adult does not

have the capacity to care for himself or herself, or caregivers are unable to provide

adequate care, signs of neglect or self-neglect (see Table 6.5) may be evident.

If neglect or self-neglect is suspected, Adult Protective Services (APS) should be involved.

Neglect isthe failure of a caregiver to fulfill his or her caregiving responsibilities, whether

because of willful neglect or as a result of disability, stress, ignorance, lack of maturity, or

lack of resources. Self-neglect is the inability to provide for one’s own essential needs. APS

will investigate for neglect, self-neglect, or abuse of the older adult. APS can secure

services such as case planning, monitoring, and evaluation, and can arrange for medical,

social, economic, legal, housing, law enforcement, and other emergency or supportive

services. Contact information for each State office can be obtained by calling the Eldercare

Locator at 800-677-1116.

Table 6.1 TransportationAlternatives

• Walking

• Train/subway

• Bus

• Taxi/Uber-like services

• Family and friends

• Community transportation services

• Hospital shuttles

• Medi-car

• Delivery services

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

• Private for-profit senior care services

Table 6.2 Family/CaregiverAssistance

• Encourage family members and caregivers to promote the health and safety of the

older adult by endorsing clinician recommendation and assisting in securing needed

transportation.

• Include caregivers in the mobility counseling process.

• Provide resourcesto caregivers.

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

• Look for signs of caregiver burnout.
89

• Keep the communication door open to caregivers.

• 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 recommendationsisimperative.

• 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.

Websites(Accessed July 2015)

• AAA Foundation (www.aaafoundation.org/senior-drivers ) 

The emphasis of the AAA Foundation is the behaviors and safety-related attitudes of drivers 65

and older.

• Alzheimer’s Association (www.alz.org/care/alzheimers-dementia-and-driving.asp) 

The Alzheimer’s Association provides links to driving counseling support for caregivers.

• American Occupational Therapy Association (www.aota.org) 

Locate an occupational therapists able to conduct driving assessment and locations by ZIP

code.

• Family Caregiver Alliance (www.caregiver.org)

This organization supports and sustains the important work of families nationwide caring for 

loved ones with chronic, disabling health conditions.

• The Health in Aging Foundation (www.HealthinAging.org) 

This Foundation was established by the American Geriatrics Society to bring the knowledge of

geriatrics health care professional to the public, with a wide range of resources.

• Independent Transportation Network America

(www.itnamerica.org/what-we-do/our-services)

A national non-profit transportation system for America's aging population. The ITN service is

membership-based - people 60 and older and visually impaired adults are eligible to join.

• National Association of Area Agencies on Aging (www.n4a.org/about-n4a) 

Area Agencies on Aging are a leading aging issues resource and national network.

• National Association of Social Workers (www.socialworkers.org) 

Locate a social worker by ZIP code.

• National Center for Senior Transportation (www.seniortransportation.net) 

The National Center on Senior Transportation strives to increase transportation options for

older adults to support their ability to live independently in their homes and communities

throughout the United States. It is administered by Easter Seals Inc. in partnership with the

National Association of Area Agencies on Aging.
90

• National Highway Traffic Safety Administration

(www.nhtsa.gov/Driving+Safety/Older+Drivers)

NHTSA’s priorities are to reduce the number of deaths and injuries by getting drivers, 

pedestrians, and cyclists to change their behaviors once they are behind the wheel or on the

streets. See “Talking With Older Drivers About Safe Driving.”

• National Volunteer Transportation Center

(www.NationalVolunteerTransportationCenter.org) 

The National Volunteer Transportation Center was created to support existing and emerging

volunteer transportation programs and services acrossthe country.

• Rides in Sight. A free Transportation Referral Service (www.ridesinsight.org) or call

toll free –855-607-4337. Assists the individual in finding a transportation program in

the older adult’s area. Can be searched on line or the number will be answered by a 

person during business hours.

Table 6.3 Tipsto Reinforce Driving Cessation

• Give the 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 also emphasizes the strength of your message.

• Remind the older adult that this recommendation is for his or her safety and for the

safety of other drivers.

• Ask the older adult driver how he or she might feel if he or she were to get in a crash

and injure themselves or someone else.

• Point out the economic advantages of not having a car, which will eliminate many

expenses, including gas, maintenance (oil changes, tires, tune-ups), insurance,

registration/license fees, financing expenses, and depreciation of the car’s value.

• 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)

13

These questions are in regard to most of the day or nearly every day and are not related to

another medical illness.

• Has your mood been sad, empty, or hopeless?

• Have you lost enjoyment in all or most activities?

• Have you noticed any weight changes?

• Have you noticed any changes in sleeping habits or concentration?

• Have you noticed a lack of energy or slower movement?

• Have you noticed feelings of worthlessness or recurrent ideas of death?
91

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

• An injury that has not been properly treated

• Symptoms of dehydration and/or malnourishment

• Weight loss

• Soiled clothing

• Recurrent falls with or without injuries

• Evidence of inadequate or inappropriate administration of medications

• Spoiled or outdated food in the refrigerator

• Loss of income from difficulty with finances

Table 6.6 Sample Letter

December 23, 2016

Mr. Clayton Phillips

123 Lincoln Lane

Sunnydale, XX 55555

Dear Mr. Phillips:

I am writing to follow-up on your clinic visit of December 1, 2016. You’ll 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. But your safety is

more important. To help you get around, your son and your friends have offered to help 

you. You can also use the special bus in your neighborhood. 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 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.
92

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: Your son

Note: The sample letter in Table 6.6 has been written at a grade 7 level according to FleschKincaid Readability (12/2014).
93

References

1. Betz, M., E., Jones, V. C., & Lowenstein, S. R. (2014). Physicians and advance planning 

for “driving Retirement”. American Journal of Medicine, 127, 689–690.

2. Meuser, T. M., Berg-Weger, M., Niewoehner, P. M., Harmon, A. C, Kuenzie, J. C., Carr, 

D. B., & Barco, P. P. (2012). Physician input and licensing of at-risk drivers: a review of 

all-inclusive medical evaluation forms in the US and Canada. Accident Analysis & 

Prevention, 46, 8–17.

3. Broberg, T., & Willstrand, T. D. (2014). Safe mobility for elderly drivers: considerations

based on expert and self-assessment. Accident Analysis & Prevention, 66, 104–113.

4. Naumann, R. B., West, B. A., & Sauber-Schatz, E., K. (2014). At what age do you think

you will stop driving? Views of older U.S. adults. Journal of the American Geriatrics 

Society, 62, 1999–2000.

5. Betz, M., E., Jones, J., Petroff, E., & Schwartz, R. (2013). “I wish we could normalize

driving health”: A qualitative study of clinician discussions with older drivers. Journal 

of General Internal Medicine, 28, 1573–1580.

6. Brummel-Smith, K., Munn, J. C., & Danforth, D. D. (2014). Interprofessional team care.

In R. J. Ham et al (eds). Ham’s Primary Care Geriatrics. 6th Edition. Philadelphia: 

Elsevier, Inc.

7. 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.

8. Moore, I. Assessing the geriatric patient: planning for transitions of care. Consultant 

Pharmacist, 29, 369–374.

9. Curl, A. L., Stowe, J. D., Cooney, T. M., & Proulx, C. M. (2014). Giving up the keys: how 

driving cessation affects engagement in later life. Gerontologist, 54, 423–433.

10. The Hartford Financial Services Group, Inc. (2015). You and Your Car: A Guide to Driving 

Wellness. Retrieved from the Hartford website at

http://hartfordauto.thehartford.com/UI/Downloads/You_and_Your_Car.pdf

11. Beverly Foundation. (n.a.) Transportation and Dementia (Fact Sheet, Series 1, No. 8). 

Retrieved from the Beverly Foundation website at http://beverlyfoundation.org/wpcontent/uploads/Fact-Sheet-8-transportation.Dementia.pdf. 
94

12. Brown, P. J., Roose, S. P., Fieo, R., Liu, X., Rantanen, T., Sneed, J. R., ... Avlund, K. (2014). 

Frailty and depression in older adults: a high-risk clinical population. American Journal of 

Geriatric Psychiatry, 22, 1083–1095.

13. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of 

Mental Disorders, 5th Edition. [Known as DSM-V]. Washington, DC: American

Psychiatric Association.
95

CHAPTER 7 ETHICAL AND LEGAL ISSUES

Key Points

• Laws, regulations, and policies vary not only by State but also by local jurisdiction 

and are subject to change. Health care professionals should seek legal advice on

specific issues or questions.

• It is important to know and comply with State requirements to avoid being subject to

a third-party lawsuit.

• Some States (CA, DE, NJ, NV, OR, PA) have mandatory reporting requirements that

may give rise to liability for failure to report.

• The ethical responsibility to maintain patient confidentiality as well as the ethical

responsibility to public safety is not limited to physicians; all health care

professionals have the same obligation.

• Patient permission should be obtained before contacting caregivers, and this should be

documented in the patient’s health record. If the patient maintains decisional capacity

and denies permission, their wishes must be respected.

Your next patient is Mrs. Allen, a 78-year-old woman who is accompanied by her daughter. The

daughter reports that her mother, who lives alone, has become increasing forgetful, repeats

herself within minutes, and has difficulty dressing herself, performing personal hygiene tasks,

and completing household chores. She is particularly concerned about her mother’s daily trips

to the grocery store two miles away. Mrs. Allen has become lost while on these trips and,

according to the store manager, has handled money incorrectly. Dents and scratches have

appeared on the car without explanation. Mrs. Allen’s daughter has asked her mother to stop

driving and tried to take the car keys, but Mrs. Allen responds with anger and resistance. On

previous visits you have recommended that she consider alternatives to driving. The daughter

would like to know how to manage her mother’s long-term safety and health, especially how to

address the driving issue.

This chapter provides a general overview to assist clinicians to understand the process,

including their ethical and legal responsibilities, for reporting unsafe drivers to their State

licensing agency. Although some of the issues addressed are inherently ethical and/or

legal, this chapter is not to be construed as providing legal advice. The views, discussion, 

conclusions, and legal analysis are those of the authors and do not represent the opinions,

policies, or official positions of the National Highway Traffic Safety Administration, the

AGS and do not replace local legal advice and review of State laws and local statutes. It is

important for physicians to seek out legal advice in their State on specific issues or

questions that may arise with an individual patient.
96

Older adults receive services in multiple settings from all types of professionals, including all

members of the clinical team (medicine, nursing, pharmacy, social work, occupational therapy,

etc.). Most existing legal guidance for older adult drivers refers specifically to physicians,

although all clinical professionals have similar ethical duties and obligations. The following

discussion specifically cites physicians but the principles discussed should be adopted by the

entire clinical team.

Clinician: Mrs. Allen, I understand you drove yourself to the appointment today. This worries

me. At our last visit, I recommended you retire from driving. Please share the reason you drove

here today.

Mrs. Allen: Well, I don’t understand why you’re so concerned. I’ve never gotten into a car crash.

My driving is fine and, frankly, I don’t think you have any right to tell me not to drive.

Clinician: It sounds like you are frustrated, and I can’t imagine how difficult it must be for you

to adjust to a life without driving. It’s not an easy choice to make; however, it’s the best choice

for your health and safety, and as your health care provider, that is my primary concern. I want

to help make this easier for you. Your Rapid Pace Walk (15 seconds) and MoCA test results

(score 18/30) show that your responses are not as sharp as they need to be for you to drive

safely. Let’s talk about some of your concerns regarding retiring from driving.

Laws, regulations, and policies vary not only by State but also by local jurisdiction. They are also

subject to change, and the State licensing agency should be contacted for the most up-to-date

information. For a State-by-State list of licensing agency contact information and additional

resourcesfor locating licensing requirements and renewal criteria, reporting procedures, etc.,

see Chapter 8.

Clinician: Mrs. Allen, when do you think it’s an appropriate time for a person to stop driving?

Mrs. Allen: I suppose when they drive unsafely or are a threat to others on the road.

Clinician: That is an excellent observation, and I would agree with you.

Mrs. Allen: Well, a friend of mine doesn’t drive very well. He drives all over the road and runs

red lights. I won’t get in the car with him anymore because I worry about what may happen.

Clinician: That is indeed a scary situation for your friend and others on the road, too. It’s great

that you’re aware of the potential danger and know how to ensure your own safety. I’m

wondering if there’s someone you trust who would tell you when they thought it was unsafe for

you to continue driving?
97 

The case studies in this chapter serve to illustrate the range of opinions in attempting to fairly

define the scope of the physician’s responsibility to report impaired drivers. In addition, they

consider society’s efforts to provide a safe environment for its citizens.

On further evaluation, you diagnose Mrs. Allen with Alzheimer disease. It is readily apparent

that her condition has progressed to the extent that she can no longer drive safely and that

rehabilitation is not likely to improve her driving safety. Youtell Mrs. Allen that she must stop

driving for her own safety and that of others on the road. Youalso explain that the State

reporting law requires physicians to notify the State licensing agency of your diagnosis. Initially,

Mrs. Allen does not understand but when you specifically tell her that she can no longer drive

herself to the grocery store every day, she becomes agitated and abusive, screaming, “I hate

you!” and “I’m going to sue you!” Her daughter understands your decision to report Mrs. Allen

to the Statelicensingagency, but is now concerned that her mother will encounter problems if

she attempts to drive without a license, since she no longer has the ability to drive. Mrs. Allen’s

daughter asks if it is absolutely necessary for you to report her mother. What do you say?

Many physicians are uncertain of their legal responsibility, if any,to report unsafe drivers to

their State licensing agency.1,2 The situation is further complicated by the risks of damaging the

physician-patient relationship, violating patient confidentiality, and potentially losing patients.

As a result, physicians are often faced with a dilemma: should they report the unsafe driver, or

should they forego reporting and risk being liable for any potential patient or third-party

injuries for failing to report? Furthermore, how should physicians engage caregivers to lessen

the burden of a driving restriction or cessation?

Ethical Duties

Current legal and ethical debates highlight duties of the physician that are relevant to the issue

of driving. These include the duties to protect patient health as well as maintain patient

confidentiality.

Duty to Protect

The Patient: Protecting the patient’s physical and mental health is considered thephysician’s

primary responsibility. This includes not only treatment and prevention of illnessbut also caring

for the patient’s safety. With regard to driving, physicians should advise and counsel patients

about medical conditions and possible medication adverse effects that may impair the ability to

drive safely and documentthis discussion in the medicalrecord. Some States have mandatory

reporting requirements that may give rise to both civil and criminal liability for failure to 

report.3 For example, wording in the Pennsylvania law hasled the Pennsylvania State licensing

agency to conclude that physicians who do not report “could beheld responsible as a proximate

cause of an accident resulting in death, injury or property loss caused by your patient; the
98

Pennsylvania statute further states that providers who do not comply with their legal

requirement to report may be convicted of a summary criminal offense.”4 Case law illustrates

that failure to advise patients about such medical conditions and medication adverse effects

can be considered negligent behavior, making the physician liable for monetary damages.5

The Public: In addition to caring for their patients’ health, physicians may,in certain

circumstances and jurisdictions, have some responsibility for protecting the safety of the

public.6,7 In certain States, physicians have been found liable forthird-party injuries because

they failed to advise their patients about medical conditions, medication adverse effects, or

medical devices that may impair driving performance.8–10

Maintain Patient Confidentiality

Physicians: Patient confidentiality is the right of an individual to have personal, identifiable

medical information kept private. These protections are found in the federal Health Insurance

Portability and AccountabilityAct of 1996 (HIPAA).11 All health care professionals have a legal

duty to protect private patient information from disclosure to anyone, including the patient’s

family, attorney, or the government without authorization from the patient.12

HIPAAencouragesthe free exchange of information between the health care professional and

the patient, allowing the patient to describe symptoms for diagnosis and treatment.13

Individuals may be less likely to seek treatment, disclose information for effective treatment, or

trust the health care professional unless confidentiality is ensured.14

However, nondisclosure requirements are not absolute. There may be public policy reasons to

breach confidentiality, such as removing unsafe drivers from the road.12 Thus, patient

confidentiality may not necessarily protect the physician in the impaired driver situation.14

Other Health Care Professionals: The ethical responsibility to maintain patient confidentiality is

not limited to physicians; all health care professionals have the same obligation.15 Patient

confidentiality is crucial within the health care professional–patient relationship, because it

encourages the free exchange of information allowing the patient to describe symptoms for

diagnosis and treatment.13 Without belief that their care is confidential, patients may not trust

their health care professional and, thus, be less likely to disclose information for effective

treatment.14 This need, however, is not absolute.16 A good example of health care professional

standards for the treatment of older adult patients can be found at the American Society of

Consultant Pharmacists (www.ascp.com/articles/quality-standards-and-practice-principlessenior-care-pharmacists).17
99

Concerns about Reporting

A Canadian study explored physicians’ attitudes on medical fitness to drive and found that

although most medical professionals would report unfit drivers, theybelieved such action could

adversely affect the confidentiality expectations within the physician-patient relationship.18

Physicians have raised concerns about mandatory reporting, stating it can violate privacy,

compromise the ability to counsel patients, and negatively impact the physician-patient

relationship.19 Some physicians have suggested that mandatory reporting has the potential to

discourage patients from seeking health care.20

In the six States that have mandatory reporting requirements, studies show physicians are

more likely to report.21 Unless required by law to report, physicians may choose not to do so in 

certain situations.

Immunity and Confidentiality

Of the 43 States with voluntary reporting laws, 18 currently do not protect reporting health

professionals from liability for civil damages.22 In 1999, the National Committee on Uniform

Traffic Laws and Ordinances (now disbanded) developed a “Model Driving Impairment Law” 

that suggested physician immunity from civil liability should be an important component of any

law.23, 24

Adherence to State Reporting Laws

Each State has its own reporting laws. For a State-by-State listing of licensing agency contact

information and other resources for licensing requirements, see Chapter 8. Note that

information may change over time, and the State licensing agency should always be contacted

for the most up-to-date information.

In States without laws mandating physicians to report patients to the State licensing agency,

physicians should have written patient releases that comply with HIPAAbefore disclosing 

medical information. In these States, physicians whodisclose medical information without

patient authorization may be liable for breachof confidentiality. However,failure to disclose 

may make the physician liable to third parties who are injured by the patient.25 This presents a 

“take it or leave it” Hobson’s choice,* but ultimately safety of the patient and the public should

comefirst. 

*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. Thus, a “Hobson’s Choice” is given to one asked to choose between two 

undesirable alternatives.

Balancing Ethical and Legal Responsibilities

Balancing competing ethical and legal duties can be problematic. The following strategies may

be helpful.
100

Counsel Patients and Caregivers

Patients should be advised of medical conditions, medications, medical devices, and procedures

that may affect driving performance. (For a reference table of such medical conditions and

medications, with recommendations for each, see Chapter 9.) If the patient gives permission, his

or her caregivers should be involved in the counseling process whenever appropriate.

Caregivers included in the process are more likely to assist the patient with the changes a loss

of license will bring. Losing the driver’s license has significant psychological consequences,

because the ability to drive is inexorably intertwined with the sense of independence.

Driving cessation has other major consequences besides loss of autonomy. The older adult’s

ability to conduct the business of daily living is impaired, as is his or her ability to participate in

social activities or volunteering. Therefore, social isolation is likely. Caregivers are also

negatively impacted, because they are expected to fill in many of the gaps that will inevitably

arise as a result of the older adult’s retirement from driving. These risks need to be recognized

and weighed versus the concerns of public safety.

If the older adult does not have decision-making capacity (e.g., due to Alzheimer disease), this

information should be given to a surrogate decision-maker.

Recommend Driving Cessation

As discussed in previous chapters, clinicians should recommend driving cessation for patients

believed to be unsafe drivers who have a condition(s) likely to affect driving safety but unlikely

to improve with available medical treatment or with an adaptive device or technique. As

always, clinical judgment should be based on the older adult’s driving abilities and not on age

per se. This recommendation should be documented in the patient’s health record, and the

clinician’s office should have a system to check on compliance with recommendations.

Know and Comply with State Reporting Laws

Physicians must know and comply with their State’s reporting laws (see Chapter 8). Physicians

who fail to follow these laws may be liable for patient and third-party injuries and could face

civil or criminal charges as well.

In States that have a mandatory medical reporting law, the State licensing agency’s official form

should be used to report the required medical conditions. In States that have a voluntary

medical reporting law, the State licensing agency’s official form can be used or any other

reporting guidelines. Some States provide civil immunity if professionals report in good faith.

Patient consent, if any, should be documented. If the State licensing agency’s guidelines do not

indicate what patient information must be reported, only the minimum information necessary

to show that the patient may be an unsafe driver should be provided.
101

Reduce the Impact of Breaching Patient Confidentiality

In adhering to State reporting laws, physicians may need to breach patient confidentiality.

However, several measures can be taken to reduce the impact on the physician-patient

relationship.

Inform the Patient of Notice to the State Licensing Agency: Before reporting a patient to the

State licensing agency, physicians should inform the patient of their intent and explain that it is

the ethical, and in some cases, legal responsibility of the physician to make a referral to the

State licensing agency. Describing the kind of follow-up that can be expected from the State

licensing agencyisalsoadvised. The patientshould be assured that out of respect for his or her

privacy, only the minimum information required will be disclosed and that all other information

will remain confidential. When submitting a report to the State licensing agency, only the

minimum information necessary (or required by the reporting guidelines) should be provided to

establish that the patient maybe unsafe to drive.

Evenin States that offer anonymous reporting or reporter confidentiality, being open and honest 

with patients is a good idea. It may help to remind patientsthat the physician does not determine

whether they are licensed todrive and that this decision is ultimately made by the State. 

Providing patients with as much information as possible, perhaps including a copy of the State

licensing agency report, can involve them in the process and give them a greater sense of

control. In addition, patient permission should be obtained before contacting caregivers, and

this should be documented in the patient’s health record. If the patient maintains decisional

capacity and denies permission, their wishes must be respected.

Document Diligently: All efforts to assess and maintain the patient’s safety and that of the

public should be documented in the patient’s health record. In the event of a patient or thirdparty crash injury, good documentation may protect the physician from civil liability. 

Physicians should protect themselves legally by documenting their efforts, discussions,

recommendations, and any referrals for further testing in the patient’s health record.26 In other

words, all the steps performed in the Plan for Older Drivers’ Safety (PODS) (see Chapter 1)

should be documented, including:

• Any direct observations of the patient’s functional status, red flags as described in PODS,

or driving history that lead the physician to believe that the patient may be at risk of

unsafe driving.

• Any counseling specific to driving (e.g., documenting that the patient is aware of

the warning signs of hypoglycemia and its effects on driving performance).

• Formal assessment of the patient’s driving-related functions (e.g., documenting that

the patient has undergone the Clinical Assessment of Driving Related Skills (CADReS)

and including the CADReS scoring sheet in the patient’s health record).
102

• Any medical interventions and referrals that have been made to improve the patient’s

function, as well as any repeat testing to measure improvement.

• A copy of the driver rehabilitation specialist (DRS) report if the patient has undergone

driver assessment and/or rehabilitation.

• The physician’s recommendation on whether the patient should continue driving or

cease driving. In the case of a cease driving recommendation, a summary of

interventions (e.g., “sent letter to patient to reinforce recommendation,” “discussed

transportation options and gave copy of ‘Patient Resource Sheet’,” “contacted family

members with patient’s permission,” “reported patient to State licensing agency with

patient’s knowledge”) should be included. Copies of any written correspondence should

also be included in the patient’s health record.

• Follow-up for degree of success in using alternative transportation options and any signs

of social isolation and depression, including any further interventions, such as referral to

a social worker, geriatric care manager, or mental health professional.

Additional Legal and Ethical Concerns

Other particularly challenging situations may arise. The following examples provide some

possible actions that may be used as a guide.

Situation 1: The patient threatens to sue if he or she is reported to the State licensing

agency.

A patient’s threat to sue should not deter the physician from complying withState reporting

laws. If a patient threatens to sue, physicians can take several steps to protect themselves in

the event of a lawsuit:

• Know if your State has passed legislation specifically protecting health care professionals

against liability for reporting unsafe drivers in good faith16 (see Chapter 8).

• Understand that even in the absence of such legislation, physicians generally run little

risk of liability for following mandatory reporting statutes in good faith. Consult your

attorney or malpractice insurance carrier to determine your degree of risk.

• Make certain the reasons for believing that the patient is an unsafe driver have been

clearly documented.

Be aware that physician-patient privilege does not preclude the physician from reporting the

patient to the State licensing agency. Physician-patient privilege, which is defined as the

patient’s right to prevent disclosure by the physician of any communication between the

physician and patient, does not apply in cases of mandatory reporting. Patients can be

reminded that physicians do not determine licensing. Ultimately, this is the responsibility of the

State, and thus the State makes the final decision on determining whether the patient can

continue to drive.
103

Situation 2: The patient is an unsafe driver in a State without State reporting laws.

In this situation, the physician’s first priority is to ensure that the unsafe driver does not drive. If

this can be accomplished without having the patient’s license revoked, then there may be no

need to report the patient to the State licensing agency. Before reporting a patient, physicians

may address the risk of liability for breaching patient confidentiality by following the steps listed

under Situation 1.

However, if the patient continues to refuse to stop driving, then physicians must consider which

is more likely to cause the greatest amount of harm: breaching the patient’s confidentiality

versus allowing the patient to potentially injure himself or herself or third parties in a motor

vehicle crash.

Situation 3: The patient’s license has been suspended by the State licensing agency for

unsafe driving, but the physician is aware that he or she continues to drive.

This patient is violating the law, and several questions are raised: Is the physician responsible

for upholding the law at the expense of breaching patient confidentiality? Because the license

has been revoked by the State licensing agency, isthe driving safety of the patient now the

responsibility of the State, the physician, or both?

Several steps can be taken in this situation:

• Ask the patient why he or she continues to drive. Address the specific causes brought up

by the patient (see Chapter 6 for recommendations). With the patient’s permission,

caregivers should be involved in finding solutions, such as alternative methods of

transportation.

• Ask the patient if he or she understands that continuing to drive is breaking the law.

Reiterate concerns about the patient’s safety, and ask how he or she would feel about

causing a crash and potentially being injured or injuring someone else. Discuss the

emotional burden a car crash would cause the patient, his or her family, and all others

involved.

• Discuss the financial and legal consequences of being involved in a crash without a 

license or auto insurance. Many clinicians remind patients and families/caregivers of the

possibility of their financial liability for any injuries caused by driving.

• If the patient is cognitively impaired and lacks insight into this problem, the issue must

be discussed with the individual who holds decision-making authority for the patient, if

the patient has a designated decision maker. If not, the patient and caregiver(s) should

pursue the process of appointing one. These parties should understand their

responsibility to prevent the patient from driving.

• If the patient continues to drive and the State has a mandatory reporting law, physicians

must adhere to the law by reporting patients who are unsafe drivers (even if the patient
104

has been reported previously). If the State does not have a mandatory reporting law,

the physician should base the decision to report as in Situation 2 (see above). The State

licensing agency, as the agency that grants and revokes the driver’s license, will follow

up as it deems appropriate.

Situation 4: The patient threatens to find a new physician if reported to the State

licensing agency.

Although unfortunate, this situation should not prevent physicians from caring for the 

patient’s health and safety. In addition, physicians must adhere to State reporting laws, 

regardless of such threats.

Several strategies may help diffuse this situation:

• Reiterate the process and information used to support the recommendation that

the patient stop driving.

• Reiterate concern for the safety of the patient, any passengers, and others on the road.

• Remind the patient that providing him or her with the best possible health care

includes safety measures of all types. State that driving safety is as much a part of

patient care as encouraging patients to keep smoke detectors in the house and have

regular physical check-ups.

• Encourage patients to seek a second opinion, if appropriate. A DRS may evaluate the

patientif this has not already been done, or the patient may consult another

physician.

• If the State licensing agency follows up on physician reports with driver retesting,

inform the patient that just as it is the physician’s responsibility to report the patient 

to the agency,it is the patient’s responsibility to prove his or her driving safety to the

agency. Emphasize that the State licensing agency makes the final decision, and that

only the State can legally revoke a driver’s license. Remind the patient that everything

medically possible has been done to help him or her pass the driver test.

• As always, maintain professional behavior by remaining matter-of-fact and not

expressing hostility toward the patient, even if he or she ultimately makes the

decision to seek a new physician.

Patient Resources

Driving Safely While Aging Gracefully27, a brochure available from the National Highway

Traffic Safety Administration, can help older adults assess whether they should still be driving. 

There is also a Drive Well Toolkit28 online and Getting Around: Alternatives for Seniors Who No

Longer Drive29, another brochure designed to help families cope with an older adult who

should not be driving. Physicians may wish to keep a supply of these documents on hand.

Additional resources are discussed in Chapter 6 and listed in Appendix B.
105

Glossary of Terms

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

following terms and concepts (Table 7.1).

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.30

Driverrehabilitation programs These programs, run by driver rehabilitation specialists

(DRS), 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

interactions31

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.
106

Table 7.1 Glossary of Terms

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.

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.32

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.33

Renewal procedures License 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 physician’s report for license 

renewal.34
107

Table 7.1 Glossary of Terms

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 physician but who

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

the patient.
108

References

1. Kelly, R., Warke, T., & Steele, I. Medical restrictions to driving: the awareness of patients

and doctors. Postgraduate Medical Journal, 75, 537–539.

2. Miller, D., & Morley J. (1993). Attitudes of physicians toward elderly drivers and driving 

policy. Journal of the American Geriatrics Society, 40, 722–724.

3. OR. REV. STAT.§ 807.710 (2001).

4. Title 75 PA. CODE § 1518(b) The Vehicle Code (stating physicians are immune from

any civil or criminal liability if they do report patients 15 years of age or older who

have been diagnosed as having a condition that could impair his/her ability to safely

operate a motor vehicle; but, if the physician does not report could, then, possibly

be held responsible as a proximate cause of an accident resulting in death, injury, or 

property loss caused by the physician’s patient. Also, physicians who do not comply

with their legal requirement to report may be convicted of a summary criminal

offense). Available at www.dmv.state.pa.us/pdotforms/fact_sheets/fs- pub7212.pdf.

5. Gooden v. Tips, 651 S.W.2d 364, 1983 Tex. App., 43 A.L.R.4th 139 (Tex. App. Tyler 1983)

(case stating that physicians have a duty to warn patients that medications may impair 

driving but that physicians do not have a duty to control a patient’s behavior). However, 

the Supreme Court of Texas significantly narrowed physicians' duties to third parties. In 

Praesel v. Johnson, 967 S.W.2d 391, 396 (Tex. 1998), the court noted that it had "generally

limited the scope of the duty owed by physicians in providing medical care to their

patients." The court "declined to impose on physicians a duty to third parties to warn an

epileptic patient not to drive. Somewhat similarly that court "weighed the risk,

foreseeability, and likelihood of injury against the social utility of the actor's conduct, the 

magnitude of the burden of guarding against the injury, and the consequences of placing 

the burden on the defendant," and also considered "whether one party would generally 

have superior knowledge of the risk or a right to control the actor who caused the harm."

967 S.W.2d at 397-98. For a general discussion on this topic see 43 A.L.R. 4th 153; 35 U.

Mem. L.Rev. 173; See Comment: Driving on the center line: Missouri physician’s potential 

liability to third persons for failing to warn of medication side effects (46 St. Louis L.J. 873);

Wilschinsky v. Medina, 1989- NMSC-047, 108 N.M. 511, 775 P.2d 713, (N.M. 1989). (New 

Mexico case stating that the physician owed a duty of care to an individual harmed by the

physician’s patient, that the patient’ patient’s duty specifically extended to persons the

patient injured by driving a car from the doctor’s office after being injected with drugs 

that were known to affect judgment and driving ability; the medical standards for

administering drugs had to define the physician’s duties of care). Limited by Lester by & 

Through Mavrogenis v. Hall, 1998-NMSC-047, 126 N.M. 404, 970 P.2d 590, 38 N.M. B. Bull.

2, 38 N.M. B. Bull. 11 2 (1998) (This Court did not extend the duty articulated in

Wilschinsky to prescription cases under the case fact pattern.) See also Brown v. Kellogg, 

2015-NMCA-006, 340 P.3d 1274 (N.M. Ct. App. 2014).
109

6. Tarasoff v. Regents of University of California, 17 Cal. 3d 425; 551 P.2d 334; 131 Cal. Rptr. 

14 (Cal. 1976 Cal.); 83 A.L.R.3d 1166, 1976 (rehearing to the California Supreme Court

upheld on the duty to warn and protect). In Tarasoff, the California Supreme Court held

that, under certain circumstances, a therapist had a duty to warn others that a patient 

under the therapist's care was likely to cause personal injury to a third party. There the 

court said, "Although . . . under the common law, as a general rule, one person owed no 

duty to control the conduct of another, nor to warn those endangered by such conduct, 

the courts have carved out an exception to this rule in cases in which the defendant 

stands in some special relationship to either the person whose conduct needs to be 

controlled or in a relationship to the foreseeable victim of that conduct." (P. 435.)

Applying that exception to the facts of Tarasoff, the court held that where a therapist

knows that his patient is likely to injure another and where the identity of the likely victim

is known or readily discoverable by the therapist, he must use reasonable care to prevent 

his patient from causing the intended injury. Such care includes, at the least, informing 

the proper authorities and warning the likely victim. However, the court did not hold that

such disclosure was required where the danger presented was that of self-inflicted harm 

or suicide or where the danger consisted of a likelihood of property damage. Instead, the 

court recognized the importance of the confidential relationship which ordinarily obtains

between a therapist and his patient, holding that ". . . the therapist's obligations to his

patient require that he not disclose a confidence unless such disclosure is necessary to

avert danger to others . . . ." (Tarasoff, supra, p. 441; italics added). The holding in 

Tarasoff was questioned in Mason v. IHS Cedars Treatment Ctr. of Desoto Tex., Inc. (Tex. 

App. Dallas Aug. 15, 2001); criticized in Gregory v. Kilbride, 150 N.C. App. 601, 565 S.E.2d 

685 (N.C. App. 2002) and Tedrick v. Cmty. Res. Ctr., Inc., 235 Ill. 2d 155, 920 N.E.2d 220 (Ill.

2009); and superseded in part by Nebraska State statue in Munstermann v. Alegent

Health - Immanuel Med. Ctr., 271 Neb. 834, 716 N.W.2d 73, (Neb.2006). It should be 

noted that the Tarasoff ruling per se, upon which the principles of “Duty to Warn” and

“Duty to Protect” are based, originally applied only in the State of California and now 

applies only in certain jurisdictions. The U.S. Supreme Court has not heard a case

involving these principles. Many States have adopted statutes to help clarify steps that

are considered reasonable when a physician is pre-sentenced with someone making a 

threat of harm to a third party. Tasman, A., Kay, J., Lieberman, J. A., Fletcher, J. (eds). 

Psychiatry, 1st ed. Philadelphia: W.B. Saunders Company; 1997, p 1815.

7. Brisbane v. Outside in Sch. of Experiential Educ., Inc., 799 A.2d 89 (Pa. Super. Ct. 2002)

(defining factors in a Pennsylvania case to determine the existence of a duty: (1) the

relationship between the parties, (2) the social utility of the actor’s conduct, (3) the

nature of the risk imposed and foreseeability of the harm incurred, (4) the 

consequences of imposing a duty upon the actor, (5) the overall public interest in the

proposed solution). Pennsylvania did not expand the duty of a parent to encompass

supervision of adult children see Kazlauskas v. Verrochio (M.D. Pa. Oct. 27, 2014). Case

questioned by Bellah v. Greenson, 81 Cal. App. 3d 614, 146 Cal. Rpt., 535, 1978, 17

A.L.R. 4th 1118 (Cal. App. 1st Dist. 1978). Explained by Felty v. Lawton, 1977 OK 109, 578

P.2d 757 (Okla. 1977). For a general discussion on this topic see A.L.R. 3d 1201; 46 Ca. Jur., 

Negligence Sections 10 and 212.
110

8. Gooden v. Tips, supra at FN 5; Kaiser v. Suburban Transp. System, 65 Wn.2d 461, 398 P.2d 

14 (Wash.1965) (Washington case stating that a physician could be held liable due to the

fact that a patient took medication completely unaware that it would have any adverse

effect on him because the physician failed to warn his patient, whom he knew to be a bus 

driver, of the dangerous side effects of drowsiness or lassitude that may be caused by 

taking this particular medication). Superseded on other grounds by statute State v. Fisher

(Wash. Ct. App. May 29, 2012).

9. Calwell v. Hassan, 260 Kan. 769, 925 P.2d 422 (Kan. 1996) (Kansas case stating that the

doctor had no duty to protect bicyclists - a third party from his patient’s actions because 

the patient who had a sleep disorder was aware of the problem and admitted to knowing

that she should have stopped driving). Adams v. Bd. of Sedgwick County Comm'rs, 289

Kan. 577, 214 P.3d 1173 (Kan. 2009); Wilson v. McDaniel, 327 P.3d 1052, 2014 Kan. App.

Unpub. (Kan. Ct. App. 2014) (cited in dissenting opinion). Duvall v. Goldin, 139 Mich. App.

342, 362 N.W.2d 275, (Mich. App. 1984) (Michigan case stating the physician was liable to

third persons injured as it was foreseeable that a doctor’s failure to diagnose or properly 

treat an epileptic condition could have created a risk of harm to a third party and that as a 

result of the patient’s medical condition, caused an automobile accident involving the

third persons). Dawe v. Dr. 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 Veterans Affairs, 

2013 U.S. Dist. (E.D. Mich. Aug. 15, 2013). Myers v. Quesenberry, 144 Cal. App. 3d 888, 193

Cal. Rptr. 733 (Cal. App. 4th Dist. 1983) (California case stating that if a physician knows or

should know a patient’s condition will impair the patient’s mental faculties and motor

coordination, a comparable warning is appropriate). Distinguished in Greenberg v. 

Superior Court, 172 Cal. App. 4th 1339, 92 Cal. Rptr. 3d 96 (Cal. App. 4th Dist.2009)

Schuster v. Altenberg, 144 Wis. 2d 223, 424 N.W.2d 159 (Wis. 1988) (Wisconsin case

stating that if it was ultimately proven that it could have been foreseeable to a 

psychiatrist, exercising due care, that by failing to warn a third person or failing to take

action to institute detention or commitment proceedings someone would be harmed, 

negligence could be established). Distinguished by Milwaukee Deputy Sheriff's Ass'n v. City 

of Wauwatosa, 2010 WI App 95, 327 Wis. 2d 206, 787 N.W.2d438 (Wisc. App.2010) and

Hornback v. Archdiocese of Milwaukee, 2008 WI 98, 313 Wis. 2d 294, 752 N.W.2d 

862(Wisc. 2008).

10. Joy v. Eastern Maine Medical Center, 581 A.2d 418 (Me. 1990) (appeal after remand

affirmed) (Mainecase stating that when the doctor knew, or reasonably should have 

known that his patient’s ability to drive has been affected by treatment that the doctor

provided, he had a duty to the driving public as well as to the patient to warn his patient

of that fact). Distinguished by Flanders v. Cooper, 1998 ME 28, 706 A.2d 589 (Me. 1998).

11. Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-

191. 45 C.F.R.§ 164.512(a)—Uses and Disclosures Required by Law (2000). Federal 

Register Vol. 65, No. 250, Thursday, December 28, 2000, Rules and Regulations, p 

82811. Available at 
111

www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/prdecember2000all8part

s.pdf (updated rule) www.ecfr.gov/cgi-bin/text-idx?tpl=/ecfrbrowse/ 

Title45/45cfr160_main_02.tpl

12. De Bord, J., Burke, W., & Dudzinski, D. (2013). Ethics in Medicine. Seattle: University of 

Washington School of Medicine. Retrieved from the university website at

https://depts.washington.edu/bioethx/topics/confiden.html (2013). See also: American

Society of Consultant Pharmacists (2011), Quality Standards and Practice Principles for 

Senior CarePharmacists at www.ascp.com/articles/quality-standards-and-practiceprinciples-senior-care-pharmacists and American Nurses Association (2001). Code of 

ethics for nurses with interpretive statements at www.nursingworld.org/provision-3 

13. Retchin, S. M., & Anapolle, J. (1993). An overview of the older driver. Clinics in Geriatric 

Medicine, 9(2), 279-296.

14. Ferguson v. City of Charleston, 532 U.S. 67, 121 S. Ct. 1281, 149 L. Ed. 2d 205 (2001).

Remanded 308, F. 3d 380 (4th Cir. S.C. 2002). Certiorari Denied. 539 U.S. 928, 123 S. Ct.

2583, 156 L. Ed. 2d 605, 2003 U.S. LEXIS 4631, 71 U.S.L.W. 3744 (2003) (deliberating in a 

South Carolina case the benefits and risks of physician disclosing confidential patient 

information when that confidential information may protect patients and society from 

possible harm). Distinguished by United States v. Zadeh, 2015 U.S. Dist. LEXIS 11538 (N.D.

Tex. Jan. 31, 2015) and United States v. Katzin, 732 F.3d 187, 2013 U.S. App. (3d Cir. Pa. 

2013). Conflicting Authority People v. Peppers, 352 Ill. App. 1002, 817 N.E. 1152 (Ill. App.

Ct. 1st Dist. 2004) at p 1006.

15. Justice, J. (1997). Patient confidentiality and pharmacy practice. Consult Pharmacist, 

12(11). Available at: www.ascp.com/articles/quality-standards-and-practice-principlessenior-care-pharmacists See also: Erickson, J., & Millar, S. (2005, May 31). Caring for

Patients While Respecting Their Privacy: Renewing Our Commitment. The Online Journal

of Issues in Nursing. Vol. 10 No. 2, Manuscript 1. Available at:

www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tab

leofContents/Volume102005/No2May05/tpc27_116017.html

16. Tasman, A., Kay, J., Lieberman, J. A., & Fletcher, J. (eds). (1997). Psychiatry, 1st ed. P. 1808.

Philadelphia: W. B. Saunders Company. See also: Quality standards and practice principles 

for Senior care pharmacists quality standard three section 8 supra.

17. American Society of Consultant Pharmacists. (2011). Quality Standards and Practice

Principles for Senior Care Pharmacists. Available at www.ascp.com/articles/qualitystandards-and-practice-principles-senior-care-pharmacists See also: American Nurses

Association. (2001). Code of ethics for nurses with interpretive statements. Available at

www.nursingworld.org/provision-3 
112

18. Shawn, C., Marshall, M., D., & Gilbert, N. (1999). Saskatchewan physicians’ attitudes 

and knowledge regarding assessment of medical fitness to drive. Canadian Medical

Association Journal, 160(12), 1701–1704.

19. Meuser, T. M., Carr, D. B., Ulfarsson, G. F., Berge-Weger, M., Niewoehner, P., Kim, J. K., ... 

Osberg, S. (2008). Medical Fitness to Drive and a Voluntary Reporting Law. Washington, DC: 

AAA Foundation for Traffic Safety. Available at 

www.aaafoundation.org/sites/default/files/MedicalFitnesstoDriveReport.pdf

20. West, K., Bledsoe, L., Jenkins, J., & Nora, L. M. (2001). The Mandatory Reporting of Adult 

Victims of Violence: Perspectives from the Field. 90 Kentucky Law Journal, 1071 (2001-

2002). See also: Kelly, R., Warke, T., & Steele, I. Medical restrictions to driving: the

awareness of patients and doctors. Postgraduate Medical Journal, 75, 537–539.

21. Older Californian Traffic Safety Task Force, Health Services Workgroup and Policy and

Legislation Workgroup, p.2. Retrieved from the Task Force website at 

http://eldersafety.org/pdfs/MandatoryPhysicianReportingFactSheet-final.pdfThe six

States are: California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania. 

22. 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. Available at http://www.biopticdriving.org/repository/main/-

drvsummaryofmedicaladvisoryboardpractices.pdf See also Meuser, T.M., Carr, D.B., 

Ulfarsson, G.F., Berge-Weger, M., Niewoehner, P., Kim, J.K., ...Osberg, S. (2008). Medical 

Fitness to Drive and a Voluntary Reporting Law. Washington, DC: AAA Foundation for 

Traffic Safety. 

23. National Committee on Uniform Traffic Laws and Ordinances. (n.d.) Reporting of Driver 

Impairment Model Law (Web page). Retreived from the committee’s website at

www.ncutlo.org/impairment.htm

24. Lococo, K., & Staplin, L. (2004). In-depth study to identify best practices for licensing 

drivers with medical and functional impairments and barriers to their implementation. 

(Published under Contract Task Order DTNH22-02-P-05111). Washington, DC: National

Highway Traffic Safety Administration. 

25. Duvall v. Goldin, supra at FN 9.

26. Carr, D. B. (2000). The older adult driver. American Family Physician., 61(1), 141–148.

27. National Highway Traffic Safety Administration. (n.d.) Driving Safely While Aging Gracefully. 

Washington, DC: Author. Available at

www.nhtsa.gov/people/injury/olddrive/Driving%20Safely%20Aging%20Web/
113

28. National Highway Traffic Safety Administration. (n.d.) Drive Well Toolkit: Promoting Older 

Driver Safety and Mobility in Your Community (Web page/portal). Washington, DC: Author. 

Available at

www.nhtsa.gov/Driving+Safety/Older+Drivers/Drive+Well+Toolkit:+Promoting+Older+Driv

er+Safety+and+Mobility+in+Your+Community

29. Kaplan, N., & White, M. (2007, May). Getting Around: Alternatives for Seniors Who No 

Longer Drive. Washington, DC: AAA Foundation for Traffic Safety. Available at

www.aaafoundation.org/sites/default/files/GettingAroundReport.pdf

30. Sterns, H. L., Sterns, R., Aizenberg, R., & Anapole, R. (2001, August). Family and Friends 

Concerned About an Older Driver (Report No. DOT HS 809 307). Washington, DC:

National Highway Traffic Safety Administration. Available at 

http://ntl.bts.gov/lib/26000/26000/26070/DOT-HS-809-307.pdf

31. American Medical Association. (2008). The American Medical Association Principles of 

Medical Ethics; Preamble, generally I-IX. Adopted June 1957, revised June 1980, revised

June 2001. Code of Medical Ethics of the American Medical Association: Council on 

Ethical and Judicial Affairs; 2008–2009 Edition. Chicago: Author.

32. 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.

33. 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.

34. 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.
114

CHAPTER 8 STATE LICENSING AND REPORTING LAWS

Key Points

• Each State has its own licensing and license renewal criteria.

• Licensing and license renewal information is subject to change, and statues for

specific States should be checked for up-to-date changes in laws or requirements.

Each State has its own licensing and license renewal criteria for drivers of private motor

vehicles. In addition, certain States require health care professionals to report unsafe drivers

or drivers with specific medical conditions to the driver licensing agency. State law

restrictions for older drivers vary according to age requirements of additional drivers, length

of renewal cycle, vision requirements, license restrictions, level of mandatory reporting by

health care professionals, civil immunity, anonymity protection, and process for evaluation

by medical advisory boards. The effectiveness of driving restrictions in reducing vehicle

crashes or fatalities involving older adults also varies from State to State. 

Licensing agency contact information by State is listed below, along with additional

resources for locating license renewal criteria, reporting procedures, and medical advisory

board information. These materials are intended to guide health care professionals in

understanding their legal responsibilities and managing the driving safety of their patients. 

The information provided should neither be construed as legal advice nor used to resolve

legal problems. If legal advice is required, a licensed attorney (in the relevant State) should

be consulted.

A database of driver licensing policies and practices for licensing requirements, license 

renewal procedures, reporting procedures, medical advisory board information, and more

can be found at http://lpp.seniordrivers.org/lpp/index.cfm?selection=visionreqs.

This information is subject to change, and statues for specific States should be checked for

up- to-date changes in laws or requirements. This is especially important when creating a 

clinic policy or deciding on an individualized approach to reporting. Legal counsel is

recommended to advise on decision-making in this area.

If information is not available from a specific State’s driver licensing agency, the following

references, which are updated frequently, may be useful:

• Insurance Institute for Highway Safety (www.iihs.org/iihs/topics/laws/olderdrivers)

• Insurance Information Institute (www.iii.org/)
115

Testing procedures and regulations impose significant costs on States and, at times,

inconvenience and costs to individual drivers. If licenses are revoked, older adults face the

problems of restricted mobility and loss of out-of-home activities, which may decrease social

connectedness. In addition, the impact on family members and caregivers, such as time away

from work, is not insignificant. This burden must be carefully weighed against the actual

“added value” or benefits of improved public safety.1

State Licensing Agencies

Alabama

Alabama Law Enforcement Agency Department of Public Safety

PO Box 1471

Montgomery, AL 36102-1471

www.alea.gov

334-242-4400

Alaska

Alaska Department of Administration Division of Motor Vehicles

1300 W. Benson Boulevard 

Anchorage, AK 99503-3696

www.state.ak.us/dmv/

907-269-5551

Arizona

Arizona Department of Transportation

Motor Vehicle Division

PO Box 2100, Mail Drop 555M

Phoenix, AZ 85001-2100

www.azdot.gov/mvd/ 

800-251-5866

Arkansas

Arkansas Department of Finance and Administration Arkansas Driver Control

1910 West W. 7th St., Rm 1070

Little Rock, AR 72201

www.state.ar.us/dfa/odd/motor_vehicle.html 

501-682-1631
116

California

California Department of Motor Vehicles Licensing Operations Division

2570 24th Street, MS J152

Sacramento, CA 95818-2698

www.dmv.ca.gov/ 

916-657-6550

Colorado

Colorado Department of Revenue Division of Motor Vehicles

1881 Pierce Street, Room 136

Lakewood, CO 80214

www.colorado.gov/revenue/dmv 

303-205-5600

Connecticut

Connecticut Department of Motor Vehicles 

60 State Street

Wethersfield, CT 06161-2510

www.ct.gov/dmv/site/default.asp 

860-263-5700

Delaware

Delaware Division of Motor Vehicles

Driver License Administration Medical Section 

PO Box 698

Dover, DE 19903

www.dmv.de.gov 

302-744-2507

District of Columbia

District of Columbia Department of Motor Vehicles Medical Review Office

301 C Street NW.

Washington, DC 20001

www.dmv.dc.gov/ 

202-737-4404

Florida

Florida Highway Safety and Motor Vehicles

Medical Review Office 

www.flhsmv.gov/floridagranddriver/reportUnsafeDriver.html 

850-617-3814
117

Georgia

Georgia Department of Driver Services Attn: Medical Unit

PO Box 80447

Conyers, GA 30013

www.dds.ga.gov/drivers/index.aspx

678-413-8400 or outside Atlanta metro 866-754-3687

Hawaii

Honolulu Department of Customer Services Division of Motor Vehicles & Licensing 1199

Dillingham Boulevard, Bay A 101

Honolulu, HI 96817

www.honolulu.gov/csd/default.html 

808-532-7730

Idaho

Idaho Transportation Department

Division of Motor Vehicles - Driver Services

PO Box 7129

Boise, ID 83707-1129

www.itd.idaho.gov/dmv/online_services.htm 

208-334-8736

Illinois

Illinois Office of the Secretary of State

Driver Services Department

2701 S. Dirksen Parkway

Springfield, IL 62723

217-782-6212

Driver ServicesDepartment–Metro 

17 N. State Street, Suite 1100

Chicago, IL 60602

312-793-1010

www.cyberdriveillinois.com/

Indiana

Indiana Bureau of Motor Vehicles

Indiana Government Center North 100 N Senate Avenue, Room 402

Indianapolis, IN 46204

www.in.gov/bmv/ 

888-692-6841
118

Iowa

Iowa Department of Transportation Motor Vehicles Division

PO Box 9204

Des Moines, IA 50306-9204

www.dot.state.ia.us/mvd/ 

515-237-3121 or 800-532-1121

Kansas

Kansas Department of Revenue

Division of Motor Vehicles, Driver Solutions 

PO Box 12021

Topeka, KS 66612-2021

www.ksrevenue.org 

785-296-3963

Kentucky

Kentucky Transportation Cabinet Division of Driver Licensing

200 Mero Street

Frankfort, KY 40622

http://transportation.ky.gov/Driver-Licensing/Pages/default.aspx 

502-564-0280

Louisiana

Louisiana Office of Motor Vehicles Office of Motor Vehicles

PO Box 64886

Baton Rouge, LA 70896

www.expresslane.org 

225-925-6146

Maine

Maine Bureau of Motor Vehicles Attn: Medical Advisory Board

29 State House Station 

Augusta, ME 04333-0029

www.state.me.us/sos/bmv 

209-624-9000 ext 52124
119

Maryland

Maryland Motor Vehicle Administration 6601 Ritchie Highway NE

Glen Burnie, MD 21062

www.mva.maryland.gov/ 

410-768-7000 or 800-492-4575

Massachusetts

Massachusetts Registry of Motor Vehicles Medical Affairs Branch

PO Box 199100

Boston, MA 02119-9100

www.mass.gov/portal/ 

857-368-8000 or 800-858-3926

Michigan

Michigan Department of State

Driver Assessment and License Appeal Unit 

Lansing, MI 48918

www.michigan.gov/sos

888-767-6424

Minnesota

Minnesota Department of Public Safety Driver and Vehicle Services

Attn: Medical Unit

445 Minnesota Street, Suite 170

St Paul, MN 55101-5170

http://dps.mn.gov/Pages/default.aspx 

651-296-2025

Mississippi

Mississippi Department of Public Safety Driver Improvement PO Box 958

Jackson, MS 39205

www.dps.state.ms.us

601-987-1515 or 601-987-1231

Missouri

Missouri Department of Revenue

301 West High Street, Room 470

Jefferson City, MO 65105-0200

www.dor.mo.gov/mvdl/drivers/ 

573-751-2730
120

Montana

Montana Department of Justice Motor Vehicles Division

PO Box 201430

Helena, MT 59620-1430

https://dojmt.gov/driving/#contact 

406-444-4590

Nebraska

Nebraska Department of Motor Vehicles Driver Licensing Services

301 Centennial Mall South, PO Box 94726

Lincoln, NE 68509-4726

www.dmv.nebraska.gov/ 

402-471-3861

Nevada

Nevada Department of Motor Vehicles Management Services and Programs Division 555

Write Way 

Carson City, NV 89711

www.dmvnv.com 

775-684-4562

New Hampshire

New Hampshire Department of Safety Division of Motor Vehicles

10 Hazen Drive

Concord, NH 03305

www.nh.gov/safety 

800-735-2964

New Jersey

New Jersey Division of Motor Vehicles Medical Fitness Review Unit

PO Box 173

Trenton, NJ 08666-0173

www.state.nj.us/mvc/Licenses/medical_review.htm 

609-292-7500 ext 5032

New Mexico

New Mexico Motor Vehicles Division Drivers Services Bureau

PO Box 1028

Santa Fe, NM 87504-1028

www.mvd.newmexico.gov/ 

888-683-4636
121

New York

New York Department of Motor Vehicles Medical Review Unit

6 Empire State Plaza, Room 337

Albany, NY 12228

http://dmv.ny.gov/driver-license/dmvs-medical-review-program

518-474-0774

North Carolina

North Carolina Division of Motor Vehicles Driver License Medical Division

1100 New Bern Ave

Raleigh, NC 27697

www.ncdot.gov/DMV/ 

919-861-3809

North Dakota

North Dakota Department of Transportation Drivers License Division

Attn: Chief Examiner

608 East Boulevard Avenue

Bismarck, ND 58505-0750

www.dot.nd.gov/ 

701-328-4353

Ohio

Ohio Bureau of Motor Vehicles

Driver License Special Case Section/Medical Unit 

PO Box 16784

Columbus, OH 43216-6784

www.bmv.ohio.gov 

614-752-7500

Oklahoma

Oklahoma Department of Public Safety Driver Improvement Division

Attn: Medical Advisory Committee

PO Box 11415

Oklahoma City, OK 73136-0415

www.dps.state.ok.us/dls/ 

405-425-2059
122

Oregon

Oregon Department of Motor Vehicles Driver Safety Unit

1905 Lana Avenue NE

Salem, OR 97314-4120

www.oregon.gov/ODOT/DMV/Pages/index.aspx 

503-945- 5083 or 503-945-5295

Pennsylvania

Pennsylvania Department of Transportation Bureau of Driver Licensing

Driver Qualifications Section 

PO Box 68682

Harrisburg, PA 17106-8682

www.dmv.state.pa.us/centers/olderDriverCenter.shtml 

717-787-9662

Rhode Island

Rhode Island Department of Revenue Division of Motor Vehicles

Medical Review Board 

600 New London Ave

Cranston, RI 02920

www.dmv.ri.gov/ 

401-462-0800

South Carolina

South Carolina Department of Motor Vehicles 

PO Box 1498

Blythewood, SC 29016

www.scdmvonline.org/DMVNew/ 

803-896-5000

South Dakota

South Dakota Department of Public Safety Driver Licensing 

118 West Capitol Avenue

Pierre, SD 57501

http://dps.sd.gov/

800-952-3696 or 605-773-6883
123

Tennessee

Tennessee Department of Safety & Homeland Security Driver License Division

1150 Foster Ave

Nashville, TN 37249-1000

http://state.tn.us/safety/driverservices.shtml 

615-741-3954

Texas

Texas Department of Public Safety Driver License Division

Enforcement and Compliance Service

PO Box 4087

Austin, TX 78773-0320

www.txdps.state.tx.us 

512-424-2600

Utah

Utah Department of Public Safety Driver License Division

PO Box 144501

Salt Lake City, UT 84129

www.driverlicense.utah.gov 

801-965-4437

Vermont

Vermont Department of Motor Vehicles 

120 State Street

Montpelier, VT 05603-0001

http://dmv.vermont.gov/

802-828-2000 or 802-828-2011

Virginia

Virginia Department of Motor Vehicles Medical Review Services

PO Box 27412

Richmond, VA 23269-0001

www.dmv.state.va.us/ 

804-497-7100
124

Washington

Washington State Department of Licensing Driver Records

PO Box 9030

Olympia, WA 98507-9030

www.dol.wa.gov/ 

360-902-3900

West Virginia

West Virginia Department of Transportation Division of Motor Vehicles

Medical Review Services

PO Box 17030

Charleston, WV 25317

www.transportation.wv.gov/dmv/Pages/default.aspx 

800-642-9066 or 304-926-3961

Wisconsin

Wisconsin Department of Transportation Medical Review

PO Box 7918

Madison, WI 53707-7918

www.dot.wisconsin.gov/drivers/index.htm 

608-266-2327

Wyoming

Wyoming Department of Transportation Driver Services Program

5300 Bishop Blvd.

Cheyenne, WY 82009-3340

http://dot.state.wy.us

307-777-4800

AdditionalResources

AAA/CAA Digest of Motor Laws 

http://drivinglaws.aaa.com/

Driver Licensing Policies and Practices

http://lpp.seniordrivers.org/lpp/index.cfm?selection=visionreqs

Insurance Institute for Highway Safety 

www.iihs.org/laws/olderdrivers.aspx

Insurance Information Institute 

www.iii.org
125

Reference

1. Miller, T. R., & Levey, D. T. (2000). Cost-outcome analysis in injury prevention and

control: Eighty-four recent estimates for the United States. Medical Care, 28(6), 562–

582.
126

CHAPTER 9 MEDICAL CONDITIONS, FUNCTIONAL DEFICITS, AND MEDICATIONS

THAT MAY AFFECT DRIVING SAFETY

Key Points

• Many medical conditions, functional deficits, and/or medications may potentially

impair driving.

• Treat the underlying medical condition and/or functional deficit to improve the

condition/impairment or limit progression.

• If the functional deficit is due to an identifiable offending agent (e.g., medication

with potentially driver-impairing [PDI] effects), remove the offending agent or

reduce the dose, if possible.

• Advise the older adult about the risks to his or her driving safety, consider referral for

assessment of driving performance, recommend driving restrictions or driving cessation

as needed, and document the discussion in the health record.

This chapter contains reference tables of medical conditions, functional deficits, and

medications that may impair driving skills, with associated consensus recommendations.

Whenever scientific evidence supports the recommendations, it is included. These

recommendations apply only to drivers of private motor vehicles and should not be applied to

commercial drivers. Although many of the listed medical conditions are more prevalent in the

older population, the recommendations apply to all drivers with medical impairments,

regardless of age.

The medical conditions were chosen for their relevance to clinical practice and/or because

there is some evidence-based literature indicating an association with driving impairment.

Interested clinicians are referred to reviews that provide details regarding individual conditions

or deficits, as well as guidelines from other countries, including Australia, Canada, Ireland, and

the United Kingdom.1-8

Although these recommendations are based on scientific evidence whenever possible, their use

per se has not yet been proved to reduce crash risk.* However, increasing evidence suggests

that interventions for some medical conditions (e.g., treating obstructive sleep apnea,

performing cataract surgery, discontinuing a benzodiazepine) and functional deficits (e.g.,

improving information processing speed, physical ability), combined with classroom and onroad training may lower crash risk or enhance/maintain driving performance. As such, these

recommendations are provided as a means to help raise awareness of which drivers might be at

increased risk, suggest options for intervention, and guide the decision-making process.

When evidence is not available, the recommendations are based on consensus

recommendations and best clinical judgment. They are not intended to substitute for the

individual clinician’s judgment.

*Note: Although scientific evidence links certain medical conditions and levels of functional impairment with crash
127

risk, more research is needed to establish that driving restrictions based on these medical conditions and levels of

functional impairment significantly reduce crash risk.

How to Use This Chapter

Clinicians may consult this chapter for questions on specific medical conditions, functional

deficits (e.g., deficits in vision, cognition, or motor function), and/or medications that may have

an effect on driving safety. If an older adult presents with any of these issues, clinicians may

base further assessment and interventions for driving safety on the guidelines presented here.

General Recommendations

• Treat the underlying medical condition and/or functional deficit to improve the

condition/impairment or limit progression.

• If the functional deficit is due to an identifiable offending agent (e.g., medication

with PDI effects), remove the offending agent or reduce the dose, if possible.

• If the functional deficit can be addressed through compensation or modification

(e.g., hand controls, left foot accelerator), refer for a comprehensive driving

evaluation.

• Advise the older adult about the risks to his or her driving safety, consider referral for

assessment of driving performance, recommend driving restrictions or driving cessation

as needed, and document the discussion in the health record. 

• For acute or episodic illnesses (e.g., seizure disorder and/or diabetes with

hypoglycemia), clinical judgment and subspecialist input is recommended, in addition to

following specific State statutes.

If further evaluation is required and desirable, or the conditions and/or functional deficits are

not medically correctable, the older adult should be referred to a driver rehabilitation specialist

(DRS) for a driving evaluation (including on-road assessment). The DRS may prescribe adaptive

equipment and training on how to use it (see Chapter 5).

Clinicians should advise older adults against driving if they report symptoms that are

irreversible, for which no safe compensatory techniques/equipment are available, and are

incompatible with safe driving (e.g., visual changes, syncope or presyncope, vertigo, etc.). If

these symptoms continue despite extensive medical evaluation and treatment, such

individuals should be strongly urged to seek alternative forms of transportation, including

taxis, rides from family and friends, and medical transportation services.

In the hospital and the emergency department, driving should be routinely addressed before

the older adult’s discharge whenever appropriate, especially in the presence of new functional

deficits or when prescribing new medications. Even for the older adult whose symptoms or

treatment clearly precludes driving, it should not be assumed that the person is aware that he

or she should not drive. The clinician should counsel the older adult regarding driving and
128

discuss a future plan (e.g., resumption of driving on resolution of symptoms, driver

rehabilitation on stabilization of symptoms, reassessment by the primary clinician or relevant

specialist before driving resumption) and document the discussion in the health record.

An older adult’s driving purposes may range from being responsible for taking grandchildren to

day care to driving for a vocation (e.g., a salesperson who drives throughout a region). Such

differences may influence the extent of the interventions or advice in regard to an evaluation.

For example, more restriction or a performance-based road test may be more aggressively

pursued for an older adult who frequently drives long distances over unfamiliar roads versus

for one who drives short, familiar routes.

Reference Tables of Medical Conditions, Functional Deficits, and Medications

That May Affect Driving Safety

Various medical conditions and/or functional deficits are covered in the following sections (with

corresponding tables). Conditions treated with medications with PDI effects are listed at the

end of the discussion for that condition and cross-referenced to Section 13 (on medications) for

more information.

Section 1: Vision and Hearing Loss

Section 2: Cardiovascular Disorders

Section 3: Cerebrovascular Disorders

Section 4: Neurologic Disorders

Section 5: Psychiatric Disorders

Section 6: Metabolic Disorders

Section 7: Musculoskeletal Disorders

Section 8: Peripheral Vascular Disorders

Section 9: Renal Disorders

Section 10: Respiratory and Sleep Disorders

Section 11: Effects of Anesthesia and Surgery

Section 12: Cancer

Section 13: Medications
129

Section 1: Vision and Hearing Loss

Vision is the primary sense used in driving (versus hearing and proprioception) and is responsible

for 95% of driving-related sensory inputs.9 Age- and disease-related changes of the eye and brain

may affect visual acuity, visual fields, night vision, contrast sensitivity, and other aspects of vision.

External obstruction of view (e.g., blepharoptosis) should not be overlooked, because it may

significantly limit visual fields. The literature on eye disease suggests that driving impairment is 

likely mediated by impairment in contrast sensitivity,10 visual fields,11 or visual processing speed.

Whenever possible, vision deficits should be managed and corrected. Interventions for 

common eye diseases such as age-related macular degeneration,12 glaucoma,13 and cataracts14

have the potential to improve or stabilize the condition, and in some cases these interventions

have been noted to reduce crash risk.15 Older adults with persistent vision deficits may

potentially reduce their effect on driving safety by restricting travel to low-risk areas and

conditions, such as familiar surroundings, low-speed areas, non-rush hour traffic, daytime, and

good weather conditions. This has been noted for certain eye diseases, such as glaucoma.16 It

should also be noted that bioptic driving is now allowed in 37 States.17 Bioptic driving is a 

method of driving in which a small telescopic system is used to improve a person’s far vision for

some visually impaired individuals and might be considered for some drivers. The

recommendations below are subject to each State’s licensing requirements. For resources to

locate Internet listings for current individual State laws, see Chapter 8.

SensoryDeprivation

1. Visual acuity

a. Cataracts

b. Retinopathy (diabetic or hypertensive)

c. Keratoconus

d. Macular degeneration

e. Nystagmus

f. Telescopic lens

2. Visual field

a. Glaucoma

b. Hemianopia/quadrantanopia

c. Monocular vision

d. Ptosis or upper lid redundancy

e. Retinitis pigmentosa

3. Contrast sensitivity

4. Defective color vision

5. Poor night vision and glare recovery

6. Diplopia

7. Hearing loss
130

Table 9.1 SensoryDeprivation

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

retinopathy

No restrictions if standards for visual acuity and visual fields are

met.

Annual eye examinations are recommended for diabetic

individuals.
131

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

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 Requirementsfor

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.
132

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 along 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 rear view

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/

quadrantanopia

Clinicians may choose to refer older adults to a DRS for

assessment and rehabilitation. With or without rehabilitation,

older adults should drive only if they demonstrate safe driving

ability in an on-road assessment performed by a DRS.
133

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.

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 

blepharospasm restrictions if their eyelids do not obscure the visual axis of either

eye and they are able to meet standards for visual acuity and visual

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.

Contrastsensitivity 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).
134

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.20 Some 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.

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, a recent study suggested

that a combination of hearing and vision deficits might increase

crash risk.21
135

Section 2: Cardiovascular Disorders

1. Unstable coronary syndrome (unstable angina or myocardial infarction)

2. Cardiac rhythm abnormalities that may cause a sudden, unpredictable loss of consciousness

a. Atrial flutter/fibrillation with bradycardia or rapid

ventricular response

b. Paroxysmalsupraventricular tachycardia, including WolfParkinson-White syndrome

c. Prolonged, nonsustained ventricular tachycardia

d. Sustained ventricular tachycardia

e. Cardiac arrest

f. High-grade atrioventricular block

g. Sick sinus syndrome/sinus bradycardia/sinus exit

block/sinus arrest

3. Cardiac disease resulting from structural or functional abnormalities

a. Congestive heart failure with low output syndrome

b. Hypertrophic obstructive cardiomyopathy

c. Valvular disease (especially aortic stenosis)

4. Time-limited restrictions: cardiac procedures

a. Percutaneoustransluminal coronary angioplasty

b. Pacemaker insertion or revision

c. Cardiac surgery involving median sternotomy

d. Coronary artery bypass graft

e. Valve repair or replacement

f. Heart transplant

5. Internal cardioverter defibrillator (ICD)

Although the data are still unclear in regard to a definitive relationship between crash risk and

cardiovascular diseases, one study noted a modest increase in total crash risk and at-fault risk

for older adults with cardiac disease.22 For older adults with known cardiac disease, clinicians

should strongly and repeatedly caution such individuals to seek help immediately on

experiencing any symptoms that may indicate an unstable cardiac situation, including

prolonged chest discomfort, acute shortness of breath, syncope, presyncope, palpitations,

lightheadedness, etc. Under no circumstances should the older adult drive while experiencing

these symptoms, even to seek help.
136

Table 9.2 Cardiovascular Disorders

Unstable coronary syndrome

(unstable angina or myocardial

infarction)

Older adults should not drive if they experience symptoms at

rest or at the 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 conditionsthat may

cause a sudden, unpredictable

loss of consciousness

A main consideration in determining medical fitness to

drive for older adults with cardiac conditions is the risk of

presyncope or syncope due 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 or rapid ventricular

response

No further restrictions once heart rate and symptoms

have been controlled.

Paroxysmal supraventricular

tachycardia, including WolfParkinson-White syndrome

No restrictions if the older adult is asymptomatic during

documented 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.
137

Prolonged, nonsustained 

duringventricular tachycardia 

(VT)

No restrictions if the older adult is asymptomatic documented

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

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.
138

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/sinus exit 

block/sinus arrest

No restrictions if the older adult is asymptomatic. Regular

medical follow-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

structural orfunctional

abnormalities

A main consideration in determining medical fitness to

drive for older 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
139

Congestive heart failure with

low output syndrome

Older adults should not drive if they experience symptoms at

rest or while 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

cardiomyopathy

OIder adults who experience syncope or presyncope should

not drive until they have been successfully treated.

Valvular disease (especially

aortic stenosis)

Older adults who experience syncope or presyncope or

unstable angina should not drive until the underlying

disease is corrected.

Time-limitedrestrictions:

cardiac procedures

Driving restrictions for the following cardiac procedures are

based on the older adult’s recovery from both the

procedure itself and the underlying disease for which the

procedure was performed.

Percutaneoustransluminal

coronary angioplasty (PTCA)

Older adults may resume driving 48 hours to 1 week after

successful 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
140

Cardiac surgery involving

median sternotomy

Driving may usually resume 4 weeks after coronary artery

bypass grafting (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, onroad testing performed by a DRS may be useful in

assessing the older adult’s fitness to drive.

Internal cardioverter

defibrillator(ICD)

See the recommendations for nonsustained and sustained

ventricular 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 asymptomatic.27
141

Section 3: Cerebrovascular Disorders

1. Post intracranial surgery

2. Stroke

3. Transient ischemic attacks

4. Subarachnoid hemorrhage

5. Vascular malformation

6. Syncope

Strokes and other insults to the cerebrovascular system may cause a wide variety of symptoms,

including sensory deficits (e.g., numbness or loss of sensation), motor deficits (e.g., weakness),

and cognitive impairment (e.g., memory, hemispatial inattention). These symptoms range from

mild to severe and may resolve almost immediately or persist for years. Because each person is

affected uniquely, the clinician must take into account the individual older adult’s constellation

of symptoms, severity of symptoms, course of recovery, and baseline function when making

recommendations concerning driving. Studies have indicated that a substantial number of

community-dwelling stroke patients continue to drive a car.28 However, most stroke patients

may not receive any type of formal driving evaluation, but simply resume driving.29 If present,

the larger a homonymous visual field defect, the greater the likelihood of losing one’s license.

Unfortunately, many individuals may not be aware of this deficit.30

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 this evaluation depends on the severity

and extent of the deficits, many evaluations for cognitive and motor defects are performed

between 3 and 6 months. Once symptoms have stabilized, the DRS should assess the older adult

for fitness-to-drive through a comprehensive driving evaluation that includes clinical and onroad components. After assessment, the DRS may recommend compensatory techniques

and/or adaptive devices (e.g., wide rear view mirror, spinner knob for steering wheel, left foot

accelerator) and provide training in their use. Even individuals with mild deficits should undergo

driver evaluation before resuming driving, if possible. Research indicates that a post-stroke

determination of driving safety made on a medical basis alone may be inadequate.31 Several

studies note associations with impairment on road tests with measures of perception, visual

selective attention, mental speed, working memory, executive function, and complex visualperception/attention information.32-34

For older adults whose symptoms clearly preclude driving, it should not be assumed that the

individual is aware that he or she should not drive. In such cases, the clinician should counsel

the older adult on driving cessation and document the discussion in the health record. Recovery

from stroke may take up to a year and even though the older adult may not be able to drive

within the first 3–6 months, it is possible that he or she may improve after a year to have the

potential to drive.35-37
142

Table 9.3 Cerebrovascular Disorders

Post intracranialsurgery Older adults should not drive until symptoms of the disease

and/or surgery have stabilized or 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 ortemporary.

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.
143

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 attacks (TIA) Older adults who have experienced a single TIA or recurrent

TIAs should not drive until they have undergone medical

assessment and appropriate treatment.

Subarachnoid hemorrhage Older adults should not drive until symptoms have stabilized

or resolved. Driving may resume after medical assessment

and, if deemed necessary by the clinician, driver evaluation,

including on-road assessment, performed by a DRS.

Vascular malformation If a brain aneurysm or arteriovenous malformation is

detected, the older adult should not drive 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).

Syncope Although the cause of syncope is often not identified,

neurocardiogenic (or reflex mediated), orthostatic, and

cardiac arrhythmia are among the most common etiologies

when a cause can be found.38,39 In a case-control study of

patients evaluated for syncope, neurally mediated and cardiac

arrhythmia were the most common etiologies when a cause

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
144

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

1. Brain tumor

2. Closed head injury

3. Dementia

4. Migraine and other recurrent headache syndromes

5. Movement disorders

6. Multiple sclerosis

7. Paraplegia and quadriplegia

8. Parkinson disease

9. Peripheral neuropathy

10. Seizure disorder

a. Single unprovoked seizure

b. Withdrawal or change of anticonvulsant drug therapy

11. Sleep disorders

a. Narcolepsy

b. Sleep apnea

12. Stroke

13. Tourette syndrome

14. Vertigo

Dementia deserves special emphasis, because it presents a significant challenge to driving

safety. As the disease progresses, individuals will ultimately lose the ability to drive safely. In

addition, older adults with dementia often lack insight into their deficits and, therefore, may be

more likely than drivers with visual or motor deficits (who tend to self-restrict their driving to

accommodate their declining abilities) to drive even when it is unsafe. In this case, it becomes

the responsibility of family members and other caregivers to protect the safety of older adult

drivers with dementia by enforcing driving cessation when this becomes necessary.

Several reviews on this topic may be of interest to clinicians.42-45 Fitness-to-drive studies in

older adults with dementia indicate that 90% may be able to pass a road test in the very mild

stages of the disease (clinical dementia rating of 0.5), whereas 40% may fail at a mild level of

cognitive impairment (clinical dementia rating of 1.0).46 Furthermore, most older adults with

Alzheimer disease will eventually fail subsequent road tests when followed longitudinally,

indicating that repeat testing at 6–12 months should be strongly considered.47 However, there

is uncertainty about prospective risk, at least in the near term. In one longitudinal study, some
145

mildly demented drivers not only passed a performance-based road test but also had an

acceptable crash risk prospectively.48 Although in-office evaluation may not replace an on-road

assessment,49 classification rates may improve as evidence mounts for measures of relevant

cognitive and other abilities.50-51 In addition, a dementia and driving curriculum modeled after

an earlier version of this guide has been shown to improve knowledge, attitudes, confidence,

and behaviors for health professionals who deal with older adults with dementia.52

Although it is optimal to initiate discussions of driving safety with older adults and caregivers

before driving becomes unsafe, dementia may be undetected and undiagnosed until late in the

course of the disease. Initially, caregivers and clinicians may assume that the older adult’s

decline in cognitive function is a part of the “normal” aging process. Clinicians may also hesitate

to screen for and diagnose dementia, because they feel that it is futile and that nothing can be

done to improve the older adult’s situation or slow disease progression. In addition, clinicians

may be concerned about the amount of time required to effectively diagnose dementia and

educate older adults and caregivers.53 However, some individuals are able to achieve cognitive

stability, at least for a time, with cholinesterase inhibitors or N-methyl-D-aspartate (NMDA)

receptor antagonists. In addition, older adults are now being diagnosed on the “cusp” of the

disease in the very early stages. A diagnosis of dementia by itself should not preclude driving

but should prompt a discussion about meeting transportation needs and eventual driving

cessation.

Clinician reluctance to screen for dementia is unfortunate, because early diagnosis is the first

step in promoting the driving safety of these individuals and allowing them to maintain out-ofhome mobility regardless of driving status. The second step is intervention, which includes

medications to slow or stabilize the course of the disease, counseling to prepare the older adult

and caregivers for eventual driving cessation, and serial assessment of the individual’s driving

abilities. When assessment shows that driving may pose a substantial safety risk to the older

adult, driving cessation is a necessary third step, along with consideration of other

transportation options that allow the individual to maintain out-of-home mobility. With early

planning, older adults and their caregivers can make a more seamless transition from driving to

non-driving status.
146

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 ofsome

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.54 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
147

process as possible. When appropriate, older adults should

be included in decisions about current or future driving

restrictions and cessation; otherwise, clinicians and

caregivers must decide in the best interests of the patient

whose decision-making capacity is impaired.

• 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 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 other recurrent

headache syndromes

Individuals with recurrent severe headaches should be

cautioned against driving when experiencing neurologic

manifestations (e.g., visual disturbances or dizziness), when

distracted by pain, and while on any potentially 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)
148

Movement disorders(e.g.,

parkinsonism,dyskinesias)

If the clinician elicits complaints of interference with driving

tasks or 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.

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 quadriplegia Referral to a DRS is necessary if the individual wishes to

resume driving and/or requires a 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.55

Driving should be restricted until the individual demonstrates

safe driving ability in the adapted vehicle.
149

Parkinson disease Older adults with Parkinson disease may be at increased risk of

driving difficulties because of motor, visual, and cognitive

dysfunction.56 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 antiparkinson

medications.) Serial physical and cognitive evaluations are

recommended every 6–12 months because of the progressive

nature of the disease.

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:57

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 (antiparkinson 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:

o Consider annual comprehensive driving

evaluations.

o Start planning for eventual driving cessation.

o Seek consultation to develop a plan for use of

alternative transportation options.

o 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
150

scoring >7 seconds on the Rapid Pace Walk),

recommendationsinclude:

• 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-thewheel training, compensatory strategies, adaptive

devices, driving restrictions, and/or self-regulation)

• Providing strategies to address transitioning to nondriving (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 neuropathy Lower extremity deficits in sensation and proprioception may

be exceedingly dangerous 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.

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.58These 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.59

This 3-month interval may be lengthened or shortened based
151

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

• Noncorrectable brain functional or metabolic condition

• Frequent seizures afterseizure-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 anti-epileptic drugs necessary to achieve

seizure control
152

Single unprovoked seizure The patient should not drive until he or she has been seizurefree for 3 months.

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.

Withdrawal or change of 

anticonvulsant drug therapy

The patient should temporarily cease driving during the time

of medication withdrawal or change because of the risk of

recurrent seizure and PDI effects of the medication.

If there is significant risk of recurrent seizure during

medication withdrawal or change, 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 seizurefree 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.60

Sleep apnea See Section 10.
153

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)

Section 5: Psychiatric Disorders

1. Affective disorders

a. Depression

b. Bipolar disorder

2. Anxiety disorders

3. Psychotic illness

a. Acute episodes

b. Chronic illness

4. Personality disorders

5. Substance abuse

6. Attention deficit disorder/attention deficit hyperactivity disorder

7. Tourette syndrome
154

Older adults in the acute phase of a psychiatric illness need to be aware that driving skills could

be affected. In general, driving is safe when the condition is stable, although adverse effects

from medications and compliance with the medication regimen may need to be taken into

consideration. (For recommendations on medications and driving, see Section 13, Medications.)

Psychiatrists may wish to consult the American Psychiatric Association’s Position Statement on

the Role of Psychiatrists in Assessing Driving Ability.61

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 severe episodes of

anxiety. Otherwise, there are no restrictions if the condition is

stable.

PDI medications: benzodiazepines (see Section 13)
155

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 intoxicated 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

nonjudgmental and supportive attitude and frequent follow-up

may aid substance abusers in their efforts to achieve and

maintain sobriety.
156

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

disorder/attentiondeficit

hyperactivitydisorder

A review noted increased risk of driving behaviors and a positive

effect of stimulant medications on driving performance.62

Clinicians should educate older adults about the increased risk

associated with the disease and the potential benefits of

treatment.

Tourette syndrome See Section 4.

Section 6: Metabolic Disorders

1. Diabetes mellitus

a. Insulin dependent diabetes mellitus (IDDM)

b. Non-insulin dependent diabetes mellitus (NIDDM)

2. Hypothyroidism

3. Hyperthyroidism

Older adults in the acute phase of a metabolic disorder (e.g., diabetes, Cushing disease,

Addison disease, hyperfunction of the adrenal medulla, thyroid disorders) may experience

signs and symptoms incompatible with safe driving. Clinicians should advise these individuals 

to refrain from driving (including driving to seek medical attention) until the symptoms have

abated.

There are data that suggest that older adults with diabetes may be at increased risk of impaired

driving, but the literature is not consistent in this area. Concern has been raised that the trend

in the medical profession has been toward tighter control of blood glucose levels, which could

result in hypoglycemia and possibly increased crash risk.

Table 9.6 Metabolic Disorders

Diabetes mellitus

Insulin dependent diabetes

mellitus (IDDM)

No restrictions if the older adult demonstrates satisfactory

control of his or her diabetes, recognizes the warning

symptoms of hypoglycemia, and meets required visual

standards.

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
157

hypoglycemia and were unaware of their low blood glucose at

the time of driving assessment.63,64

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.65

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.

Non-insulin dependent diabetes 

mellitus (NIDDM)

Older adults who are managed by lifestyle changes and/or oral

medications have no 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.
158

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: Musculoskeletal Disorders

1. Arthritis

2. Foot abnormalities

3. Limitation of cervical movement

4. Limitation of thoracic and lumbar spine

5. Loss of extremities or loss of use of extremities

6. Muscle disorders

7. Orthopedic procedures/surgeries

a. Amputation

b. Anterior cruciate ligament reconstruction

c. Limb fractures and treatment involving splints and casts

d. Rotator cuff repair (open or arthroscopic)

e. Shoulder reconstruction

f. Total hip replacement

g. Total knee arthroplasty

Pain, decreased motor strength, and compromised range of motion associated with

musculoskeletal disorders can affect an individual’s ability to drive. Clinicians should encourage

older adults with musculoskeletal disorders to drive a vehicle with power steering and

automatic transmission. Such vehicles require the least amount of motor ability for operation

among all standard vehicles. If the clinician is concerned that the individual’s musculoskeletal

disorders impair his or her driving performance, referral to a DRS for a comprehensive driving

evaluation (clinical and on road) is also recommended. In addition to assessing the older 

adult’s driving skills, the DRS can prescribe compensatory techniques and adaptive devices and

train the individual in their use.
159

Older adults with musculoskeletal disorders, typically have problems with using the seat belt

and ignition key, adjusting mirrors and seats, steering, transferring in and out of the car, driving

in reverse, and using controls like the foot pedals.66 Driving impairment has been correlated

with the inability to reach above the shoulder.67 Older adults with physical frailty or disabilities

may be at increased risk of a crash68,69 and are more likely to be injured.70 Presence of foot

abnormalities, walking less than one block a day, and impaired left knee flexion have been

associated with adverse driving events.69 In one study, older participants involved in a crash

were more likely to have difficulty walking one-quarter mile than controls; increased crash risk

for drivers with a history of falls was also noted.71

An examination of medically impaired drivers in Utah found an increased crash risk for drivers

with musculoskeletal disorders but not for those with muscle or motor weakness.72 In a 

Canadian longitudinal study, self-reported arthritis/rheumatism and back pain were associated

with motor vehicle injuries.73

Conversely, individuals with a specific diagnosis of osteoarthritis74were no more at risk of a 

crash than controls in one study. Also reassuring was a study noting no increase in crash risk of

drivers with cars that had been adapted for their musculoskeletal restrictions.75 Improvements

in relevant physical abilities and driving performance have been noted with a physical

conditioning program.76

Older drivers are at increased risk of death and serious injury in motor vehicle crashes, in part

due to age-related fragility.77-79 Therefore, clinicians should advise older adults to avoid driving

in potentially risky situations, such as making unprotected left turns, and driving in unfamiliar

areas or on suburban highways.80

In sum, clinicians can play a role in diagnosing, managing, and referring older adults with

musculoskeletal disorders, thereby helping to maintain driving privileges and improve traffic

safety.

Rehabilitative therapies such as physical or occupational therapy and/or a consistent regimen

of physical activity may improve the older adult’s ability to drive and overall level of physical

fitness.

Whenever possible, the use of narcotics, barbiturates, and muscle relaxants should be avoided

or minimized in those individuals with musculoskeletal disorders who wish to continue

driving. See Section 13 for recommendations on specific classes of medications.
160

Table 9.7 MusculoskeletalDisorders

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 toe

nails,

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.

Limitation of cervical

movement

Some loss of head and neck movement is acceptable if the

older adult has sufficient 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.
161

Limitation of thoracic or Older adults with marked deformity, who wear braces or body

lumbar spine casts, or who have painfully 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 or loss of

use of extremities

For older adults who have lost (or lost the use) of one or

more extremities, referral to a DRS is highly recommended.

The DRS can prescribe vehicle adaptive devices and/or

adaptations 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.
162

Orthopedic

procedures/surgeries

Amputation See Loss of extremities (above).

Anterior cruciate ligament (ACL) Individuals should not drive for 4 weeks after right ACL

reconstruction reconstruction. If the older adult drives a vehicle with manual

transmission, he or she should not drive for 4 weeks after right

or left ACL reconstruction.81

Limb fractures and treatment

involving splints and casts

No restrictions if the fracture or splint/cast does not interfere

with driving tasks.

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 (open or

arthroscopic)

Individuals should not drive for 4–6 weeks after rotator cuff

repair. If the older adult’s vehicle does not have power

steering, the waiting period may be much longer.

Physicians 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 reconstruction Individuals should not drive for 4–6 weeks after shoulder

reconstruction. If the older adult’s 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.
163

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.82

Total knee arthroplasty (TKA) Individuals should not drive for 3-4 weeks after right TKA. If

the older adult drives a vehicle 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.83–89

Section 8: Peripheral Vascular Disorders

1. Aortic aneurysm

2. Deep vein thrombosis

3. Peripheral arterial aneurysm

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.
164

Deep vein thrombosis(DVT) Older adults with acute DVT may resume driving when their

international normalized ratio (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 aneurysm No restrictions unless other disqualifying conditions are

present. Older adults 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.

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.
165

Renaltransplant Older adults may resume driving 4 weeks after successful

renal transplant on the recommendation of the physician.

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.90 Sleep disorder crash risk may be increased further

by medication use, such as narcotics or antihistamines.91 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.92 Individuals with these disorders may also be at increased risk of injurious

crashes.93 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.94 In addition, recent studies indicate a high prevalence of sleep disorders or

daytime sleepiness in older adults95 and in individuals with diabetes.96 However, in the case of

older adults, the effect on driving safety is unclear.97

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.
166

Chronic obstructive

pulmonary disease (COPD)

No restrictions if symptoms are well controlled, and the older

adult does not experience any significant adverse effects from

the condition or medication.

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:55

• 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, 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 effectsthat 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
167

devicesfor 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).

Section 11: Effects of Anesthesia and Surgery

1. Abdominal, back, and chest surgery

2. Anesthesia

a. General
168

b. Local

c. Epidural

d. Spinal

3. Neurosurgery

4. Orthopedic surgery

Clinicians should be alert to peri- and postoperative risk factors that may affect the older adult’s

cognitive function after surgery, or restrictions on limb movement or joint range of motion that

place the individual at risk of impaired driving performance. Risk factors include:

• Preexisting cognitive impairment

• Duration of surgery

• Age (>60 years old)

• Altered mentalstatus after surgery

• Presence of multiple comorbidities

• Emergency surgery

If the clinician is concerned that residual visual, cognitive, or motor deficits after surgery may

impair the older adult’s driving performance, referral to a DRS for a comprehensive driving

evaluation (clinical and on road) is highly recommended.

Clinicians should counsel older adults who undergo surgery—both inpatient and outpatient— 

not to drive themselves home after the procedure. Although they may feel capable of driving,

their driving skills may be affected by pain, physical restrictions, anesthesia, cognitive

impairment, and/or analgesics. (For specific recommendations on musculoskeletal restrictions

and narcotic analgesics, see Sections 7 and 13, respectively.)

In counseling older adults about their return to driving after a surgical procedure, clinicians

may find it useful to ask whether the individual’s car has power steering and automatic

transmission. Advice can then be tailored accordingly.

As older adults resume driving, they should be counseled to assess their comfort level in

familiar, traffic-free areas before driving in heavy traffic. Those who feel uncomfortable driving

in certain situations should avoid these situations until their confidence level has returned.

Older adults should never resume driving before they feel ready to do so and have received

approval from the clinician.

Table 9.11 Effects of Anesthesia and Surgery

Abdominal, back, and chest

surgery

Older adults may resume driving after demonstrating the

necessary strength and range of motion needed for driving.

See Section 2 for recommendations for surgeries involving

median sternotomy.
169

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 surgery See the recommendations for orthopedic procedures/surgeries

in Section 7.

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.)
170

Section 13: Medications

1. Anticholinergics

2. Anticonvulsants

3. Antidepressants

4. Antiemetics

5. Antihistamines

6. Antiparkinson agents

7. Antipsychotics

8. Benzodiazepines and nonbenzodiazepine hypnotics

9. Muscle relaxants

10. Narcotic analgesics

As described in the previous sections of this chapter, medications may promote safe driving in

older adults through adequate management of medical conditions and better physical

functioning. However, many commonly used prescription and over-the-counter medications

may impair driving by adversely affecting the cognitive, visual, and/or motor abilities needed

for safe driving. In general, any drug with a prominent effect on the central nervous system

(CNS) has the potential to impair an individual’s ability to operate a motor vehicle. The level of

impairment varies from person to person and between different medications within the same

therapeutic class.

Expert panels convened by NHTSA to develop a list of safe and unsafe drugs with regard to

driving were not able to develop a conclusive list and were only able to comment on the

potential impact of various medications.98 This difficulty stems from inconsistent research

findings, lack of a standardized protocol for assessing the potential for medications to impair

driving, and the difficulty in distinguishing the impact of the medical condition from the impact 

of the medication itself that is used to treat the medical condition on driving safety.98 For

studies that have taken into account both the medical condition and the medications used to

treat the condition, the impact of the medical condition on crash risk is much stronger than that

of the medication.98 Thus, this section discusses potentially driver-impairing (PDI) medications

based on information from observational studies examining risk of crashes; from experimental

studies assessing driving performance, astested in different actual driving tests or driving

simulator tests; and/or from the known adverse effect profile of the medication. Some PDI

medications are included based on adverse-effect profile alone, because research evidence is

not available delineating risk of traffic crashes.

The most common PDI medications include the anticholinergics, anticonvulsants,

antidepressants, antiemetics, antihistamines, antipsychotics, barbiturates,

benzodiazepines/hypnotics, muscle relaxants, and narcotic analgesics.99-101 Of these medication

classes, benzodiazepines have been subject to the most scrutiny, and studies have consistently

found higher risk of traffic crashes associated with their use in older adults.99,100
171

Older adults often take multiple medications concurrently, with approximately 30% using five

or more prescription medications.102 Crash risk is likely to increase with use of multiple PDI

medications103 or concomitant use with alcohol. Table 9.13 summarizes the common PDI

medications and the specific adverse effects (cognitive, visual, and motor abilities) that may

contribute to impaired driving. Adverse effects on cognition include fatigue,

sedation/sleepiness, light-headedness, dizziness, or global cognitive impairment (e.g., impaired

judgment, attention, psychomotor speed). Medications that cause tremor, dyskinesias, or

extrapyramidal symptoms may impair motor ability needed for driving. A history of falls has

been associated with an increased crash risk, and medications with CNS effects are known risk

factors for falls. Medications that cause drowsiness, euphoria, and/or anterograde amnesia

may also diminish insight, and older adults may experience impairment without being aware of

it (e.g., benzodiazepines, narcotics, antihistamines).

104–107 This list of medications is not

exhaustive. Other medication classes, such as oral hypoglycemics and antihypertensives, may

cause dizziness or impaired cognition if the individual is hypoglycemic or blood pressure is too

low, respectively. Furthermore, any medication side effect (e.g., nausea) that reducesthe

ability to concentrate could potentially impair driving.

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 impairing then

secondary)

Sedation, blurred vision, impaired cognition,

tremor, heart palpitations

Selective serotonin reuptake inhibitors

(SSRIs)

Impaired concentration, lightheadedness,

tremor

Others

Duloxetine Sedation

Mirtazapine Sedation

Bupropion Insomnia (leading to next day somnolence)

Antihistamines (first generation and

cetirizine)

Sedation, blurred vision, impaired cognition

Antiparkinson agents

Dopamine agonists, levodopa,

Anticholinergics

All classes may cause sedation.

Medication-specific adverse events: sleepattacks (most likely with dopamine agonists),

dyskinesias (most likely with levodopa)

Antipsychotics Sedation, blurred vision, impaired cognition,

extrapyramidal symptoms, (to varying extent

among agents)
172

Table 9.13 Potentially Driver-Impairing (PDI) Medications

Medication Class PDI Symptom

Benzodiazepines/sedatives Sedation, clumsiness, dizziness, impaired

vision, impaired cognition

Muscle relaxants Sedation, blurred vision, impaired cognition

Opioid analgesics Sedation, lightheadedness, impaired vision

Other agents not discussed in text

Antihypertensives Dizziness (low blood pressure)

CNS effects(guanfacine, reserpine,

methyldopa, clonidine)

Hypoglycemics Symptoms of hypoglycemia (shakiness,

impaired concentration, lightheadedness)

Indomethacin CNS effects

Clinicians should be aware of the PDI risk and attempt to use the safest class of medication

when possible. It is difficult to know whether increased risk of impaired driving is associated

with the drug (e.g., antidepressant), the disease itself (e.g., depression, which may

independently impair attention, judgment), or a drug-drug interaction.99Because of age-related

changes in pharmacokinetics (e.g., reduced renal function) and pharmacodynamics, older adults

may begin to have adverse effects to medications that they have tolerated well for many years,

which may make it difficult to ascertain the cause of new PDI symptoms.

Alcohol Interaction with Medications

As little as one serving of alcohol (1.25 oz. 80-proof liquor, 12 oz. beer, 5 oz. wine) has the

potential to impair driving performance in many individuals. Because of age-related changes in

body composition (e.g., increased body fat and decreased lean muscle mass), the same

weight- adjusted amount of alcohol (hydrophilic) is likely to result in higher blood levels of

alcohol and functional impairment in advanced age. In many cases, older adults may be

impaired without being aware of it. Furthermore, alcohol can potentiate the CNS effects of PDI

medications to produce profound and dangerous levels of impairment. Clinicians should

always warn older adults against drinking and driving, and against combining alcohol and their

CNS-active medications.

General Prescribing Principles

It may not be possible to avoid use of PDI medications in older adults; however, several general

prescribing principles can be considered to minimize risk.

1. Whenever possible, clinicians should select nonimpairing medications.

2. When prescribing new medications, clinicians should always consider the individual’s
173

existing regimen of prescription and nonprescription medications and consider risk of

additive PDI medications. Combinations of drugs may affect drug metabolism and

excretion, and produce additive or synergistic interactions to impair driving ability.
174

3. Clinicians should add new medications at the lowest dosage possible, counsel the older

adult to be alert to any impairing effects, and adjust the dosages as needed to achieve

therapeutic effects while minimizing driving impairment. For individuals on multiple PDI

medications, it is wise to start with low doses of each and gradually increase the dosage

of each one at a time to minimize substantial undesirable effects.

4. Older adults should be regularly assessed for PDI symptoms during follow-up visits.

5. If medication therapy is initiated while the older adult is hospitalized, the impact of

adverse effects on driving performance should be discussed before discharge.

6. These precautions and discussions should be documented in the health record.

7. If there is a question of cognitive or motor impairment, whether or not due to

medications, the clinician should consider referral to a DRS for a driver evaluation

(potentially including on-road assessment).

CounselingConsiderations

The following counseling points are important to consider when a new PDI medication is

started, or the dosage of an existing PDI medication is increased.

1. Inform the older adult and caregivers about the specific effects of the medication, so

that they know what to expect and can self-monitor for adverse events that may affect

driving.

2. Advise the older adult and caregivers to take the first few doses in a safe environment

to determine the presence and extent of any adverse effects. Individuals should be

advised not to drive during the initial phase of PDI dosage adjustment(s) if they

experience drowsiness, lightheadedness, or other undesirable effects that may impair

driving performance.

3. Inform the older adult and caregivers that some medications that cause drowsiness,

euphoria, and/or anterograde amnesia may also diminish insight (benzodiazepines,

antihistamines, narcotics), and that the individual may experience impairment without

being aware of it.

4. Discourage the use of alcohol while driving and inform the older adult and caregivers

about the potential for exacerbation of the PDI effects of certain medications with

concomitant alcohol use.

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).108 These

include several medication classes such as antidepressants 

(e.g., tricyclic antidepressants and paroxetine), medications for 

overactive bladder (e.g., oxybutynin, tolterodine, trospium, 
175

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 antiparkinson 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.

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 effectsthat 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.108
176

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 firstline 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 serotoninnorepinephrine reuptake inhibitor used for depression,

chronic pain, fibromyalgia, and anxiety disorders, may also

cause sedation and other CNS effects.

Selective serotonin-reuptake

inhibitors (SSRIs)

SSRIs are commonly prescribed agents to treat depression 

and anxiety. Paroxetine is unique in that it has anticholinergic 

effects, so may be more likely than the other SSRIs (e.g.,

sertraline, 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 antidepressants

(TCAs)

Better tolerated agents have replaced TCAs for depression;

however, they are still used 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.108

See Anticholinergics in this section.
177

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.99 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 for

excessive daytime somnolence, but treatment with these

medications can further contribute to this symptom.

Individuals taking antiparkinson 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.

109,110

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,
178

lurasidone, and ziprasidone having the most pronounced 

effects.

Benzodiazepines 

and nonbenzodiazepine

hypnotics

Studies have demonstrated impairments in vision, attention, 

motor coordination, and driving performance with

benzodiazepine use. Evening doses of long-acting

benzodiazepines (e.g., flurazepam, diazepam) markedly impair

psychomotor function the following day, while comparable

doses of short-acting benzodiazepines produce a lesser

impairment.99 Zolpidem, eszopiclone, and zaleplon are

nonbenzodiazepine hypnotics. Zolpidem has been associated 

with driving at night without recollection the next morning and

increased crash risk.111Women 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.111

In general, it is recommended to avoid benzodiazepines and

nonbenzodiazepine hypnotics in older adults because of the

risk ofseveral adverse health outcomes, including increased

risk of car crashes.108 However, if hypnotics are needed,

evening doses of short-acting hypnotics 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.
179

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.108

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.)
180

References

1. Charlton, J., Koppel, S., Odell, M., Devlin, A., Langford, J., O’Hare, M., ... Scully, M.

(2010, November). Influence of chronic illness on crash involvement of motor vehicle

drivers (Report No. 300). Victoria, AU: Monash University Accident Research Centre.

2. Dobbs, B. M. (2005, September). Medical conditions and driving: A review of the

literature (1960–2000) (Report No. DOT HS 809 690). Washington DC: National Highway

Traffic Safety Administration. Available at www.nhtsa.gov/people/injury/-

research/Medical_Condition_Driving/Medical%20Cond%20809%20690-8-

04_Medical%20Cond%20809%20690-8-04.pdf

3. Staplin, L., Lococo, K. H., Martell, C., & Stutts, J. (2012, February). Taxonomy of Older

Driver Behaviors and Crash Risk (Report No. DOT HS 811 468A). Washington, DC:

National Highway Traffic Safety Administration. Available at

www.nhtsa.gov/staticfiles/nti/pdf/811468a.pdf

4. National Highway Traffic Safety Administration. (2009, September). Driver fitness

medical guidelines (Report No. DOT HS 811 210). Washington, DC: Author. Available at

http://ntl.bts.gov/lib/31000/31100/31148/6061_MedicalReviewGuide_10-1_v2a.pdf

5. Austroads. (2012). Assessing Fitness to Drive for Commercial and Private Vehicle Drivers.

Medical Standards for Licensing and Clinical Management Guidelines. Sydney, Australia:

Austroads Ltd.

6. Canadian Medical Association. (2012). CMA Driver’s Guide: Determining Medical Fitness

to Operate Motor Vehicles, 8th edition. Ottawa, Ontario: Canadian Medical Association,

p 49.

7. Road Safety Authority. (2014). Medical Fitness to Drive Guidelines, 3rd edition.

Dublin, Ireland: Road Safety Authority.

8. Drivers Medical Group DVLA. (2014). For Medical Practitioners: At a Glance Guide to

the Current Medical Standards of Fitness to Drive. Swansea, UK: Driver & Vehicle

Licensing Agency.

9. Shinar, D., & Schieber F. (1991). Visual requirements for safety and mobility of older

drivers. Human Factors, 33(5), 507–519.

10. Mabtyjari. M., & Tuppurainen, K. (1999). Cataracts in traffic. Graefe's Archive for Clinical

and Experimental Ophthalmology, 237, 278–282.
181

11. Szlyk J. P., Mahler C. L., Seiple, W., Edward, D. P., & Wilensky, J.T. (2005). Driving

performance of glaucoma patients correlates with peripheral visual field loss. Journal

of Glaucoma, 14, 145–150.

12. Smith, B., T., Joseph D. P., & Grand, M. G. (2007). Treatment of neovascular agerelated macular degeneration: past, present, and future directions. Current Opinion in

Ophthalmology, 18, 240–244.

13. Leske, M. C., Hejl, A., Hussein, M., Bengtsson, B., Hyman, L., & Komaroff, E. (2003).

Factors for glaucoma progression and the effect of treatment: the Early Manifest

Glaucoma Trial. Archives of Ophthamology [now JAMA Ophthmology], 121, 48–56.

14. Van Den Berg, T. J., Van Rijn, L. J., Rene, M., Heine, C., Coeckelbergh, T., Nischler,

C., ... Franssen, L. (2007). Straylight effects with aging and lens extraction. American

Journal of Ophthalmology, 144(3), 358–363.

15. Owsley, C., McGwin, G. Jr., Sloane, M., Wells, J., Stalvey, B. T., & Gauthreaux, S. (2002).

Impact of cataract surgery on motor vehicle crash involvement by older adults. Journal

of the American Medical Association, 288, 841–849.

16. Adler, G., Bauer, M. J., Rottunda, S., & Kuskowski, M. (2005). Driving habits and

patterns in older men with glaucoma. Social Work Health Care, 40(3), 75–87.

17. Low Vision Centers of Indiana. (n.d.) Bioptic Driving State Laws (Web page). Retrieved

from the center’s website at www.biopticdrivingusa.com/state-laws/

18. Peli, E., & Peli, D. (2002). Driving With Confidence: A Practical Guide to Driving

With Low Vision. Singapore: World Scientific Publishing Co. Pte. Ltd., , pp 20-22,

25, 100–101.

19. Owsley, C., Stalvey, B. T., Wells, J., Sloane, M. E., & McGwin, G. Jr. (2001). Visual risk

factors for crash involvement in older drivers with cataract. Archives of Ophthalmology,

119, 881–887.

20. Owsley, C., & McGwin, G. (2010). Vision and driving. Vision Research, 50, 2348–2361.

21. Green, K. A., McGwin, G., & Owsley C. (2013). Associations between visual, hearing,

and dual sensory impairments and history of motor vehicle collision involvement of

older drivers. Journal of American Geriatric Society, 61, 252–257.

22. McGwin, G., Sims R. V., Pulley, L., & Roseman, J. M. (2000). Relations among chronic

medical conditions, medications, and automobile crashes in the elderly: A populationbased case-control study. American Journal of Epidemiology, 152, 424–431.

23. Petch, M. C. (1998). European Society of Cardiology Task Force Report: Driving and Heart
182

Disease. European Heart Journal, 19(8), 1165–1177.

24. Binns, H., & Camm J. (2002). Driving and arrhythmias. British Medical Journal, 324, 927–

928.

25. Epstein, A. I., Miles, W. M., Benditt, D. G., Camm, A. J., Darling, E. J., Friedman,

P.L., ... Wilkoff, B. L. (1996). Personal and public safety issues related to

arrhythmias that may affect consciousness: implications for regulation and

physician recommendations. Circulation, 94, 1147–1166.

26. Consensus Conference, Canadian Cardiovascular Society. (1992). Assessment of the

cardiac patient for fitness to drive. (1992). Can Journal of Cardiology, 8, 406–412.

27. Epstein, A. E., Baessler, C. A., Curtis, A. B., Estes, N. A. 3rd, Gersh, B. J., Grubb, B.,

Mitchell, L. B., American Heart Association, & Heart Rhythm Society. (2007).

Addendum to “Personal and public safety issues related to arrhythmias that may

affect consciousness: Implications for regulation and physician recommendations.”

Circulation, 115, 1170–1176.

28. Legh-Smith, J., Wade D. T., & Langton Hewer, R. L. (1986). Driving after stroke. Journal of

the Royal Society of Medicine, 79, 200– 203.

29. Fisk, G. D., Owsley, C., & Vonne Pulley, L. (1997). Driving after stroke: driving

exposure, advice, and evaluations. Archives of Physical Medicine and

Rehabilitation, 78, 1338–1345.

30. Poole, D., Chaudry, F., & Jay, W.M. (2008). Stroke and driving. Topics in Stroke

Rehabilitation, 15, 37–41.

31. Wilson, T., & Smith T. (1983). Driving after stroke. International Rehabilitation Medicine,

5(4), 170–177.

32. Engrum, E. S., Lambert, E. W., & Scott, K. (1990). Criterion-related validity of the

cognitive behavioral driver’s inventory: brain injured patients versus normal controls.

Cognitive Rehabilitation, 8, 20– 26.

33. Lundberg, C., Caneman, G., Samuelson, S., Halamies-Blomqvist, L., & Almqvist, O. (2003).

The assessment of fitness to drive after stroke: The nordic stroke driver screening

assessment. Scandanavian Journal of Psychology, 44, 23–30.

34. Nouri, F. M., & Lincoln, N. B. Predicting driving performance after stroke. (1993). British

Medical Journal, 307, 482–483.

35. Devos, H., Akinwuntan, A. E., Nieuwboer, A., Ringoot, I, Van Berghen, K., Tant, M., ... De

Weerdt, W. (2010). Effect of simulator training on fitness-to-drive after stroke: a 5 year

follow-up of a randomized controlled trial. Neurorehabilitation Neural Repair, 24(9), 843–
183 

850.

36. Kewman, D. G., Seigerman, C., Kintner, H., Chu, S., Henson, D., & Reeder, C. (1985).

Simulation training of psychomotor skills: teaching the brain-injured to drive.

Rehabilitation Psychology, 30(1), 11–27.

37. Lundqvist, A., Gerdle, B., & Ronnberg J. (2000). Neuropsychological aspects of driving

after a stroke— the simulator and on the road. Applied Cognitive Psychology, 14(2),

135–150.

38. Kapoor, W. N. (2002). Current evaluations and management of syncope. Circulation, 106,

1606–1609.

39. Sakaguchi, S., & Li, H. (2013). Syncope and driving, flying and vocational concerns.

Progress in Cardiovascular Diseases, 55, 454–463.

40. Sorajja, D., Nesbitt, G. C., Hodge, D. O., Low, P. A., Hammill, S. C., Gersh, B. J., &

Shen, W-K. (2009). Syncope while driving: clinical characteristics, causes, and

prognosis. Circulation, 120, 928-934.

41. Epstein, A. E., Miles, W. M., Benditt, D. G., Camm, A. J., Darling, E. J., Friedman, P. L., ...

Wilkoff, B. L. (1996, September 1). Personal and Public Safety Issues Related to

Arrhythmias That May Affect Consciousness: Implications for Regulation and Physician

Recommendations (Part 3 of 4). Circulation, 94(5):1147-66.

42. Dobbs, B., Carr, D. B., & Morris, J. C. (2002). Management and assessment of the

demented driver. Neurologist, 8, 61–70.

43. Brown, L. B., & Ott, B. R. (2004). Driving and dementia: a review of the literature. Journal of

Geriatric Psychiatry and Neurology, 17, 232–240.

44. Carr, D. B., & Ott, B. R. (2010). The older adult driver with cognitive impairment: “It’s a

very frustrating life.” Journal of the American Medical Association, 303, 1632–1641.

45. Iverson D.J., Gronseth, G. S., Reger, M. A., Classen, S., Dubinsky, R. M, & Rizzo, M.

(2010). Practice parameter update: evaluation and management of driving risk in

dementia. (Report of the quality standards subcommittee of the American Academy of

Neurology). Neurology, 74, 1316–1324.

46. Hunt, L., Murphy, C., Carr, D., Duchek, J. M., Buckles, V., & Morris, J.C. (1997). The

reliability of the Washington University Road Test. Archives of Neurology, 54, 707–712.

47. Duchek, J. M., Carr, D. B., Hunt, L., Roe, C. M., Xiong, C., Shah, K., & Morris, J. C. (2003).

Longitudinal driving performance in early stage dementia of the Alzheimer type. Journal

of the American Geriatrics Society, 51, 1342–1347.
184

48. Ott, B. R., Heindel, W. C., Papandonatos, G. D., Festa, E. K., Davis, J. D., Daiello, L. A., & 

Morris, J. C. (2008). A longitudinal study of drivers with Alzheimer’s disease. Neurology, 

70, 1171–1178.

49. Ott, B. R., Anthony, D., Papandonatos, G. D., D’Abreu, A., Burock, J., Curtin, 

A., ... Morris,J. C. (2005). Clinician assessment of the driving competence of 

patients with dementia. Journal of the American Geriatrics Society, 53(5), 

829–833.

50. Grace, J., Amick, M. M., D’Abreu, A., Festa, E. K., Heindel, W. C., & Ott, B. R. (2005).

Neuropsychological deficits associated with driving performance in Parkinson’s and

Alzheimer’s disease. Journal of the International Neuropsychology Society, 11(6), 766–

775.

51. Brown, L. B., Stern, R. A., Cahn-Weiner, D. A., Rogers, B., Messer, M. A., Lannon, M. C., 

... Ott, B. R. (2005). Driving scenes test of the Neuropsychological Assessment Battery

and on-road driving performance in aging and very mild dementia. Archives of Clinical 

Neuropsychology, 20, 209–221.

52. Meuser, T. M., Carr, D. B., Berg-Weger, M., Niewoehner, P., & Morris, J. C.

(2006). Driving and dementia in older adults: implementation and evaluation

of a continuing education project. Gerontologist, 46, 680–687.

53. Valcour, V. G., Masaki, K. H., Curb, J .D., & Blanchette, P. L. (2000). The detection of 

dementia in the primary care setting. Archives of Internal Medicine, 160, 2964–

2968.

54. Carr, D. B., Duchek, J., & Morris, J. C. (2000). Characteristics of motor vehicle crashes

with dementia of the Alzheimer type. Journal of the American Geriatrics Society, 48(1), 

18–22.

55. Stressel, D., Hegberg, A., & Dickerson, A. E. (2014). Driving for adults with acquired physical 

disabilities. Occupational Therapy Health Care, 28(2), 148–153.

56. Crizzle, A. M., Classen, S., & Uc, E. Y. (2012). Parkinson disease and driving: An evidencebased review. Neurology, 79, 2067–2074.

57. Classen, S. (2014). Consensus statements on driving with people with Parkinson’s

disease. Occupational Therapy Health Care, 28(2), 140–147.

58. American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation 

of America. (1994). Consensus statements, sample statutory provisions, and model 

regulations regarding driver licensing and epilepsy. Epilepsia, 35(3), 696–705.

59. Drazkowski, J. F., Fisher, R. S., Sirven, J. I., Demaerschalk, B. M., Uber-Zak, L., Hentz, J. 
185

G., & Labiner, D. (2003).Seizure-related motor vehicle crashes in Arizona before and

after reducing the driving restriction from 12 to 3 months. Mayo Clinic Proceedings, 78, 

819–825.

60. Johns, M. W. (1991). A new method for measuring daytime sleepiness: the Epworth 

Sleepiness Scale. Sleep, 14, 540–545.

61. Council on Aging. (1995). Position Statement on the Role of Psychiatrists in Assessing

Driving Ability. American Journal Psychiatry, 152(5), 819.

62. Barkley, R. A., & Cox, D. (2007). A review of driving risks and impairments associated

with attention-deficit/hyperactivity disorder and the effects of stimulant medication

on driving performance. Journal of Safety Research, 38(1), 113–128.

63. Weinger, I., Kinsley, B. T., Levy, C. J., Bajaj, M., Simonson, D. C., Cox, D. J., ... 

Jacobson, A. M. (1999). The perception of safe driving ability during 

hypoglycemia in patients with type I diabetes. American Journal of Medicine, 

107, 246–253.

64. Cox, D. J., Gonder-Frederick, L. A., Kovatchev, B. P., Julian, D. M., & Clarke, W. L. 

(2000). Progressive hypoglycemia’s impact on driving simulation performance: 

occurrence, awareness, and correction. Diabetes Care, 23, 163–170.

65. American Diabetes Association. (2012). Diabetes and driving. Diabetes Care, 35 (Supp1), 

S81– S86.

66. Jones, J. G., McCann, J., & Lassere, M. N. (1991). Driving and arthritis. British Journal of 

Rheumatology, 30, 361–364.

67. Hu, P. S., Trumble, D. A., Foley, D. J., Eberhard, J. W., & Wallace, R. B. (1998). Crash risks

of older drivers: a panel data analysis. Accident Analysis & Prevention, 30, 569–581.

68. Sims, R. V., McGwin, G., Allman, R. M., Ball, K., & Owsley, C. (2000). Exploratory study of 

incident vehicle crashes among older drivers. Journal of Gerontology, Series A: Biological 

Sciences and Medical Sciences, 55, M22–M27.

69. Marottoli, R. A., Wagner, D. R., Cooney, L. M., Doucette, J., & Tinetti, M. E. (1994).

Predictors of crashes and moving violations among elderly drivers. Annals of Internal 

Medicine, 121, 842–846.

70. Kent, R., Funk, J., & Crandall, J. (2003). How future trends in societal aging, air bag 

availability, seat belt use, and fleet composition will affect serious injury risk and

occurrence in the United States. Traffic Injury Prevention, 4, 24–32.

71. Sims, R. V., McGwin, G., Pulley, L., & Roseman, J. M. (2001). Mobility impairments in 

crash-involved drivers. Journal of Aging Health, 12, 430.
186

72. Vernon, D.D., Diller, E. M., Cook, L. J., Reading, J. C., Suruda, A. J., & Dean, J. M. (2002).

Evaluating the crash and citations rates of Utah drivers licensed with medical conditions, 

1992–1996. Accident Analysis & Prevention, 34, 237–246.

73. Vingilis, E., & Wilk, P. (2012). Medical conditions, medication use, and their

relationship with subsequent motor vehicle injuries: Examination of the Canadian

National Population Health Survey. Traffic Injury Prevention, 13, 327–336.

74. Koepsell, T., Wolf, M. M., & McCloskey, L. (1994). Medical conditions and motor vehicle

collision injuries in older adults. Journal of the American Geriatrics Society, 42,695-700.

75. Henriskkson, P. (2001). Drivers with disabilities: A survey of adapted cars, driving 

habits and safety. (VTI report 466). Linkoping, Sweden: Swedish National Road

and Transport Research Institute. 

76. Marottoli R.A., Allore, H., Araujo, K. L B., Iannone, L. P., Acampora, D., Gottschalk,

M., ... 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.

77. Bédard, M., Guyatt, G. H., Stones, M. J., & Hirdes, J. P. (2002). The independent 

contribution of driver, crash, and vehicle characteristics to driver fatalities. Accident 

Analysis & Prevention, 34, 717–727.

78. Massie, D. L., & Campbell, K. L. (1993). Analysis of accident rates by age, gender, and

time of day based on the 1990 Nationwide Personal Transportation Survey (Report No.

UMTRI-93-7). Ann Arbor, MI: University of Michigan Transportation Research Institute. 

79. Li, G., Braver, E. R., & Chen, L. H. (2003).Fragility versus excessive crash involvement as

determinants of high death rates per vehicle mile of travel among older drivers. 

Accident Analysis & Prevention, 35, 227–235.

80. Stutts, J., Martell, C., & Staplin, L. (2009). Identifying Behaviors and Situations Associated

with Increased Crash Risk for Older Drivers (Report No. DOT HS 811 093). Washington, 

DC: National Highway Traffic Safety Administration. Available at www.nhtsa.gov/DOT/-

NHTSA/Traffic%20Injury%20Control/Articles/Associated%20Files/811093.pdf

81. Gotlin, R. S., Sherman, A. L., Sierra, N., Kelly, M. A., Pappas, Z., & Scott, W. N. (2000).

Measurement of brake response time after right anterior cruciate ligament 

reconstruction. Archives of Physical and Medical Rehabilitation, 81(2), 201–204.

82. MacDonald, W., & Owen, J. W. (1988). The effect of total hip replacement on driving 

reactions. Journal of Bone Joint Surgery, 70B(2), 202–205.
187

83. Liebensteiner, M. C., Kern, M., Haid, C., Kobel, C., Niederseer, D., & Krismer, M. (2010).

Brake response time before and after total knee arthroplasty: A prospective cohort

study. BMC Musculoskeletal Disorders, 11, 267.

84. Dalury, D. F., Tucker, K. K., & Kelley, T. C. (2011). When can I drive? Brake

response times after contemporary total knee arthroplasty. Clinical 

Orthopaedics and Related Research, 469, 82-86.

85. Marques, C. J., Barreiros, J., Cabri, J., Carita, A. I., Friesecke, C., & Loehr, J. F. (2008). Does 

the brake response time of the right leg change after left total knee arthroplasty? A 

prospective study. Knee, 15, 295–298.

86. Pierson, J. L., Earles, D. R., & Wood, K. (2003). Brake response time after total knee

arthroplasty: When is it safe for patients to drive? Journal of Arthroplasty, 18(7), 840–

843.

87. Marecek, G. S., & Schafer, M. F. (2013). Driving after orthopaedic surgery. Journal 

of the American Academy of Orthopedic Surgery, 21, 696–706.

88. Pierson, J. L., Ramsey, J., Clayton, R. T., & Stippich, K. T. (1999, February 7). TKA 

improves drivers’ brake reaction time. Rosemont, Il: The American Academy of 

Orthopaedic Surgeons, Academy News. 

89. Spalding, T. J., Kiss, J., Kyberd, P., Turner-Smith, A., Simpson, A.H. (1994). Driver 

reaction times after total knee replacement. The Journal of Bone & Joint Surgery 

(British Volume) [now The Bone & Joint Journal], 76(5), 754–756.

90. Garharino, S., Nohili, L., Beelke, M., De Carli, F., & Ferrillo, F. (2001). The contributing role

of sleepiness in highway vehicle accidents. Sleep, 24, 203–206.

91. Howard, M. E., Desal, A. V., Grunstein R. R., Hukins, C., Armstrong, J. G., Joffe, D., ... 

Pierce, R. J. (2004). Sleepiness, sleep-disordered breathing and accident risk factors

in commercial vehicle drivers. American Journal of Respiratory and Critical Care 

Medicine, 170, 1014–1021.

92. Teran-Santos, J., Jimenez-Gomez, A., Cordero-Guevara, J., and the Cooperative 

Group Burgos-Santander. (1999). The association between sleep apnea and the risk

of traffic accidents. New England Journal of Medicine, 340(11), 847–851.

93. Mulgrew, A. T., Nasvadi, G., Butt, A., Cheema, R., Fox, N, Fleetham, J. A., & Ayas, N. T.

(2008). Risk and severity of motor vehicle crashes in patients with obstructive sleep 

apnoea/hypopnea. Thorax, 63, 536–541.

94. George, C. F. (2001). Reduction in motor vehicle collisions following treatment of sleep 

apnea with nasal CPAP. Thorax,56(7), 508–512.
188

95. Vaz Fragoso, C.A., Arauio, K. L., Van Ness, P.H., & Marottoli, R. A. (2008). Prevalence of 

sleep disturbances in a cohort of older drivers. Journal of Gerontol Series A: Biological 

Sciences and Medical Sciences, 63, 715–723.

96. Hayashino, Y., Yamazaki, S., Nakayama, T., Sokejima, S, & Fukuhara, S. (2008).

Relationship between diabetes mellitus and excessive sleepiness during driving.

Experimental and Clinical Endocrinology & Diabetes, 116, 1–5.

97. Vaz Fragoso, C. A., Araujo, K., Van Ness, P., & Marottoli, R. A. (2010). Sleep disturbances 

and adverse driving events in a predominantly male cohort of active older drivers.

Journal of the American Geriatric Society, 58, 1878–1884.

98. Rosenbloom, S., & Santos R. (2014, April). Understanding older drivers: an examination

of medical conditions, medication use and travel behavior. Washington, DC: AAA

Foundation for Traffic Safety. Available at www.aaafoundation.org/understandingolder-drivers-examination- medical-conditions-medication-use-and-travel-behavior.

99. Hetland, A., & Carr, D. B. (2014). Medications and impaired driving. Annals of 

Pharmacother., 48, 494–506.

100. Dassanayake, T. (2011). Effects of benzodiazepines, antidepressants and opioids on 

driving: A systematic review and meta-analysis of epidemiological and experimental 

evidence. Drug Safety, 34, 125–156.

101. Bramness, J. G., Skurtvelt, S., Neutel, C. L., Mørland, J, & Engeland, A. (2008).

Minor increase in traffic accidents after prescriptions of antidepressants: a study 

of population registry data in Norway. Journal of Clinical Psychiatry, 69, 1099–

1103.

102. Qato D. M., Alexander, G., C., Conti R. M., Johnson, M., Schumm, P., & Lindau, S. T. 

(2008). Use of prescription and over-the-counter medications and dietary 

supplements among older adults in the United States. Journal of the American 

Medical Association, 300(24), 2867.

103. LeRoy, A. A., & Morse, M. L. (2008, May). Multiple medications and vehicle crashes:

Analysis of databases (Report No. DOT HS 810 858). Washington, DC: National Highway

Traffic Safety Administration. Available at

www.nhtsa.gov%2FDOT%2FNHTSA%2FTraffic%2520Injury%2520Control%2FArticles%2

FAssociated%2520Files%2F810858.pdf

104. Weiler, J. M., Bloomfield, J. R., Woodworth, G. G., Grant, A. R., Layton, T. A., Brown, T. 

L., ... Watson, G. S. (2000). Effects of fexofenadine, diphenhydramine, and alcohol on 

driving performance. a randomized placebo-controlled trial in the Iowa Driving 

Simulator. Annals of Internal Medicine, 132(5), 354–363.
189

105. Tashiro, M., Horikawa, E., Mochizuki, H., Sakurada, Y., Kato, M., Inokuchi, T., ... Yanai, 

K. (2005). Effects of fexofenadine and hydroxyzine on brake reaction time during car

driving with cellular phone use. Human Psychopharmacology, 20, 501–509.

106. Mattila, M. (1988). Acute and subacute effects of diazepam on human 

performance: Comparison of plain tablet and controlled release capsule. 

Pharmacological Toxicology, 63(5), 369–374.

107. Aranko, K., Mattila, M. J., & Bordignon, D. (1985). Psychomotor effects of alprazolam 

and diazepam during acute and subacute treatment, and during the follow-up phase. 

Acta Pharmacologica Toxicologica, 56(5), 364–372.

108. American Geriatrics Society 2015 Beers Criteria Update Expert Panel (2015, 

November). American Geriatrics Society 2015 updated Beers Criteria for potentially 

inappropriate medication use in older adults. Journal of the American Geriatrics 

Society, 63(11), 2227-46. 

109. Avorn, 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.

110. Hobson, 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.

111. Hansen, R. N., Boudreau, D. M., Ebel, B. E., Grossman, D. C., & Sullivan, S. D. (2015).

Sedative hypnotic medication use and the risk of motor vehicle crash. American Journal 

of Public Health, 105, e64–e69.
190

CHAPTER 10 MEETING FUTURE TRANSPORTATION NEEDS OF OLDER ADULTS

Key Points

• A holistic approach that incorporates assessment and intervention and that facilitates the

transition to driving limitation or cessation when necessary is encouraged.

• A tiered assessment strategy offers potential advantages for gauging risk in clinical offices

and licensing agencies, although more evidence is needed regarding content, efficiency, and

effectiveness.

• Clinicians should be aware of and use driving evaluation resources in their area, including

driving rehabilitation specialists (DRSs).

• As new technologies are developed, their role in enhancing safety of older adult drivers,

passengers, and pedestrians should be assessed.

• Clinician involvement and communication with driver licensing agencies should be

encouraged and facilitated.

• Coordination among clinicians, licensing agencies, and relevant State/local/community

agencies/organizationsis encouraged to help older adults and their caregivers become

aware of transportation resources in their community and how to access these resources.

The previous chapters provide the clinical team with recommendations and tools for enhancing

the driving safety of older adults. As in other aspects of patient care, however, further research

can lead to more effective care. Further progress on the following would be beneficial:

• In-office tools that can predict crash risk or determine fitness to drive

• Improved access to driver assessment and rehabilitation

• Advanced technology in vehicles to assist drivers with navigation and safety issues

• Safer roads

• Better transportation alternatives

• Increased crashworthiness of vehicles

• Other vehicular improvements that can help keep older adult drivers safe on the road as

long as possible

• Intervention trials to lower risk, maintain driving life expectancy and/or improve driving

To accomplish these objectives, coordinated efforts among the health care and transportation

communities, policymakers, community planners, the automobile industry, and government

agencies are needed to achieve the common goal of safe transportation for the older

population. As this population continues to expand and live longer, the challenge is to keep

pace with its transportation needs. Although many transportation alternatives are beginning to

develop (e.g., fully automated vehicles, golf cart communities, private car rideshare programs),

review of the use of these by older adults is beyond the scope of this chapter.
191

This chapter discusses the research, initiatives, applications, and system changes deemed

essential for improving driving safety of older adults. Readers are also encouraged to review the

National Highway Traffic Safety Administration’s Traffic Safety for Older People – 5-Year Plan to

address traffic concerns of older adults for additional ideas.1

Improved Clinician Toolsfor Assessment of Driving Safety

Clinicians need an assessment approach that reliably identifies older adult drivers at increased

risk of a car crash. A tiered assessment strategy can be considered for clinical settings in which

older adult drivers are screened routinely (on the basis of certain risk criteria) or if concerns

about their driving arise (a similar strategy for licensing agencies is discussed below). Depending

on test results, the driver would be scheduled for more detailed assessment or an on-road

driving evaluation. Fully implementing such a strategy in different clinical settings would involve

logistical challenges. The ideal tests would assess the primary functions related to driving and

form the basis for interventions to correct or ameliorate any identified conditions or functional

deficits. In addition, this tool should be brief, inexpensive, easy to administer, and validated to

predict crash risk and/or ability to pass a performance-based, standardized, reliable and valid

road test.

At present, no one comprehensive tool is available, in part because of the multifactorial nature

of driving ability and because of the limitations of potential measures. Global cognitive

measures are easy to administer and score but may not adequately address the cognitive

abilities necessary for safe driving. One such measure, the Mini–Mental State Examination, was

not associated with crash involvement in a recent large multisite study.2 Despite the large

sample size, participants were relatively young and there was limited adjustment for driving

exposure. The limited ability of global cognitive measures to predict adverse driving events has

increasingly led to a focus on other measures that address relevant cognitive domains such as

executive function, attention, information processing speed, or visuospatial ability. One such

measure, the Trail-Making Test Part B, has shown potential in predicting adverse driving

events.3 However, findings have been mixed, and the Trail-Making Test has its limitations as

well.4 Part of the difficulty is studying heterogeneous groups of drivers who may have very

different risk factors. One approach is to narrow testing to individuals with a specific disorder or

particular disease (e.g., glaucoma, dementia); however, this will obviously not be broadly

applicable.

Clinical teams desire a quick, cost-effective, widely available comprehensive tool to determine

driving recommendations. Until such a tool is available, given the multiple complexities of

driving, the clinical team may be better served by tailoring assessment and intervention to the

particular strengths and limitations of each older adult driver. Clinicians can evaluate older

adults’ potential driver risk by assessing functions related to driving (see Chapter 3) and

reviewing the presence and/or severity of important medical conditions, functional deficits, and

use of potentially driver-impairing medications (see Chapter 9). Given the projected increase in
192

prevalence of dementia, clinicians should also try to ascertain caregiver concerns and factor

these into the assessment and intervention process.5

Increased Availability and Affordability of Driver Rehabilitation Services

When the results of clinician assessment are unclear, or when further correction of functional

deficits through clinical team management is not possible, DRSs are an excellent resource. DRSs

can perform a focused clinical assessment, observe the older adult during the actual driving

task, and train him or her in the use of adaptive techniques or devices to compensate for

medical conditions or functional deficits (see Chapter 5).

Unfortunately, access and cost remain major barriers to use of DRSs by older drivers and

referring clinicians. DRSs are not available in all communities, and there are presently too few

to provide services to all older drivers in need. Furthermore, driver assessment and

rehabilitation are expensive, and Medicare and private insurance companies rarely pay for

these services.

The American Occupational Therapy Association (AOTA) has tried to address these issues

through a number of initiatives. AOTA has devised a framework to increase the number of

DRSs within the occupational therapy (OT) profession, including strategies to promote older

driver expertise among current OT practitioners, curriculum content for continuing education

programs, and training modules for entry-level OT educational programs. AOTA also

continues to actively lobby for consistent Medicare and insurance coverage of OT-performed

driver assessment and rehabilitation, under the premise that these services fall within the

scope of OT practice and that driving is an instrumental activity of daily living.

In the effort to keep older adult drivers on the road safely as long as is reasonable, increased

access to and affordability of driver assessment and rehabilitation are essential. Clinicians need

to be aware of DRS services and programs in their area and use these resources whenever

possible. Further research in thisfield is encouraged to demonstrate the efficacy and costeffectiveness of DRS services, and to create standardized off-road and on-road driving tests

that have respectable levels of reliability, validity, and test stability. Correlating results of onroad tests with prospective at-fault crash data remains an important area of future study.

Increased Investigation Into Use of Simulators and Comprehensive Assessment

Methods and Techniques

Validated driver assessment technologies may help make driver assessment more widely

available to older drivers. Simulated driving assessments offer a number of potential

advantages compared with on-road testing, including standardization of the driving

environment and scenarios encountered during testing, time efficiency, and safety for testing

high-risk individuals. However, a number of challenges exist, including potential trade-offs

between fidelity/realism versus cost/complexity of systems, tolerability and motion sickness in
193

an older adult population, and complexity of scoring results. It remains to be seen whether

simulator testing will remain an adjunct to the assessment process or can reliably substitute for

on-road evaluations, particularly in a population less familiar with simulator use. It will be useful

to determine if familiarity with computers and electronic games by successive aging cohorts

affects the outcome of simulator performance and/or reduces crashes. As interventions

develop, it will be useful to determine the role of simulator training in relation to classroom and

on-road training.

Efforts should continue to better understand the complex role the central nervous system plays

in operating a motor vehicle.6,7As new technologies are developed to better delineate different

disorders, it will be helpful to determine the role these can play in determining driver risk. State

licensing agencies and driver rehabilitation programs are encouraged to investigate the use of

technologies to increase availability of reliable driver assessment services to the public. Such

technologies, if integrated into or aligned with current practices, could help form an

intermediate step between clinician assessment and driver rehabilitation or increase the

licensing agency’s capacity to offer specialized driver assessment to at-risk drivers.

Enhanced Role of the State Licensing Agency in Promoting Safety of Older

Drivers

As the agency that ultimately issues, renews, restricts, and revokes driver licenses, each State’s

driver licensing agency has the task of distinguishing unsafe drivers from safe drivers. Although

each State has its own procedures, potentially unsafe drivers are usually identified by one of

four means: failure of the individual to meet licensing or license renewal criteria; report from

the individual or family; report from clinicians, DRSs, law enforcement officers, and others; and

judicial report.

To meet the standards for licensing, the driver licensing agency initially requires individuals to

pass assessments of knowledge, vision, and driving skills. License renewal tends to be less

stringent, with many States permitting renewal by mail. In recent years, certain States have

increased their efforts to identify drivers at risk of unsafe driving by stipulating special renewal

procedures based on different criteria. These procedures include shortened renewal intervals,

in-person renewal, and mandatory reassessment of knowledge, vision, or driving skills.

Numerous studies have examined safety confounders for older adult drivers and hypothesized

about the most beneficial approach. A recent review of studies in this area summarized the

evidence as suggesting that in-person renewal was associated with lower fatal crash risk,

license restrictions were associated with decreased exposure, and more renewal requirements

or medical reporting were linked with delicensure.8 Whether the latter findings are viewed as a 

positive outcome depends on individual perspective. If those targeted for restriction or more

intense renewal requirements are truly at increased safety risk, then public safety may benefit.

If not, those individuals’ mobility may be adversely affected without clear gains in public safety.
194

This area warrants further investigation. States are encouraged to maintain or adopt renewal

procedures for the most effective identification of at-risk drivers (see also Enhanced Role of the

Medical Advisory Board, below). States are also encouraged to base their standards for licensing

on current scientific data. For example, visual acuity standards based on outdated research may

be unnecessarily restrictive to all drivers and to older adult drivers in particular.

In addition to the vision screens currently in use, driver licensing agencies may also wish to use

newer tools (e.g., contrast sensitivity and the useful field-of-view test) that have been shown

to correlate with crash risk.9,10 Some of these tools, along with other tests of function and

driving skills, have been field tested by the California Department of Motor Vehicles as part of

its three-tier assessmentsystem. Although this approach has many conceptual advantages, as

tested there were limitations in its effectiveness.11,12 Many lessons can be learned from this

large-scale, practical experiment, and all jurisdictions would benefit from a better

understanding of what worked well, what did not, and how to improve on the approach and

implementation. In Maryland, a tiered approach is used to identify and assess medical fitness

to drive in clients for whom decline in cognitive function is raised in materials submitted to the

licensing agency. Most of the drivers in cohort are older adult drivers. A free, five-element

screening test is routinely used to assess these individuals.13,14

Driver licensing agencies could also create a more supportive system for older drivers. For

example, the agency can work more closely with the at-risk driver’s clinical team or the Medical

Advisory Board to correct functional deficits through treatment, if possible. Drivers with a high

potential for rehabilitation can be referred by the licensing agency to a DRS to learn adaptive

techniques and devices. Licensing agencies can also consider the older adult’s driving needs by

issuing restricted (e.g., geographic or time of day) licenses whenever possible to help the driver

maintain driving ability while protecting his or her safety. For older adult drivers who must

relinquish their license, the agency can provide guidance in seeking alternative transportation

and linkages to other agencies that might be helpful in identifying available resources.

At-risk drivers can also be brought to the attention of the driver licensing agency by clinician

referral. However, many clinicians are not aware of their State’s referral procedures,15 and

others fear legal liability for breach of confidentiality. With the advent of the Health Insurance

Portability and Accountability Act (HIPAA), clinicians may have questions about the extent and

detail of patient information they should or can provide in a referral. Driver licensing agencies

can encourage clinician referral by establishing clear guidelines and simple procedures for

referral (e.g., comprehensive referral forms that can be accessed over the Internet) and 

promoting clinician awareness of these guidelines and referral procedures. A 2012 review

critiqued the forms used by 52 jurisdictions in North America and made a number of

recommendations on best practices.16 In many States, clinicians who refer older adults to their

State’s driver licensing agency are not granted legal protection against liability for breaching the

patient’s confidentiality. Indeed, several States encourage or require clinicians to report
195

impaired drivers without specifically offering this legal protection. Most statutes that do

provide immunity for reporting in good faith apply only to physicians.

Clinicians should join advocacy groups in their States to pass fair laws that protect clinicians

who report in good faith and that ensure anonymity for reporting. Statutes providing immunity

should include all members of the clinical team who are involved in the care and evaluation of

drivers for whom there are concerns about medical fitness to drive (e.g., physicians, nurse

practitioners, physician assistants, driver rehabilitation specialists, social workers, pharmacists,

occupational therapists, nurses, etc.). State legislatures are encouraged to establish or maintain

good-faith reporting laws that provide immunity from breach of confidentiality lawsuits for

clinicians and others who report potentially impaired drivers to their State licensing authority.

The State licensing agency should be involved in outreach education to clinicians, law

enforcement, drivers and their caregivers to improve awareness of their obligations regarding

the reporting of medical conditions to the agency, which could promote earlier interventions. A

website with easily accessible information and resources is essential. Ideally, the medical

review unit staff and/or members of the medical advisory board should be available for

outreach efforts and should partner with appropriate agencies and groups (e.g., departments on

aging, health care professional societies, etc.) to facilitate outreach education.

Future older adult drivers will present with increasingly complex driving ability questions. For

instance, palliative care providers may be confronted with an older adult’s determination to

continue driving past the time of medical fitness to drive. Such cases will challenge medical

understanding, ethics, and legal counsel.17 Health care teams and licensing agencies should

anticipate preparing for diverse driving capacity scenarios in the years to come.

Enhanced Role of the Medical Advisory Board

A Medical Advisory Board (MAB) is generally composed of State-licensed clinicians who work in

conjunction with the driver licensing agency to determine whether mental or physical

conditions may impair an individual’s ability to drive safely. MABs vary among States in size,

role, and level of involvement. For example, the MAB of the Maryland Motor Vehicle

Administration reviews the fitness of individuals to drive safely, while California’s MAB provides

recommendations to licensing agency staff for use in developing policies that affect medically

and functionally impaired drivers.18 Many States lack an MAB or have one that is suboptimally

used.

Each State driver licensing agency is encouraged to enhance the role of its MAB to provide

improved capacity for assessment, rehabilitation, and support to older adult drivers. States that

lack MABs are also encouraged to create a multidisciplinary team of medical experts to develop

and implement recommendations on the medical fitness of their State’s licensed drivers. Such

recommendations should be based on the most current scientific data and implemented in an

efficient review process.
196

The National Highway and Traffic Safety Administration and the American Association of

Motor Vehicle Administrators completed a study of each State’s MAB practices.19 This

project detailed the function of each State’s MAB; its regulatory guidelines; and barriers to

implementation of screening, counseling, and referral activities. The executive summary of

this study had many important recommendations for States that license medically impaired

drivers, including:

• Each State should have an active board to set standards and guidelines and to be

involved in fitness-to-drive evaluations.

• Board members should be adequately compensated.

• Clinicians should be granted immunity for reporting.

• National standards and forms, and referrals for mobility counseling and/or DRSs,

should be considered.

Increased Public Awareness of Medication Adverse Effects that May Impair

Driving

Many prescription and over-the-counter medications have the potential to impair driver

performance. Despite warnings on the label and counseling by clinicians, many older adults and

their caregivers are unaware of these risks.

To address this problem, the National Transportation Safety Board (NTSB) has recommended20

that the U.S. Food and Drug Administration (FDA) establish a clear, consistent, and easily

recognizable warning label for all prescription and over-the-counter medications that may

interfere with ability to operate a vehicle. This recommendation was the focus of an FDA/NTSB 

joint public meeting held in November 2001. This meeting hosted presentations of

epidemiologic and controlled data on the effects of sedating drugs and crash risk, as well as

presentations from innovators of devices designed to test the degree to which drugs may impair

driving. As a result of the meeting, the FDA and NTSB concluded that steps must be taken to

better educate the public and prescribing clinicians on adverse effects of potentially driverimpairing medications. Efforts to increase older adult driver, caregiver, and clinician education

and to clarify labeling for consumers are encouraged.

Currently, manufacturers of medications do not routinely test their products for effects on

driving, nor are they required to do so. The identification and routine use of effective testing

parameters to identify medications that may interfere with the ability to safely operate a motor

vehicle is encouraged. Similarly, such parameters could be used to identify medications that do

not typically impair drivers when used as directed.

Promotion of Self-Awareness and Appropriate Self-Regulation

Generally, older adult drivers modify their driving routine by self-regulation. Some drivers

participate in educational programs or occupational therapy interventions in an effort to
197

decrease crash risk by increasing their awareness of questionable driving habits and learning

adaptive strategies. Occupational therapy interventions assist older adult drivers to develop

objectivity in themselves and their driving environment.21 In late life, both women and men do

compensate for individual changes in their health and capacity to drive, but a recent study

found that older women were somewhat more likely than older men to stop or limit driving

over time and that the factors associated with these changes differed by gender.22

Vehicle Designs that Optimize Safety of Older Adult Drivers and Passengers

Age-related changes in vision, cognition, and motor ability may affect an individual’s ability to

enter/exit a motor vehicle with ease, assess critical driving information, and handle a motor

vehicle safely. Older adults are also less able to endure and recover from injuries sustained in

an automobile crash. Vehicle manufacturers are encouraged to explore and implement

enhancements in vehicle design that address and compensate for these physiologic changes.

In particular, vehicle designs based on the anthropometric parameters of older adults (i.e.,

physical dimensions, strength, fragility, and range of motion) may be optimal for entry/exit;

seating safety and comfort; seat belt/restraint systems; and placement and configuration of

displays, mirrors and controls. Improvements in headlamp lighting to enhance nighttime

visibility and reduce glare, as well as the use of high-contrast legible fonts and symbols for invehicle displays, may help compensate for age-related changes in vision.23 In addition,

prominent analog gauges may be easier to see and interpret than small digital devices.24

Computers have revolutionized the motor vehicle industry by managing airbag safety systems,

antilock brakes, and global positioning systems. In-vehicle tools to assess for high-risk

conditions may be developed in the future.

In the event of a crash, improved crashworthy vehicle designs and restraint systems

designed for fragile occupants may enhance the safety of older adult drivers and 

passengers. Certain add-on features may also make current vehicle designs safer and more

accessible for older adult drivers. For example, handholds and supports on door frames may

facilitate entry/exit for both drivers and passengers. Padded steering wheels and seat

adjuster handles (rather than knobs) may benefit drivers with decreased hand grip, and

adjustable steering wheels and foot pedals may aid drivers with limited range of motion or

of smaller stature.25

Crashes involving older adult drivers and fatality rates have fallen in recent years, despite

the increased fragility of older adults. It may be possible to enhance these gains by better

understanding the factors that enter into older drivers’ vehicle selection and incorporating

the issues outlined above into this process.26 A initial effort to promote the selection of

vehicles that may be a better fit for older adults is in place at the American Automobile 

Association website.27 Other adjustable controls and displays may allow older drivers to

tailor their vehicle to their changing abilities and needs. Safety features that may benefit
198

older adults include smart headlights, emergency response systems, reverse monitoring,

blind spot/lane departure warning, stability control, assisted parking, voice-activated

controls, crash mitigation systems, and drowsy driver alerts.28 Electronic stability control is

now standard equipment on all new vehicles and may lead to further safety gains as it

becomes more prevalent in the vehicle fleet.29

Optimal Environmentsfor Older Adult Drivers and Pedestrians

To promote aging in place, clinical teams are encouraged to be realistic regarding

environmental features essential for older adults. A recent review noted that older adults

prioritized safety considerations when making mobility choices. Additional desirable elements

included aesthetics (clean surroundings), land use (commercial/residential availability), format

of street networks, and the older adult’s cognitive and physical abilities to utilize these

characteristics of their environment.30

Many older adult drivers are at a disadvantage on roads and highways that are most heavily

used by and traditionally designed for a younger population. In a telephone survey of 2,422

people 50 and older, nearly one of five participants considered inconsiderate drivers to be a 

major problem. Other commonly identified problems included traffic congestion, crime, and

fast traffic.31

These problems may be ameliorated through traffic law enforcement and better road and

traffic control designs. One of the top requests of the nearly 200 Iowans (older drivers,

transportation professionals, and senior-related professionals) attending the Iowa Older Drivers

Forum was the enhanced enforcement of speed and aggressive driving laws.32 In terms of road

and traffic engineering, the Federal Highway Administration has recognized and addressed the

needs of older adult drivers in its Handbook for Designing Roadways for the Aging Population, a 

supplement to existing standards and guidelines in the areas of highway geometry, operations,

and traffic control devices.33 These design features may be implemented in new construction,

renovation and maintenance of existing structures, and “spot” treatment at certain locations

where safety problems exist or are anticipated.27 The Federal Highway Administration

handbook is updated periodically to incorporate the latest research on the effectiveness of

design and engineering enhancement to accommodate older adult drivers.

Better Alternativesto Driving

Alternatives to driving are often less than ideal or nonexistent. When faced with the choice of

unsafe driving or losing mobility, many older adults risk their safety by continuing to drive.

Existing forms of transportation clearly need to be optimized for use by older adults. In a 

telephone survey of 2,422 people 50 and older, ride-sharing was the second most common

mode of transportation (after driving); however, nearly a quarter of the survey participants

cited feelings of dependency and concerns about imposing as a barrier to use. Public
199

transportation was the usual mode of transportation for fewer than 5% of survey participants,

with many citing unavailable destinations, problems with accessibility, and fear of crime as

barriers to use. Fewer than 5% used taxis as their usual mode of transportation because of the

high cost. 31

Until these barriers are addressed, these forms of transportation will remain suboptimal for

many older adults.

Transportation programs created specifically for the older population, such as senior shuttles

and vans, exist in certain communities. A number of locations have adopted the independent

transportation network model.34 These programs address the Five A’s of Senior-Friendly

Transportation: availability, accessibility, acceptability, affordability, and adaptability (see

below).35 As the older population continues to grow in numbers, the creation of new programs

or expansion of existing ones is encouraged to keep pace with passengers’ needs, as well as

stronger community outreach to increase awareness of such programs.

The Five A’s of Senior-Friendly Transportation*

• Availability: Transportation exists and is available when needed (e.g.,

evenings, weekdays, weekends).

• Accessibility: Transportation can be reached and used (e.g., bus stairs are

negotiable, seats are high enough, vehicle comes to the door, transit stops are

reachable).

• Acceptability: Deals with standards, including cleanliness and safety (e.g., the

transporting vehicle is clean, transit stops are in safe areas, drivers are courteous and

helpful).

• Affordability: Deals with costs (e.g., fees are affordable, vouchers or coupons

are available to defray out-of-pocket expenses).

• Adaptability: Transportation can be modified or adjusted to meet special needs 

(e.g., the vehicle can accommodate a wheelchair, trip chaining is possible, escorts

can be provided).

* Source: Supplemental Transportation Programs for Seniors, The Beverly Foundation.

The occupational therapy discipline has been at the forefront of driving and community

mobility issues. Its work reminds the clinical team to maintain a client-centered approach when

counseling older adult drivers and to avoid the one-size-fits-all perspective. Most clinical team

members and especially occupational therapists agree that often no single element of physical

and cognitive capacity is sufficient to require driving cessation, but rather a multidimensional

approach is necessary.36 The number of different fitness-to-drive assessment tools and

simulator evaluation techniques reflect the heterogeneity of the older adults these strategies

are designed to assess.
200

To address these issues, the roles and responsibilities of all parties involved in the process need

to be better defined, delineated, and disseminated. Drivers, caregivers, clinicians, DRSs, other

health professionals, licensing authorities, and other community/State/national agencies and

organizations have a role to play. Society as a whole needs to be involved in a discussion of

acceptable thresholds of risk. In the process of identifying drivers potentially at increased risk of

driving safety difficulties, a fair and appropriate assessment of risk is needed, identifying factors

potentially influencing risk, considering interventions to lower risk, and identifying ways to

facilitate the transition to driving limitations or cessation if drivers prefer to do so or if

interventions are not possible or successful. More communication and coordination among the

parties involved is needed, as well as demonstrating the effectiveness of different steps in the

process, and more information on feasibility and sustainability. A holistic approach to the

process is needed that considers not just driving, but mobility in a broad sense.37An ideal

system would also consider competing risks (e.g., falls, pedestrian safety) and interventions that

might benefit these as well.

Evidence emerging in the last 10–15 years has allowed a realistic consideration of expanding

from a decision regarding driving versus not driving, or licensing versus revocation of licensing,

to a discussion that includes interventions. Interventions have been developed that enhance

relevant functional abilities, driver awareness of deficits, clinician and caregiver awareness of

how to address the issue, and facilitating the transition to driving cessation. 38-47 Many of these

studies have been preliminary or small scale, and much more information is needed on how to

broaden their applicability and to determine the ancillary effects if they are applied more

broadly.

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 Ride to Wellness

Program, 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.
201

References

1. National Highway Traffic Safety Administration. (2013, December). Traffic safety for older 

people — 5-year plan (Report No. DOT HS 811 837). Washington, DC: Author. Available at 

www.nhtsa.gov/staticfiles/nti/older_drivers/pdf/Older_People_811873.pdf

2. Joseph, P.G., O’Donnell, M. J., Teo, K. K., Gao, P., Anderson, C., Probstfield, J. L., ... 

Yusuf, S. (2014). The Mini–Mental State Examination, clinical factors, and motor

vehicle crash risk. Journal of the American Geriatric Society, 62, 1419–1426.

3. Staplin, L., Gish, K., W., & Sifrit, K. J. (2014). Using cognitive status to predict crash risk:

Blazing new trails? Journal of Safety Research, 48, 19–25.

4. Vaucher, P., Herzig, D., Cardoso, I., Herzog, M. H., Mangin, P., & Favrat, B. (2014). The trail

making test as a screening instrument for driving performance in older drivers; a 

translational research. BioMed Central Geriatrics, 14, 123.

5. Meuser, T. M., Carr, D. B., Unger, E. A., Ulfarsson, G. F. (2015). Family reports of 

medically impaired drivers in Missouri: cognitive concerns and licensing outcomes. 

Accident Analysis & Prevention,74, 17–23.

6. Walter, H., Vetter, S. C., Grothe, J., Wunderlich, A. P., Hahn, S., & Spitzer, M. (2001).

The neural correlates of driving. Neuroreport, 12(8), 1763–1767.

7. Ott, B. R., Heindel W.C., Whelihan W. M., Caron, M.D., Piatt, A. L., & Noto, R. B. (2000). A 

single-photon emission computed tomography imaging study of driving impairment in 

patients with Alzheimer’s disease. Dementia and Geriatric Cognitive Disorders, 11(3), 

153–160.

8. Dugan, E., Varton, K. N., Coyle, C., & Lee, C. M. (2013). U.S. policies to enhance

older driver safety: a systematic review of the literature. Journal of Aging & Social 

Policy, 25, 335–352.

9. Owsley, C., Stalvey, B. T., Wells, J., Sloane, M. E., & McGwin, G. Jr. (2001). Visual risk

factors for crash involvement in older drivers with cataracts. Archives of 

Ophthalmology, 119, 881–887.

10. Owsley, C., Ball, K., & McGwin, G. (1998). Visual processing impairment and risk of 

motor vehicle crash among older adults. Journal of the American Medical 

Association, 279, 1083–1088.

11. Hennessy, D. F., & Janke, M. K. (2009). Clearing a Road to Being Driving Fit by Better
202

Assessing Driving Wellness: Development of California’s prospective three tier drivingcentered assessment system. (Report No. RSS-OS-216). Sacremento: California 

Department of Motor Vehicles. 

12. Camp, B. J. (2014).The overall program effects of California’s 3-tier assessment system 

pilot on crashes and mobility among senior drivers. Journal of Safety Research, 47, 1–8. 

13. Ball, K., Roenker, D. L., Wadley, V. G., Edwards, J. D., Roth, D. L., McGwin Jr, G., ... Dube T. 

(2006) Can high-risk older drivers be identified through performance-based measures in a 

department of motor vehicles setting. Journal of American Geriatrics Society, 54, 77-84.

14. Soderstrom, C. A., & Joyce, J. J. (2008). Medical Review of fitness to drive in older drivers: 

The Maryland experience. Traffic Injury Prevention, 9, 342-349.

15. Cable, G., Reisner, M., Gerges, S., & Thirumavalavan, V. (2000). Knowledge, attitudes, and

practices of geriatricians regarding patients with dementia who are potentially dangerous 

automobile drivers: a national survey. Journal of the American Geriatrics Society, 48(1), 

14–17.

16. Meuser, T. M., Berg-Weger, M., Niewoehner, P. M., Harmon, A. C., Kuenzie, J. C., Carr, D.

B., & Barco, P. D. (2012). Physician input and licensing of at-risk drivers: A review of allinclusive medical evaluation forms in the US and Canada. Accident Analysis & 

Prevention, 46, 8–17.

17. Gaertner, J., Vent, J., Greinwald, R., Rothschild, M. A., Ostgathe, C., Kessel, R., & Voltz, R. 

(2011). Denying a patient’s final will: public safety vs. medical confidentiality and patient 

autonomy. Journal of Pain Symptom Management, 42, 961– 966.

18. Raleigh, R., & Janke, M. (2001). The role of the medical advisory board in DMVs: 

protecting the safety of older adult drivers. Maximizing Human Potential: Newsletter of 

the Network on Environments, Services and Technologies for Maximizing

Independence. American Society on Aging, 9(2), 4–5.

19. Lococo, K. H, & Staplin, L. (2005, July). Strategies for medical advisory boards and licensing 

review(Report No. DOT HS 809 874). Washington, DC: National Highway Traffic Safety 

Administration. Available at www.nhtsa.gov/people/injury/research/MedicalAdvisory/-

pages/Job%201602%20-%20final%20new.pdf
203

20. National Transportation Safety Board. (2000, January 13). Safety Recommendation I-00-5.

Retrieved from the NTSB website at www.ntsb.gov/safety/safetyrecs/recletters/I00_1_4.pdf

21. Golisz, K. (2014). Occupational therapy interventions to improve driving performance in 

older adults: a systematic review. American Journal of Occupational Therapy, 68, 662–

669.

22. Dit Asse, L. M., Fabrigoule, C., Helmer, C., Laumon, B., & Lafont, S. (2014). Automobile

driving in older adults: factors affecting driving restriction in men and women. Journal of 

American Geriatric Society, 62, 2071–2078.

23. Schieber, F. (1994). High-priority research and development needs for maintaining the

safety and mobility of older drivers. Experimental Aging Research, 20, 35–43.

24. Koonce, J. M., Gold, M., & Moroze, M. (1986). Comparison of novice and experienced

pilots using analog and digital flight displays. Aviation and Space Environmental

Medicine, 57(12 pt. 1), 1181– 1184.

25. Organization for Economic Co- Operation and Development. (2001). Ageing and

Transport: Mobility Needs and Safety Issues. Paris: Author, pp 60, 69–71.

26. Cicchino J.B., & McCartt, A. T. (2014). Trends in older driver crash involvement rates and

survivability in the United States: an update. Accident Analysis & Prevention, 72, 44–54.

27. AAA Senior Driving. (2015). Find the Right Vehicle for You (Web page, no longer 

available). Retrieved from the AAA website at:

http://seniordriving.aaa.com/maintain-mobility-independence/car-buyingmaintenance-assistive-accessories/find-right-vehicle-you. 

28. The Hartford Financial Services Group, Inc. (2012). Top Technologies for Mature

Drivers. Hartford, CT:, Author. 

29. Ferguson, S. A. (2007). The effectiveness of electronic stability control in reducing

real-world crashes: a literature review. Traffic Injury Prevention, 8, 329–338.

30. Yen, I. H., Flood J. F., Thompson, H., Anderson, L. A., & Wong, G. (2014). How design of 

places promotes or inhibits mobility of older adults: realist synthesis of 20 years of 

research. Journal of Aging Health, 26, 1340–1372.
204

31. Ritter, A. S., Straight, A., & Evans, E. (2002). Understanding Senior Transportation: Report

and Analysis of a Survey of Consumers Age 50+. Washington, DC: American Association 

for Retired Persons. 

32. Iowa Safety Management System: Safe Mobility Decisions for Older Drivers Forum. June 

19–20, 2002,; Ames, IA. The Forum Outlined.

33. Brewer. M., Murillo, D., & Pate, A. (2014). Handbook for designing roadways for the 

aging population. (Report No. FHWA-SA-14-015). Washington, DC: Federal Highway 

Administration.

34. ITNAmerica. (2015). What We Do: Research & Policy (Web page). Retrieved from the iTN 

website at: www.itnamerica.org/what-we-do/research-policy

35. Beverly Foundation. (2011, June). Supplemental Transportation Programs for 

Seniors. Washington, DC: AAA Foundation for Traffic Safety. 

36. Dickerson, A. E., Meuel, D. B., Ridenour, C. D., & Cooper, K. (2014). Assessment tools

predicting fitness to drive in older adults: a systematic review. American Journal of 

Occupational Therapy, 68, 670–680.

37. Satariano, W. A., Guralnik, J. M., Jackson, R. J., Marottoli, R. A., Phelan, E. A., & 

Prohaska, T. R. (2012). Mobility and aging: new directions for public health action. 

American Journal of Public Health, 102, 1508–1515.

38. Owsley, C., McGwin, G., Sloane, M., Wells, J., Stalvey, B. T., & Gauthreaux, S. (2002).

Impact of cataract surgery on motor vehicle crash involvement by older adults. Journal of 

the American Medical Association, 288, 841–849.

39. Owsley, C., Stalvey, B. T., & Phillips, J. (2003). The efficacy of an educational intervention

in promoting self-regulation among high risk-older drivers. Accident Analysis & 

Prevention, 35, 393–400.

40. 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, 371–381.

41. Roenker, D. L., Cissell, G. M., Ball, K. K., Wadley, V. G., & Edwards, J. D. (2003). Speed-ofprocessing and driving simulator training result in improved driving performance. Human 

Factors, 45, 218–233.
205

42. 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.

43. 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.

44. 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.

45. 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 Geriatric 

Society, 58, 2107–2113.

46. 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.

47. 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.
APPENDIX A

CPT® Codes

206
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®) 2015 Professional Edition. Chicago, IL: American Medical Association; 2015. 

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 Established Patient, Office or Outpatient Service 

Evaluation and management of an individual including an age- and 

gender-appropriate history, examination, counseling/anticipatory 

guidance/risk factor reduction interventions, and the ordering of 

appropriate immunizations(s), laboratory/diagnostic procedures. 

These codes can be used for a complete Preventive Medicine 

history and physical examination 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. If significant driver assessment and 

counseling take place at the time of an office or outpatient service 

(99201-99215), Modifier-25 may be added to the codes above. 

99396 40–64 years old Established Patient, Periodic Comprehensive Preventive Medicine 

99397 ≥65 years old Reevaluation and management of an individual including an ageand gender-appropriate history, examination, 

counseling/anticipatory guidance/risk factor reduction 

interventions, and the ordering of appropriate immunization(s), 

laboratory/diagnostic procedures. 

Note: Codes from the Preventive Medicine Services 99386-99387 and 99396-99397 can be 

reported only once per year. If driver assessment and counseling take place at the time of an 

office or outpatient service (99201-99215), Modifier-25 may be added to the codes above. 

207
Modifier-25 is appended 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. 

99401

99402 

99403 

99404

Approximately 15 

minutes 

Approximately 30 

minutes 

Approximately 45 

minutes 

Approximately 60 

minutes

Counseling and/or Risk Factor Reduction Intervention 

Preventive medicine counseling and risk factor reduction 

interventions provided as a separate encounter will vary 

with age and should address such issues as family 

problems, diet and exercise, substance abuse, sexual 

practices, injury prevention, dental health, and 

diagnostic and laboratory test results available at the 

time of the encounter. (These codes are not to be used 

to report counseling and risk factor reduction 

interventions provided to patients with symptoms or 

established illness.) 

These are time-based codes, to be reported based 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 99420, 95831 and either 99172 or 99173. The 

CADReS Score Sheet can serve as the report. 

99420 Administration and Interpretation of Health Risk Assessment Instrument 

95831 Muscle and Range of Motion Testing 

Muscle testing, manual (separate procedure) with report; extremity (excluding 

hand)or trunk. 

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 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, longer than 3 

208
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; longer than 30 minutes 

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 

209
APPENDIX B

Patient and Caregiver Educational Material

● Am I a Safe Driver?

● Getting by Without Driving

● How to Assist the Older Driver

● NHTSA’s How to Understand and Influence Older Drivers

● Ten Tips to Aging Well

● Tips for Safe Driving

210
Patient and Caregiver Educational Materials 

These handouts were designed to be user-friendly and simple to read. All patient education 

materials were written at or below a 6th grade reading level, and all family and caregiver 

material was written at a 7th grade reading level. 

We encourage physicians to make copies of these handouts for their patients, have them 

available in the office setting, educate office staff to distribute them when appropriate, and use 

them as talking points when discussing driving issues with patients. 

211
Am I a Safe Driver?

Check the box if the statement applies to you.

☐ I get lost while driving. 

☐ My friends or family members say they are worried about my driving. 

☐ Other cars seem to appear from nowhere. 

☐ I have trouble finding and reading signs in time to respond to them. 

☐ Other drivers drive too fast. 

☐ Other drivers often honk at me. 

☐ Driving stresses me out. 

☐ After driving, I feel tired. 

☐ I feel sleepy when I drive. 

☐ I have had more “near-misses” lately. 

☐ Busy intersections bother me. 

☐ Left-hand turns make me nervous. 

☐ The glare from oncoming headlights bothers me. 

☐ My medication makes me dizzy or drowsy. 

☐ I have trouble turning the steering wheel. 

☐ I have trouble pushing down the foot pedal. 

☐ I have trouble looking over my shoulder when I back up. 

☐ I have been stopped by the police for my driving. 

☐ People no longer will accept rides from me. 

☐ I have difficulty backing up. 

☐ I have had accidents that were my fault in the past year. 

212
☐ I am too cautious when driving. 

☐ I sometimes forget to use my mirrors or signals. 

☐ I sometimes forget to check for oncoming traffic. 

☐ I have more trouble parking lately.

If you have checked any of the boxes, your safety may be at risk when you drive. 

Talk to your doctor about ways to improve your safety when you drive. 

213
Getting By Without Driving

Who doesn’t drive?

If you live long enough, you will eventually have to stop driving. The average male will have 

seven years without the ability to drive, and the average female ten years! Many people 

choose to stop driving because of the hassle and expense of auto insurance, car maintenance, 

and gasoline. Other people stop driving because they feel unsafe on the road. And some 

people have never learned to drive! 

If you don’t drive, you’re in good company. Although most Americans use their cars to get 

around, many people get by just fine without one. In this sheet, we suggest ways to get by 

without driving. 

Where can you find a ride?

Here are some ways to get a ride. See which ones work best for you. 

• Ask for a friend or relative for a ride. Offer to pay for the gasoline.

• Take public transportation. Can a train, subway, or bus take you where you need to go? Call

your regional transit authority and ask for directions.

• Take a taxi cab. To cut down costs, try sharing a cab with friends or find out if your

community offers discounted fares for seniors.

• Ride a senior transit shuttle. Call your community center or local Area Agency on Aging to

see if your neighborhood has a shuttle service.

• Ask about volunteer drivers. Call your community center, church, synagogue, temple, or

mosque to see if they have a volunteer driver program.

• Ride a Medi-car. If you need a ride to your doctor’s office, call your local Area Agency on

Aging to see if a Medi-car can get you there.

214
If you can’t go out to get something, have it come to you.

Many stores can deliver their products straight to your door. 

• Have your groceries delivered. Many stores deliver for free or for a low fee. You can even

call your family and friends, or volunteers from your local community center, church,

synagogue, temple, or mosque to see if someone can pick up your groceries

• Order your medicines by mail. Not only is this more convenient—it’s often less expensive,

too.

Order only from pharmacies that you know and trust. Some pharmacists will also deliver

medications to the home.

• Have your meals delivered to you. Many restaurants will deliver meals for free or for a low

fee. Also, you may be eligible for Meals-on-Wheels, a program that delivers hot meals at low

cost. Call your local Area Agency on Aging for more information about Meals-on-Wheels.

• Shop from catalogs. You can buy almost anything you need from catalogs: clothing, pet

food, toiletries, gifts, and more! Many catalogs are now online, with the most recent

selections available from Internet websites.

Who can tell me more about services in my area? 

The following agencies can provide you with information to get you started: 

Area Agency on Aging (AAA) Eldercare Locator 

www.eldercare.gov

800-677-1116 weekdays

Call this toll-free number and ask for the phone number of your local Area Agency on Aging 

(AAA). Your local AAA can tell you more about ride options, Meals-on-Wheels, and senior 

recreation centers in your area. 

Administration on Aging Resource Directory for Older People 

https://chs-nhlbi.org/node/5868

800-677-1116

Call this toll-free number and ask the National Institute on Aging to send you their Resource 

Directory for Older People. This 120-page directory lists organizations that provide services for 

older people. 

215
We’ve listed additional resources on the following pages to help you assess and enhance 

driving safety for the retired driver. Some resources can help you create a transportation plan 

for your loved one. 

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 Web site above to find a 

geriatric care manager in your loved one’s area. 

National Association of Social Workers (NASW) 

www.socialworkers.org/register/default.asp

A social worker can provide counseling to your loved one, assess his/her social and emotional 

needs, and assist in locating and coordinating transportation and community services. To find a 

qualified clinical social worker in your loved one’s area, search the NASW Register of Clinical 

Social Workers on the Internet.

Alternative Transportation Options

American Administration on Aging (AOA)

Eldercare locator

Assists in finding older adult resources in your community. 

www.eldercare.gov

Community Transportation Association (CTAA)

Information on transportation in the United States. 

www.ctaa.org/ntrc/

American Public Transportation Association (APTA)

Locate a local transportation provider in your community. 

www.publictransportation.org/systems/

Easter Seals

Transportation solutions for caregivers 

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

216

Where Can I Find More Information? 
National Center for Senior Transportation 

Transportation options for older adults. 

www.seniortransportation.net/Portals/0/Cache/Pages/Resources/Trans_Options_Panels.pdf

Local Agency on Aging

Assists in finding resources for the aging in your community. 

www.n4a.org/

Seniors on the MOVE

Assists with relocating to another community. 

www.seniorsonthemoveinc.com

National Association of Social Workers (NASW)

Locate a social worker near you. 

www.socialworkers.org/register/default.asp

United We Ride

Coordination of transportation services. 

www.unitedweride.gov

217
How to Assist the Older Driver 

As experienced drivers age, changes in vision, reaction time, and/or medical conditions may 

cause them to drive less safely. Sometimes these changes happen so slowly that drivers may 

not even be aware that their skills have declined. 

If you have concerns about someone’s driving safety, here’s what you can do to keep your 

older driver safe AND mobile. 

Is your loved one a safe driver?

If you have the chance, go for a ride with this driver. Look for the following warning signs in 

his/her driving: 

• Forgets to buckle up (use seat belts)

• Does not obey stop signs or red traffic lights

• Fails to yield right of way

• Drives too slowly or quickly

• Often gets lost, even on familiar routes

• Stops at a green light or at the wrong time

• Doesn’t seem to notice other cars, walkers, or bike riders on the road

• Doesn’t stay in the lane

• Gets honked at or passed often

• Reacts slowly to driving situations

• Makes poor driving decisions

• Fails to use mirrors, check for blind spots, use turn signals

• Mixes up gas and brake pedal or no longer can use them smoothly

• Too cautious or too aggressive when driving

Other signs of unsafe driving: 

• Recent near misses or fender benders

• Recent tickets for moving violations

218
• Repeated comments from those riding with your driver or watching them in traffic about

close calls, near misses, or the driver not seeing other vehicles.

• Accidents, especially those that were the driver’s fault.

• Recent increase in the car insurance premium

Riding with or following your driver, every once in a while, is one way to keep track of your 

loved one’s driving. Another way is by talking to the spouse or friends of the driver you are 

concerned about. 

If you are concerned about your loved one’s driving, what can you do?

Talk to your loved one. Say that you are concerned about his/her driving safety. Ask if he or 

she shares your concern. 

• Don’t bring up your concerns while driving. It’s dangerous to distract the driver! Wait until

he or she is calm and you have the driver’s full attention.

• Explain why you are concerned. Give specific reasons—for example, a medical condition

like poor vision, recent fender benders, getting lost, or running stop signs.

• Realize that your loved one may become negative or defensive. After all, driving is

important for independence and self-esteem.

• If the person you are concerned about does not want to talk about driving at that time,

bring it up again later. Your continued concern and support may help your loved one feel

more comfortable with this topic.

• Be a good listener. Take your loved one’s concerns seriously.

• Consider using a handout like the Hartford’s “We Need to Talk” which can be accessed at the

following website: www.thehartford.com/talkwitholderdrivers/brochure/brochure.htm or

writing the Hartford and requesting brochures at:

The Hartford

We Need to Talk

200 Executive Boulevard

Southington, CT 06489

Help make plans for transportation. When your loved one is ready to talk about his/her 

driving safety, you can work together to create plans for future safety. 

• Make a formal agreement about driving. In this agreement, your loved one chooses a

219
person to tell him/her when it is no longer safe to drive. 

This individual then agrees to help your loved one make the transition to driving 

retirement. 

(You can find a sample agreement in At the Crossroads: A Guide to Alzheimer’s Disease, Dementia & Driving. Order a free copy by writing to At the Crossroads booklet, The Hartford, 

200 Executive Boulevard, Southington, CT, 06489.) 

• Help create a transportation plan. Your loved one may rely less on driving if he/she has other

ways to get around. Starting to use other ways to travel even before the person stops driving

may make the change easier in the future.

Encourage a visit to the doctor. The doctor can examine a person’s medical history, 

medication regimen, and current health to see if any of these may be affecting his/her 

driving safety. If so, the doctor can provide treatment to help improve medical conditions 

and possibly driving safety. 

Encourage your loved one to take a driving test.

A driver rehabilitation specialist (DRS) can assess a person’s driving safety through an office 

exam and driving test. The DRS can also teach special techniques or provide special equipment 

to help a person drive more safely. (To find a DRS in your area, ask your doctor for a referral or 

contact: 

The Association for Driver Rehabilitation Specialists (ADED): 

http://www.aded.net/ 

Also provides a locating tool for finding a DRS near you: 

http://aded.site-ym.com/search/custom.asp?id=1984

If a DRS is not available in your area, contact a local driving school or your state’s 

Department of Motor Vehicles to see if they can do a driving test. 

How to help when your loved one needs to stop driving.

At some point, your loved one may need to stop driving for his/her own safety and the safety of 

others. You and your family members may come to this decision yourselves, or at the 

recommendation of the doctor, a driver rehabilitation specialist, driving instructor, or the 

Department of Motor Vehicles. When someone close to you retires from driving, there are 

several things you can do to make this easier for him/her: 

• Help create a transportation plan. It may be easier for someone to give up driving if they

are aware of other ways to get around. Help them create a list of “tried-and-true” ride

220
options. 

This list can include: 

• The names and phone numbers of friends and relatives who are willing to give rides, with

the days and times they are available. You should even consider writing in specific duties,

dates, and times, with the places your loved one needs to go and the name of the driver on

a calendar to make this a reality.

• The phone number of a local cab company.

• Which bus or train to take to get to a specific destination. Try riding with your loved one

the first time to make him/her feel comfortable.

(This may not be possible for many people with physical weakness or arthritis and certainly

could not be done for those with memory or thinking problems.)

• The phone number for a shuttle service. Call your community center and regional transit

authority to see if they offer a door-to-door shuttle service for older passengers.

• The names and phone numbers of volunteer drivers. Call your community center, church,

synagogue, temple, or mosque to see if they have a volunteer driver program.

• If you need help finding other ride options, contact your local Area Agency on Aging.

Local Agency on Aging

Assists in finding resources for the aging in your community. 

www.eldercare.gov

If your loved one can’t go shopping, help him/ her shop from home. Arrange for medicines 

and groceries to be delivered. Explore online ordering or subscribe to catalogs and “go 

shopping” at home. Locate which services make house calls—local hairdressers or barbers may 

be able to stop by for a home visit. 

Encourage social activities. Visits with friends, time spent at the senior center, and volunteer 

work are important for health and well-being. When creating a transportation plan, don’t forget 

to include rides to social activities. It’s especially important to maintain social contacts and keep 

spirits up during this time of adjustment. 

Be there for your loved one. Let the person you care for know that he or she has your 

support. 

Offer assistance willingly and be a good listener. This may be an emotionally difficult time, and 

it’s important to show that you care. You may need to find additional family members or 

friends to help with this discussion.

221
O

How to 

Understand &

Influence Older Drivers
How to Understand and Influence Older Drivers i

Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

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

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

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

Step 3: Following Through on the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

Developing a Mobility Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

223
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

224
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 

225
How to Understand and Influence Older Drivers 3

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

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 

226
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 selfassessment cannot solely determine whether or not the person is a safe drive

227
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” selfassessment 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 th

“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 statement

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

228
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 atrisk 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.g

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 t

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 rehabilitati

facilities in your area to find an occupational therapist to help with the 

driving skills assessment and intervention

229
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_saf

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

230
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. (

or go on-line to www.eldercare.g

w Go on-line or call the Alzheimer’s Disease Education and Referral Center:

http://www.nia.nih.gov/alzheim

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?

231
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 fro

Step 1 (page 2)

2. Be sensitive to ways you can help older adult

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 famil

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 feeling

and perceptions. Use “I” messages rather than “You” messages. Fo

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 conversatio

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 peop

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 eas

7. Highlight a positive outcome by focusing on how the older adult drive

will be able to continue to stay connected to specific things that are 

important. Do not judge the person’s prioritie

8. If possible, identify a trusted friend or family member who has alread

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

232
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

233
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.g

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

234
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

235
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

236
14 How to Understand and Influence Older Drivers

NOTES

237
DOT HS 810 633

July 2013

9837-072913-v2a

238
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:

Expert information 

from Healthcare 

Professionals Who 

Specialize in the 

Care of Older Adults

EAT A RAINBOW 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 salmon, sardines, brook trout or other fish rich 

in heart healthy omega-3 fatty acids a week. Limit red meat and wholefat dairy products. And choose whole grains over the refined stuff.

SIDESTEP FALLS 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 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.

TOAST WITH A 

SMALLER GLASS

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 just 1 drink per day for older men and 1⁄2 a drink daily 

for older women. (A “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 alcohol is safe for you.

KNOW THE LOWDOWN ON SLEEP IN 

LATER LIFE

Contrary to popular belief, older people don’t need less sleep than 

younger adults. New recommendations from the National Sleep 

Foundation suggests 7 to 8 hours of shut-eye a night. If you’re getting 

that much and are still sleepy during the day, see your healthcare 

professional. You may have a sleep 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.

HealthinAging.org

239
DISCLAIMER: This information is not intended to diagnose health problems 

or to 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, symptoms, and health problems. 

February 2015

40 FULTON STREET, 18TH FLOOR

NEW YORK, NEW YORK 10038 

212.308.1414 TEL 

212.832.8646 FAX 

Info@healthinaging.org

FLATTEN YOUR 

(VIRTUAL) 

OPPONENT, 

SHARPEN YOUR 

MIND

Conquering your adversary in a complex computer game, joining a 

discussion club, learning a new language, and engaging in social giveand-take with other people can all help keep your brain sharp, studies 

suggest.

ENJOY SAFE SEX Older adults are having sex more often and enjoying it more, research 

finds. Unfortunately, more older people are also being diagnosed with 

sexually 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.

GET A MEDICATIONS 

CHECK

When you visit your healthcare professional, bring either all of the 

prescription and over-the-counter medications, vitamins, herbs and 

supplements you take, 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 brought or put on your list. He or 

she should make sure they’re safe for you to 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.

SPEAK UP WHEN 

YOU FEEL DOWN 

OR ANXIOUS

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

Lingering sadness, tiredness, loss of appetite or pleasure from things 

you once enjoyed, difficultly sleeping, worry, irritability, and wanting to 

be alone much of the time can all be signs that you need help. Tell your 

healthcare professional right away. There are many good treatments for 

these problems.

GET YOUR SHOTS They’re not just for kids! Must-have vaccines for seniors include those 

that protect against pneumonia, tetanus/diphtheria, shingles, and the flu, 

which kills thousands of older adults in the US every year.

FIND THE RIGHT 

HEALTHCARE 

PROFESSIONAL AND 

MAKE THE MOST OF 

YOUR VISITS

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 multiple, chronic health problems, your best bet may be to see a 

geriatrics healthcare professional—someone with advanced training 

that prepares her to care for the most complex patients. The AGS’ 

Health in Aging Foundation can help you find one; 

visit www.healthinaging.org.

THE OFFICIAL FOUNDATION OF 

THE AMERICAN GERIATRICS SOCIETY

240
Tips for Safe Driving

Tip #1: Drive with care.

Always—

• Plan your trips ahead of time. Decide what time to leave and which roads to take. Try to

avoid heavy traffic, poor weather, and high-speed areas.

• Wear your seat belt—and wear it correctly. (It should go over your shoulder and across

your lap.)

• Be sure you “fit” well in your car. Take advantage of a CarFit class (see resources) if one is

available in your community.

• Drive at the speed limit. It’s unsafe to drive too fast or too slow.

• Be alert—pay attention to traffic at all times.

• Keep enough distance between you and the car in front of you.

• Be extra careful at intersections. Use your turn signals and remember to look around you

for people and other cars.

• Check your blind spot when changing lanes or backing up.

• Be extremely careful with left hand turns, allowing enough time to pass through the

intersection in case of on-coming traffic.

• Be extra careful at train tracks. Remember to look both ways for trains.

• When you take a new medicine, ask your doctor or pharmacist about side effects. Many

medicines may affect your driving even when you feel fine. If your medicine makes you dizzy

or drowsy, talk to your doctor to find out ways to take your medicine so it doesn’t affect

your driving.

Never—

• Never drink and drive.

• Never drive when you feel angry or tired. If you start to feel tired, stop your car somewhere

safe. Take a break until you feel more alert.

• Never drive if your medication is making you sleepy.

• Never use a cell phone when driving.

• Never eat, drink, or do other activities while driving.

241
• Never drive in icy or snowy weather.

If—

• If you don’t see well in the dark, try not to drive at night or during storms.

• If you have trouble making left turns at an intersection, make three right turns instead

of one left turn.

• If you can, avoid driving in bad weather such as rain, sleet, or snow.

• If a certain route always causes you stress, try to find an alternate route.

• If someone in the car is bothering you (e.g., noisy grandchildren) tell him or her to stop.

Tip #2: Take care of your car.

• Make sure you have enough gas in your car.

• Make sure your tires have the right amount of air and check them each month for any

wear or damage.

• Get your car tuned up regularly.

• Keep your windshields and mirrors clean.

• Keep a cloth in your car for cleaning windows.

• Replace your windshield wiper blades when they get worn out.

• Consider using Rain-X or a similar product to keep your windows clear.

• If you are shopping for a new car, look for a car with power steering and automatic

transmission.

• If you own a computer you can check to see how well a car will do if it is involved in a crash.

This information is on the following Web site of the National Highway Traffic Safety

Administration: www.safercar.gov. You might want to consider buying a car that has the

highest rating when struck by another vehicle from the front or side.

Tip # 3: Know where you can find a ride.

How do you get around when your car is in the shop? If you don’t know the answer to this 

question, it’s time for you to put together a “transportation plan.” 

242
A transportation plan is a list of all the ways that you can get around. Use this list when your 

car is in the shop or when you don’t feel safe driving. 

Your transportation plan might include: 

• Rides from friends and family

• Taxi

• Bus or train

• Senior shuttle

• Volunteer drivers from your local community or government center.

If you need help creating a transportation plan, your doctor can get you started. 

Tip #4: Take a driver safety class.

To learn how to drive more safely, try taking a class. In a driver safety class, the instructor 

teaches you skills that you can use when you are driving. 

To find a class near you, call one of the following programs: 

AARP Driving Safety Program

The classic course with information on how to locate an educational venue in your 

community. http://www.aarp.org/home-garden/transportation/driver_safety/

American Safety Council 

Mature Driver Course 

http://www.maturedrivercourse.com/

Driving School Association of the Americas, Inc.

1-800-270-3722 

These classes usually last several hours. These classes do not cost much money—some 

are even free. As an added bonus, you might receive a discount on your car insurance 

after taking one of these classes. Talk to your insurance agent and company to 

determine if they offer a discount. 

243
APPENDIX C

Clinical Team Resources

● Clinical Assessment of Driving Related Skills (CADReS) Score Sheet

● Evidence Table for Assessments (selected in Ch. 3)

● Medical Review Board Sample Letter

● Modified Driving Habits Questionnaire

● Montreal Cognitive Assessment (MoCA) and Form

● Motor Vehicle Adaptive Equipment Descriptions and NHTSA’s 

Adapting Motor Vehicles for Older Drivers brochure

● Sample Driving Cessation Plan

● Snellen Chart

● Snellgrove Maze Test and Form

● Three Levels of Spectrum of Driver Services

● Trails A Test

● Trails B Test

244
Name:__

1. Visua

2. Visua

Was t

_____

If acu

3. Rapid

Longe

evalu

_____

4. Rang

Neck

Finge

Shou

Ankle

Ankle

With 

mana

consi

5. Maze

If com

cogni

If com

___________

al fields: Sha

al acuity:_ __

the patient w

__________

uity in either

d pace walk

er than 10 se

uation of gait

__________

ge of motion

rotation 

er curl 

lder and elb

e plantar flex

e dorsiflexio

any deficien

agement or t

der referral 

e Test: Risk C

mpleted in 6

itively fit to 

mpleted in u

__________

ade in any ar

________OD

wearing cor

___________

r eye is wors

:__________

econds is ab

t disorder. W

___________

n: Specify “w

bow flexion 

xion 

n 

ncies or pain

to occupatio

for compre

Categories _

61 seconds o

drive safely.

p to 60 seco

___________

reas of defic

D _________

rective lense

__________

e than 20/4

___ seconds

bnormal; con

Was test per

__________

within norma

R

n, consider re

onal therapy

hensive driv

_____ Secon

r longer, wit

.

onds, but wit

__________

cit.

Patient’s

___ OS ____

es? If yes, pl

___________

0, consider r

s

nsider referr

formed with

___________

l limits (WN

Right 

eferral to ph

y if impacting

ving evaluati

nds _____ Er

th or withou

th two or mo

___ Date: __

L

_______OU

ease specify

____ 

referral to o

ral for driving

h a walker or

__________

L)” or “not W

L

hysical thera

g ADLs/IADL

on if adapta

rrors _____

ut errors, the

ore errors, t

___________

y: 

ophthalmolo

g evaluation

r cane? If ye

___________

WNL.” If not

Left 

apy for exerc

Ls as indicate

ation for driv

en the perso

then the per

_____

R 

gist. 

n and/or 

es, please sp

__ 

t WNL, descr

cises or pain

ed, and/or 

ving is neede

on is not 

rson is not 

ecify: 

ribe.

ed. 

245
246

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. 
247

Assessment/Plan
Screening 

Table of Selected Studies Supporting the use of Screening Tools in CADReS. 

Citation Target 

Population 

Tools (significant)/Outcome Measure 

Main Findings 

Classen, S., Witter, D. P., Lanford, D. N., Okun, M. S., Rodriguez, R. L., Romrell, J., et al. (2011). 

Parkinson’s Disease 

MMSE Rapid Pace Walk UFOV Acuity Contrast Sensitivity Outcome: Global rating score (on road outcome) and maneuvers scores for on road assessment 

Individuals with PD did more pPace Walk, global score of the scores. UFOV and Rapid Pace Wof variance with the on-road teas good screening tools for PD

Zook, N. A., Bennett, T. L., & Lane, M. (2009). 

Older adult Hopkins verbal learning task 

Integrated visual and auditory continuous performance Trails B Outcome: on road assessment 

Hopkins verbal learning test, Inauditory continuous performapredictive of on-road than CBD

Stav W. B., Justiss, M. D., McCarthy D. P., Mann, W. C., & Lanford, D. N. (2008). 

Older adults Contrast Sensitivity, slide B 

Rapid Pace Walk UFOV Rating MMSE total score Outcome: Global Rating Scale of the standardized road test 

Using stepwise regression, the included: Contrast Sensitivity UFOV rating, and MMSE total sfor 44% of the variability in Glostandardized road test. All assesignificantly correlated with thindividually. 

Wood, J. M., Anstey, K. J., Kerr, G. K., Lacherez, P. F., & Lord, S. (2008) 

Older adults UFOV 2 

Dot motion sensitivity Knee extension strength Postural sway Trails B Color choice reaction time Outcome: on road assessment 

UFOV 2, dot motion sensitivitypostural sway, trail making B, atime were significantly correlatassessment performance. Sensitivity: 91%, specificity: 70

248
Screening 

Molnar, F. J., Marshall, S. C., Man-Son-Hing, M., Wilson, K. G., Byszewski, A. M., & Stiell, I. (2007). 

Older adults MMSE 

Driving habits Ottawa Driving & dementia Bothered by diabetes Timed Toe Tap Test Outcome: motor vehicle crashes 

Used assessment battery in ER potential predictors of crashesassociations with past or currecomponents of: MMSE, Drivinand Dementia, “bothered a greMellitus”, and the Timed Toe T

De Raedt, R., & PonjaertKristoffersen, I. (2001). De Raedt, R., & PonjaertKristoffersen, I. (2001). 

Older adults Trail A 

Acuity Clock drawing Age as factor Outcome: on road assessment 

Battery included: MMSE, Trail drawing, age as factor MMSE did not add anything to Combined: Specificity – 85% S

Owsley, C., Stalvey, B.T., Wells, J., Sloane, M. E., & McGwin, G. (2001). 

274 older adults with cataracts and 103 without 

Tested for acuity, contrast sensitivity, and glare. 

Contrast sensitivity strongly reespecially when in two eyes, bnot related to crashes. 

Decina, L.E. & Staplin, L. (1993). 

Visual exams of 12,400 drivers in PA. 

Acuity, visual fields, contrast secrashes for drivers 66-75 years 

Freeman, E.E., Munoz, B., Turano, K.A., & West, S.K. (2005). 

Older adults Salisbury Eye Evaluation Project, 

2520 older adults followed for 8 years with 4 collection points. 

Driving cessation over time: Tacuity, contrast sensitivity, and likely to cease driving. 

Crizzle, A.M., Classen, S., & Uc, Y. (2012). 

PD Evidence review that examined 

measures for predicting on road and simulator performance. 

No standard battery is able to performance of PD, more vigoSome evidence for subtest 2 of sensitivity, Trails B and B-A, funOsterrieth Complex Figure Tes

Classen, S., McCarthy, D. P., Shechtman, O., Awadzi, K. D., Lanford, D.N., Okun, M. S., Rodriguez, R. L., Romrell, J., Bridges, S., Kluger, B., & Fernandez, H. 

PD 19 individuals with Parkinson’s 

Disease and 104 age matched controls. Compared UFOV with on road assessment outcome, global rating scale, and sum of maneuvers scale. 

UFOV had strongest correlatiodriving errors. Those who faileTrails B and UFOV than those wscores for UFOV subtests sugge

249
Screening 

H. (2009). 

Amick, M. M., Grace, J., & Ott, B. R. (2007). 

PD 25 with Parkinson’s Disease with 

two of three physical issues (tremor, bradykinsesia, and rigidity). No cognitive impairments. Compared assessments to on road performance. 

Safe and marginal groups perfocontrast sensitivity, Trails B (timpresence/accuracy, UFOV subt

Uc, E.Y., Rizzo, M., Anderson, S.W., Shi, Q., & Dawson, J.D. (2005). 

AD 33 Alzheimer’s compared to 137 

normal controls on cognitive tests, vision tests, on road drive to identify landmarks and traffic signs. 

Significant difference between traffic identification; Driving erTrails B, auditory verbal learninsensitivity, judgment of line orof total landmark and traffic si

Grace, J., Amick, M. M., D'Abreu, A., Festa, E. K., Heindel, W. C., & Ott, B. R. (2005). 

AD 21 dementia, 21 Parkinson, 21 

controls. Compared motor and cognitive function with on road performance. 

Dementia made significantly mthan controls; Rey-Osterrieth fpoor on road performance, Tradementia subjects. 

Whelihan, W.M., DiCarlo, M.A., & Paul, R.H. (2004). 

AD 23 with CDR of .5 and 23 controls. 

Battery of screening measures compared with outcome measure of road assessment. 

Trails B, Maze navigation time, significantly related to on-road controls, it was only age. Regrnavigation time, Trails B time, accounted for 46% of variance insignificantly). UFOV too challdementia. Maze navigation ma

Jones, V. C., Gielen, A. C., Bailey, M. M., Rebok, G. W., Gaines, J. M., Joyce, J. & Parrish, J. M. (2011). 

Older adults 67 older adults screened with four 

of 9 assessment tools. High-risk completed qualitative interviews. 

Identifying low, medium and holder adults with assessments Only Trails B differentiated the risk group. UFOV and MVPT d

Edwards, J. D., Bart, E., O'Connor, M. L., & Cissell, G. (2010). 

Older adults 1,248 participants tested at baseline 

and 5 years later on physical and cognitive issues. 

Final regression models: Age aweek and slower processing spsubtest 2) were significant indicessation. Other models show

250
Screening 

MVPT, Trails B. 

Munro, C.A., Jefferys, J., Gower, E. W., Munoz, B. E., Lyketsos, C. G., Keay, L., ... West, S. K. (2010).

Older adults 980 adults 67-87 years who had lane 

change data 

Subjects enrolled in the Salisbury Eye Evaluation and Driving Study 

Significant predictors of lane chBrief Test of Attention, HopkinsAttention. Multiple regression demonstra

Brief Test of Attention and VMchange errors. Also those partrural vs. urban predicted lane cMade on assumption that lane errors of driver safety. 

Classen, S., Horgas, A., Awadzi, K., MessingerRapport, B., Shechtman, O., & Joo, Y. (2008). 

Older adults 127 older adults to compare 

demographics, cognitive functioning, comorbidities, medications, and failing driving evaluation. 

The strongest predictor of failiage, and time to complete Traipredictors of failure and drivinneurological diagnosis was assand increased driving errors. 

Oswanski, M. F., Sharma, O. P., Raj, S. S., Vassar, L. A., Woods, K. L., Sargent, W. M., & Pitock, R. J. (2007). 

Retrospective study232 over 55 years old referred to driving program. Subjects categorized into two groups: capable & incapable 

Mean score for the three measdifferent between two groups. ROC for MVPT was >32 with 60specificity. ROC clock task was >3 with 70% specificity. Processing time < 6.27 seconds 79% specificity 

This table was modified from Tables developed with funding from the Gaps and Pathways Project, the AOTA/NAgreement. 

251
[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 

252
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 

____ Out to eat ____ times a week ____ miles from home 

253
____ 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 

____ Other (specify) ___________________ 

254
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? 

____ Yes (go to 20b) 

255
____ 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 

Accidents and Citations 

21. How many accidents have you been involved in over the past year when you were the

driver? Please list the number of all accidents, whether or not you were at fault.

 ____ accidents 

22. How many accidents have you been involved in over the past year when you were the

driver where the police were called to the scene?

____ accidents 

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 

256
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. 

257
MoCA Version November 12, 2004 

© Z. Nasreddine MD 

 www.mocatest.org

1

Montreal Cognitive Assessment 

(MoCA) 

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. 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. 

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: Allocate one point 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 earns a score of 0. 

2. Visuoconstructional Skills (Cube):

Administration: The examiner gives the following instructions, pointing to the cube: “Copy 

this drawing as accurately as you can, in the space below”.

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

• Drawing must be three-dimensional

• All lines are drawn

• No line is added

• Lines are relatively parallel and their length is similar (rectangular prisms are

accepted)

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

3. Visuoconstructional Skills (Clock):

Administration: Indicate the right third of the space and give the following instructions: 

“Draw a clock. Put in all the numbers and set the time to 10 after 11”.

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

 Contour (1 pt.): the clock face must be a circle with only minor distortion

acceptable (e.g., slight imperfection on closing the circle); 

 Numbers (1 pt.): all clock numbers must be present with no additional numbers;

numbers must be in the correct order and placed in the approximate quadrants on the 

clock face; Roman numerals are acceptable; numbers can be placed outside the 

circle contour; 

 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 centred within the 

clock face with their junction close to the clock centre. 

A point is not assigned for a given element if any of the above-criteria are not met. 

258
MoCA Version November 12, 2004 

© Z. Nasreddine MD 

 www.mocatest.org

2

4. Naming:

Administration: Beginning on the left, point to each figure and say: “Tell me the name of 

this animal”.

Scoring: One point each is given for the following responses: (1) camel or dromedary, (2) 

lion, (3) rhinoceros or rhino. 

5. Memory:

Administration: The examiner reads a list of 5 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”. Mark a check 

in the allocated space for each word the subject produces on this first trial. When the subject indicates 

that (s)he has finished (has recalled all words), or can recall no more words, read 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.” Put a 

check in the allocated space for each word the subject recalls after the second trial. 

At the end of the second trial, inform 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: Give the following instruction: “I am going to say 

some numbers and when I am through, repeat them to me exactly as I said them”. Read the five

number sequence at a rate of one digit per second.

Backward Digit Span: Administration: Give the following instruction: “Now I am going to 

say some more numbers, but when I am through you must repeat them to me in the backwards

order.” Read the three number sequence at a rate of one digit per second.

Scoring: Allocate one point for each sequence correctly repeated, (N.B.: the correct response 

for the backwards 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 instruction: “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: Give one point if there is zero to one errors (an error is a tap on a wrong letter or a 

failure to tap on letter A). 

259
MoCA Version November 12, 2004 

© Z. Nasreddine MD 

 www.mocatest.org

3

Serial 7s: Administration: The examiner gives the following instruction: “Now, I will ask 

you to count by subtracting seven from 100, and then, keep subtracting seven from your answer until 

I tell you to stop.” Give this instruction twice if necessary. 

Scoring: This item is scored out of 3 points. Give no (0) points for no correct 

subtractions, 1 point for one correction subtraction, 2 points for two-to-three correct subtractions, 

and 3 points if the participant successfully makes four or five correct subtractions. Count each 

correct subtraction of 7 beginning at 100. Each subtraction is evaluated independently; that is, if 

the participant responds with an incorrect number but continues to correctly subtract 7 from it, 

give a point for each correct subtraction. For example, a participant 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 item 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: Allocate 1 point for each sentence correctly repeated. Repetition must be exact. Be 

alert for errors that are omissions (e.g., omitting "only", "always") and substitutions/additions (e.g., 

"John is the one who helped today;" substituting "hides" for "hid", altering plurals, etc.). 

8. Verbal fluency:

Administration: The examiner gives the following instruction: “Tell me as many words as 

you can think of that begin with a certain letter of the alphabet that I will tell you in a moment. You 

can say any kind of word you want, except for proper nouns (like Bob or Boston), numbers, or words 

that begin with the same sound but have a different suffix, for example, love, lover, loving. I will tell 

you to stop after one minute. Are you ready? [Pause] Now, tell me as many words as you can think of 

that begin with the letter F. [time for 60 sec]. Stop.” 

Scoring: Allocate one point if the subject generates 11 words or more in 60 sec. Record the 

subject’s response in the bottom or side margins. 

9. Abstraction:

Administration: The examiner asks the subject to explain what each pair of words has in 

common, starting with the example: “Tell me how an orange and a banana are alike”. If the subject 

answers in a concrete manner, then say only one additional time: “Tell me another way in which 

those items are alike”. If the subject does not give the appropriate response (fruit), say, “Yes, and 

they are also both fruit.” Do not give any additional instructions or clarification. 

After the practice trial, say: “Now, tell me how a train and a bicycle are alike”. Following 

the response, administer the second trial, saying: “Now tell me how a ruler and a watch are alike”. 

Do not give any additional instructions or prompts. 

260
MoCA Version November 12, 2004 

© Z. Nasreddine MD 

 www.mocatest.org

4

Scoring: Only the last two item pairs are scored. Give 1 point to each item 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 instruction: “I read some words to you 

earlier, which I asked you to remember. Tell me as many of those words as you can remember. Make 

a check mark (3) for each of the words correctly recalled spontaneously without any cues, in the 

allocated space. 

Scoring: Allocate 1 point for each word recalled freely without any cues. 

Optional:

Following the delayed free recall trial, prompt the subject with the semantic category cue provided 

below for any word not recalled. Make a check mark (3) in the allocated space if the subject 

remembered the word with the help of a category or multiple-choice cue. Prompt all non-recalled 

words in this manner. If the subject does not recall the word after the category cue, give him/her a 

multiple choice trial, using the following example instruction, “Which of the following words do you 

think it was, NOSE, FACE, or HAND?” 

Use the following category and/or multiple-choice cues for each word, when appropriate: 

FACE: category cue: part of the body multiple choice: nose, face, hand 

VELVET: category cue: type of fabric multiple choice: denim, cotton, velvet 

CHURCH: category cue: type of building multiple choice: church, school, hospital 

DAISY: category cue: type of flower multiple choice: rose, daisy, tulip 

RED: category cue: a colour multiple choice: red, blue, green 

Scoring: No points are allocated for words recalled with a cue. A cue is used for clinical 

information purposes only and can give the test interpreter additional information about the type of 

memory disorder. 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.

11. Orientation:

Administration: The examiner gives the following instructions: “Tell me the date today”. If 

the subject does not give a complete answer, then prompt accordingly by saying: “Tell me the [year, 

month, exact date, and day of the week].” Then say: “Now, tell me the name of this place, and 

which city it is in.” 

Scoring: Give one point for each item correctly answered. The subject must tell the exact 

date and the exact place (name of hospital, clinic, office). No points are allocated if 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 an individual 

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.

261
262
Created by Elin Schold Davis, 

 AOTA Older Driver Initiative Coordinator escholddavis@aota.org

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/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 advertises the additional utility to break windows and cut the

seatbelt.

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 retraction and feed.

C. Plastic garbage bag or seat slide (transfers) 

1. 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 a 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 leg” into the vehicle.

2. Manually show how to assist pulling leg into vehicle by pulling onto pant leg or

lifting thigh.

263
Created by Elin Schold Davis, 

 AOTA Older Driver Initiative Coordinator escholddavis@aota.org

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 and 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. It may contribute to “submarining”: under the lap belt in the event of a 

crash.

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

1. Many versions of clip on and stick on mirrors are available to expand the peripheral

field of view for the driver. For some drivers they work, for others they may distort 

or distract. 

2. Precautions/concerns/limitations: a mirror clipped to the rearview mirror may

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 should provide an evaluation of the senior driver,

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 

 Many states require testing and place a restriction on the driver’s license

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

1. Evaluation determines ideal placement of this device on the steering wheel.

264
Created by Elin Schold Davis, 

 AOTA Older Driver Initiative Coordinator escholddavis@aota.org

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 evaluation, professional installation and training.

2. Requires 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 evaluation, professional installation and training.

2. Requires new learning, evaluation of cognition is essential.

3. Many configurations are available, matching the hand control model with the

driver’s strongest abilities and the access allowed by the model of vehicle is

essential.

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, diminished strength may benefit from modifications that 

bring control of the vehicle within their physical capabilities. 

1. The Comprehensive Driving Evaluation will provide an evaluation of the senior

driver, individualized recommendations and equipment prescriptions. This 

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 

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 and trained to understand the 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 and will 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.

 Equipment and installation is costly. Refer to the driving evaluator with medical

background and trained to understand the medical condition and its progression.

265
Created by Elin Schold Davis, 

 AOTA Older Driver Initiative Coordinator escholddavis@aota.org

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 to allow driver 

to transfer and stow of 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 mobility equipment with attention to 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. 

266
Created by Elin Schold Davis, 

 AOTA Older Driver Initiative Coordinator escholddavis@aota.org

Resources 

1. Handybar (transfers, driver or passengers)

 http://www.handybar.com/ around $40

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

 http://www.shop.com/op/~Easy_Reach_Seatbelt-prod-12550917 around $8.00

3. Wedge cushion (seat height)

 http://www.asseenontv.com/prod-pages/seat_solution.html

 Purchase at Bed, Bath and Beyond for under $20

 Other foam qualities and styles may be $50 to $100

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

 http://www.drivingcomfort.com/index.cfm/fa/p/pid/183/sc/7543

 Use your professional judgment if choosing to have sample mirrors. Some are

concerned that interior mirrors could break loose in a crash. Training is essential

to benefit from ancillary mirrors.

5. Garbage bag or seat slide (transfers)

 http://www.abledata.com/abledata.cfm?pageid=19327&top=13902&productid=

78954&trail=0

 Seat Slide approximately $100.00

 garbage bag or silky scarf (nominal)

6. Leg lifter (transfers)

 http://www.dynamic-living.com/leg-lifter.htm (under $15.00)

7. Adjustable (built up) Key holder (decrease pain/trauma with turning key)

 Several style choices (prices range $8.00 to $15.00) available at

http://www.sammonspreston.com/Supply/Product.asp?Leaf_Id=6513

267
Le

Key

g Lifte

 Holde

r 

r 

268
H

Ea

andy B

sy Reac

ar 

h 

269
Button

Pedal

 Mirro

 Extend

r 

er

270
Left Foot

Steer

 Accele

ing Kno

rator

b 

271
National Highway Traffic Safety Administration

Adapting Motor Vehicles 

for Older Drivers
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

273
A Proven Process for Maintaining Freedom on the Road 

New and existing adaptive

technologies continue to broaden 

opportunities for older drivers to drive 

comfortably and safely — and enjoy the 

freedom of driving for as long as possible . 

Some of these adaptive technologies 

are as simple as swivel seats for more 

convenient access . Others, such as hand 

controls, may be necessary for a driver 

to safely operate a vehicle . All drivers 

who are facing, or may soon face, agerelated driving challenges should become 

familiar with the technologies available to 

support any special driving needs . 

The information in this brochure is based 

on the experience of driver rehabilitation 

specialists and other professionals who 

work with people who require adaptive 

devices for their motor vehicles . The 

Introduction

steps outlined here represent a proven 

process — evaluating your needs, 

making sure the vehicle “fits” you 

properly, choosing appropriate 

features, installing and knowing how 

to use adaptive devices, practicing 

good vehicle maintenance — that can 

help you avoid costly mistakes when 

modifying or purchasing a vehicle to 

accommodate age-related changes that 

may affect your driving . 

Also included is general information on 

cost savings, licensing requirements, and 

organizations to contact for additional 

assistance . Although the brochure 

focuses on drivers of modified vehicles, 

each section also contains important 

information for people who provide 

transportation for passengers with 

special needs . 

274
Cost-Saving Opportunities 

With such a wide range of adaptiveequipment solutions available, 

associated costs for modifying a 

vehicle can vary greatly depending on 

an individual’s needs . Some adaptive 

equipment, such as a special seat-back 

cushion, can provide a better view of the 

road for as little as $50 . More complex 

equipment, such as hand controls, can 

be purchased for under $1,000 . However, 

a new vehicle modified with adaptive 

equipment will cost anywhere from 

$20,000 to $80,000 . 

Whether you are modifying a vehicle you 

now own or purchasing a new vehicle 

with adaptive equipment, it pays to do 

your homework first . By consulting with 

a driver rehabilitation specialist before 

you buy, you can learn what adaptive 

equipment you need now or may need in 

the future, avoid paying for equipment 

you don’t need, and learn about 

opportunities for public and private 

financial assistance . 

There are programs that may help pay part 

or all of the cost of vehicle modification . 

For information, contact your State’s 

Department of Vocational Rehabilitation 

or another agency that provides vocational 

services, and, if appropriate, the U .S . 

Department of Veterans Affairs . You can 

find phone numbers for these State and 

Federal agencies in your local phone book . 

Also be aware of the following:

n Some nonprofits that advocate for 

individuals with disabilities offer 

programs that may help pay for 

adaptive devices . Generally, these 

groups and programs represent local 

resources . To learn about any available 

programs in your area, contact your 

State government office that handles 

services for persons with disabilities . 

n Automotive insurance may cover all or 

part of the cost of adaptive equipment 

if your need for such equipment is a 

result of a motor vehicle crash . 

n Workers' compensation typically 

covers the cost of adaptive equipment 

if your need for such equipment is a 

result of a job-related injury . 

Investigate Cost-Saving Opportunities 

and Licensing Requirements

275


n Most major vehicle manufacturers 

offer rebates on adaptive equipment, 

usually up to $1,000, provided you 

purchase a vehicle less than one year 

old. Your local automobile dealer can

supply information on these programs 

and assist you with the application 

process. Contact information for

vehicle manufacturers offering rebates 

on adaptive equipment is listed in the 

"Resources" section of this brochure

n National Mobility Equipment Dealers 

Association (NMEDA) members are 

also familiar with vehicle manufacturer 

rebates, can help you apply for these 

rebates — and can provide prepurchase 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

n Some States waive the sales tax for 

adaptive devices if you have a doctor’s 

prescription for their use

n The cost of adaptive equipment may be 

tax deductible. Check with a qualified

tax consultant to learn more.

Licensing Requirements 

All States require a valid learner’s permit 

or driver’s license to receive an on–the–

road driving evaluation. You cannot

be denied the opportunity to apply for 

a permit or license because of age or 

disability. However, a driver’s license with

restrictions may be issued based on your 

need of adaptive equipment

276
Driver rehabilitation specialists

perform comprehensive evaluations 

to identify the adaptive equipment 

most suited to your needs and medical 

condition . As part of this process, a 

rehabilitation specialist will take into 

consideration your future equipment 

needs based on your medical condition 

and the repetitive stress an adaptive aid 

may place on a particular muscle group . 

In addition, you can expect a complete 

evaluation to include vision screening as 

well as:

n Muscle strength, flexibility, and range 

of motion;

n Coordination and reaction time; 

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 .

Finding a Qualified Driver 

Rehabilitation Specialist

Check with a rehabilitation center in 

your area to find a qualified driver 

rehabilitation specialist to perform your 

evaluation . You’ll find rehabilitation 

centers for each State listed on the Web 

sites for the Association for Driver 

Rehabilitation Specialists (ADED) and 

the American Occupational Therapy 

Association, Inc . (AOTA) . These 

associations maintain lists of qualified 

driver rehabilitation specialists in areas 

across the United States and Canada . 

Contact information for these groups is 

located in the “Resources” section of this 

brochure . 

Evaluate Your Needs

277
Paying for an Evaluation

n Vocational rehabilitation agencies and 

workers' compensation agencies may 

assist in the cost of a driver evaluation

n Your health insurance company may 

pay for part or all of the evaluation

Find out from your insurance 

company if you need a doctor’s 

prescription or other documentation 

to receive such benefits

n Many driver evaluation programs 

offer senior drivers a discount on 

evaluations. Ask if your driver

rehabilitation specialist offers a 

discount to seniors

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 

the wheelchair or obtain a new one, be 

sure to tell your driver rehabilitation 

specialist prior to the evaluation

Evaluating Passengers with 

Disabilities

Driver rehabilitation specialists may 

also give advice on compatibility 

and transportation safety issues for 

passengers with special needs. They

determine the type of seating needed 

and the person’s ability to enter and 

exit the vehicle. They provide advice on

the purchase of modified vehicles and 

recommend appropriate wheelchair lifts 

or other equipment that would work in 

your vehicle

278
Although the purchase or lease of a

vehicle is your responsibility, your 

mobility equipment dealer and driver 

rehabilitation specialist are qualified 

to ensure the vehicle you select can 

be modified to meet your adaptive 

equipment needs. Take the time to

consult with these professionals before 

you make your purchase decision

To find a qualified dealer in your area, 

contact the National Mobility Equipment 

Dealers Association (NMEDA). To

find a qualified driver rehabilitation 

specialist, contact the Association 

for Driver Rehabilitation Specialists 

(ADED). Complete contact information

for these two organizations is listed in the 

“Resources” section of this brochure

The following questions can help with 

vehicle selection. They can also help

determine if you can modify a vehicle 

you already own:

n Does the vehicle have the cargo 

capacity (in pounds) to accommodate 

the equipment you require? 

n Will there be enough space and cargo 

capacity to accommodate your family 

or other passengers once the vehicle is 

modified? 

n Is there adequate parking space at 

home and at work for the vehicle and 

for loading/unloading a wheelchair? 

n Is there adequate parking space to 

maneuver if you use a walker? 

n What additional options are necessary 

for the safe operation of the vehicle? 

If a third party is paying for the vehicle, 

adaptive devices, or modification costs, 

find out if there are any limitations or 

restrictions on what is covered. Always

get a written statement on what a funding 

agency will pay before making your 

purchase

Once you select and purchase a vehicle, 

be aware that you will need to also 

purchase insurance to cover your vehicle 

while it's being modified — even though 

it will be off the road during this period

Standard Features to Look for in a New 

Passenger Vehicle

Before purchasing a new vehicle, 

always sit in it first to make sure you 

are comfortable. Check to see that you

can enter and exit the vehicle with ease

If possible, take it out for a test drive

How well does the car fit your body? To 

prevent air bag-related injury, you should 

keep 10 inches between your breast bone 

and the steering wheel, which contains 

Select the Right Vehicle

279


the driver’s side air bag. At the same time,

you’ll need to be able to easily reach the 

pedals while maintaining a comfortable 

line of sight above the adjusted steering 

wheel. Also, make sure the vehicle

provides you with good visibility in 

all directions — front, rear, and sides

Your dealer can demonstrate the use of 

adaptive features, such as adjustable foot 

pedals and driver seats, which can help 

ensure a good person-vehicle fit

Check to see if the model you are 

considering purchasing has good crash 

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;

n Oversized knobs with clearly visible 

labels;

n Support handles to assist with entry 

and exit;

n Large or adjustable-size print for 

dashboard gauges; 

n Seat adjusters that can move the seat in 

all directions — particularly raising it 

so the driver’s line of sight is 3” above

the adjusted steering wheel; and

n Dashboard-mounted ignition rather 

than steering column-mounted 

ignition

280
Even a half inch change in the

lowering of a van floor can affect a 

driver’s ability to use equipment or to 

have an unobstructed view of the road

So it’s important that you take the time 

to find a qualified dealer to modify 

your vehicle. Your driver rehabilitation

specialist may be able to provide referrals 

depending on where you live and your 

vehicle modification and adaptive 

equipment needs

Note: Some State agencies specify 

the dealer you must use if you want 

reimbursement. For example, some 

States require that dealers bidding on 

State vocational rehabilitation jobs 

be members of the National Mobility 

Equipment Dealer’s (NMEDA’s) Quality 

Assurance Program. You’ll find contact

information for NMEDA within the 

“Resources” section of this brochure

To find qualified mobility equipment 

dealers, begin with phone inquiries to 

learn about credentials, experience, and 

references. Ask questions about how they

operate. Do they work with qualified

driver rehabilitation specialists? Will 

they look at your vehicle before you buy 

it? Do they require a prescription from a 

physician or driver evaluation specialist? 

How long will it take before they can start 

work on your vehicle? 

Also ensure that the dealer you choose 

to modify your vehicle is registered 

with the National Highway Traffic 

Safety Administration (NHTSA). In

order to adapt a vehicle to meet your 

needs, registered equipment dealers are 

permitted to modify existing federally 

mandated safety equipment. In addition,

registered mobility equipment dealers 

must provide you with a written 

statement regarding the work that was 

performed, as well as list any Federal 

Motor Vehicle Safety Standards affected 

by their modification work on a label 

adjacent to the original equipment 

manufacturer’s label or the modifier’s 

certification label. These labels are

often found inside the driver’s door. Visit

www.nhtsa.dot.gov/cars/rules/adaptive/

Modifier/Index.cfm to find out if a 

mobility equipment dealer is registered 

with NHTSA as a vehicle modifier.

Questions to consider in evaluating a 

mobility equipment dealer’s qualifications 

are listed below: 

n Is the dealer registered with NHTSA?

n Is the dealer a member of NMEDA — 

and a participant in this organization's 

Quality Assurance Program? 

n What type of training has the staff 

received? 

Choose a Qualified Mobility Dealer 

to Modify Your Vehicle

281


n What type of warranty is provided on 

work? 

n Does the dealer provide ongoing 

service and maintenance? 

n Are replacement parts stocked and 

readily available? 

If you are satisfied with the answers you 

receive, check references; then arrange 

to visit the dealer’s facility. Once you are

comfortable with a dealer’s qualifications, 

you will want to ask more specific 

questions, such as: 

n How much will the modification cost? 

n Are third-party payments accepted? 

n How long will it take to modify the 

vehicle? 

n Can the equipment be transferred to a 

new vehicle in the future? 

n Will existing safety features need to 

be modified to install the adaptive 

equipment? 

While your vehicle is being modified, you 

will most likely need to be available for 

fittings. This avoids additional waiting

time for adjustments once the equipment 

is fully installed. Without proper fittings

you may have problems with the safe 

operation of the vehicle and have to go 

back for adjustments

282
10

Both new and experienced drivers

need training on how to safely use 

newly installed adaptive equipment

Your equipment installer and driver 

rehabilitation specialist should provide 

information on the new devices and offroad instruction

But literature and off-road instruction 

aren’t enough to equip you to drive safely 

with your new adaptive equipment

This equipment can be very complex

So it’s extremely important to obtain 

on-the-road training and practice with 

a driver rehabilitation specialist who 

has advanced expertise and knowledge 

of adaptive technologies. If your driver

rehabilitation specialist does not offer 

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.

Obtain Training on the Use of New Equipment

Ensuring Safe Operation and 

Warranty Compliance

Regular maintenance is importantfor keeping your vehicle and 

specially installed adaptive features safe 

and reliable. It may also be mandatory

for compliance with the terms of your 

warranty. Some warranties specify a time

period during which adaptive equipment 

must be inspected. These equipment

check-up schedules may differ from 

those for your vehicle. Make sure you

or your modifier submit all warranty 

cards for all equipment. This will not

only ensure coverage, but will also enable 

manufacturers to contact you in case of a 

recall

283
11

Vehicle Safety Checklist

Your vehicle warranty and owner’s 

manual will describe regularly required 

vehicle maintenance. Keep in mind that

your adaptive equipment may need 

special attention or more frequent checkups than your vehicle alone. However,

the following checklist represents basic 

maintenance that applies to all vehicles: 

n Check tire pressure at least once a 

month and always before a long road 

trip

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

Maintain Your Vehicle

n Remember to keep your windows and 

headlights clean. You need to clearly

see where you are going. Keeping the

headlights clean will help other cars 

see you too

n Check for damage from road hazards 

by having your vehicle put on a service 

lift at least once a year

Proper maintenance can keep your 

vehicle running smoothly, leaving you 

free to concentrate on the road and enjoy 

the freedom of driving

284
12

Association for Driver Rehabilitation 

Specialists (ADED) 

711 S. Vienna Stre

Ruston, LA 712

800-290-23

www.aded.n

American Occupational Therapy 

Association (AOTA)

4720 Montgomery Lan

P.O. Box 31

Bethesda, MD 20824-1220 

301-652-268

TDD: 800-377-8

www.aota.org/olderdriv

National Mobility Equipment Dealers 

Association (NMEDA)

3327 West Bearss Aven

Tampa, FL 3361

800-833-0

www.nmeda.o

National Highway Traffic Safety 

Administration (NHTSA)

1200 New Jersey Avenue SE

Washington, DC 2059

888-327-4

TDD: 800-424-91

www.nhtsa.g

www.safercar.g

Department of Veteran Affairs 

800-827-1000

www.va.g

State Departments of Vocational 

Rehabilitation 

Listed in telephone book

Resources

The following manufacturers offer rebates 

or reimbursements on new-vehicle 

modification

Audi 

800-822-2834

www.audiusa.co

DaimlerChrysler Corporation 

800-255-9

(TDD Users: 800-922-382

www.daimlerchrysler.c

Ford Motor Company 

800-952-2248

(TDD Users: 800-TDD-0312)

www.fordmobilitymotoring.c

General Motors Corporation 

800-323-

(TDD Users: 800-TDD-99

www.gm.c

Saturn 

800-553-6000, Prompt

(TDD Users: 800-833-600

www.saturn.c

Toyota

800-331-

www.toyota.com/mobili

Volkswagen 

800-822-89

www.vw.co

Selected photos courtesy of Bruno 

Independent Living Aids.

285
286
DOT HS 810 7

February 200

287
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. 

Sample Driving Cessation Plan for _______________________: 

1) You are experiencing medically related changes that may require you to stop driving at

some point in the future. Your physician or medical professional will assist you in

monitoring these changes and will do everything possible to extend 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.

3) Frequent locations:

a. Grocery

b. Drugstore

c. Bank

d. Post office

e. Senior Center

f. Exercise/physical activity facility

288
g. Outdoor park

h. Library

i. Medical office(s)

j. Dental office(s)

k. Personal care (hairdresser, barber shop, nail care, etc)

l. General shopping (mall, discount store, etc)

m. Entertainment venue (concerts, performances, movie theater, etc)

n. Club activities (card-playing, garden, bingo, community service, etc)

o. Volunteer service locations (food pantry, homeless shelter, etc)

4) Explore your personal options. Who might provide a ride, and for which of the

destinations from your list?

a. Family

b. Neighbors

c. Friends

d. Others participating in the same activity

5) Become experienced with the transportation options available so you can decide which

you prefer and for what destinations.

a. Public transportation--local bus and train routes

b. The medical/para transit system

c. Taxi cabs

d. Volunteer driver programs

e. Other transportation providers

f. For assistance contact your Area Agency on Aging, ask about Mobility

Management, contact a social worker or senior center.

Resources: 

1. Administration for Community Living State/Area Agency on Aging Finder. Available at

http://aoa.gov/AoA_programs/OAA/How_To_Find/Agencies/find_agencies.aspx.

Accessed July 17, 2015.

2. Area Agency on Aging Eldercare Locator. Available at www.eldercare.gov. Accessed

July 17, 2015.

289
In order to perform this test, please follow the instructions:

290
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.

291
Maze Test Instructions 

The Maze Test was developed as a pencil and paper test of attention, visuoconstructional 

ability, and executive functions of planning and foresight. The participants compete a simple 

demonstration maze first in order to establish the rule set, then complete the Maze Task. 

Performance is measured in time (in seconds), using a stop watch, and the total number of 

errors. Errors are determined by the number of times the participant enters a dead-end or fails 

to stay in the lines. Time to administer is 1–4 minutes. The Maze Test is in Appendix C; it should 

be printed on an 8 × 11” paper with the Maze Test at least 5.5” square and the practice 4.5”. 

The Maze Test is placed in front of the participant, and the examiner states, “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 of the maze (point to the exit). Draw a line representing the 

route from the start to the exit of the maze. Don’t run into any dead ends (point to a dead end) 

or cross any solid lines (point to a solid line). Go!” The instructions can be repeated, and the 

administrator should correct any rule breaks. There is a limit of 3 minutes for the Maze Test. If 

the maze has not been completed in this time, discontinue. 

292
Date: 

Patient name: 

Task completed: 

Number of times patient 

required instructions: 

________________

________________

________________ (yes / no) 

________________

© 2006 Dr. Carol Snellgrove 

© 

293
Date: 

Patient name: 

Task completed: 

Time to complete task: 

Number of errors: 

________________

________________

________________ (yes / no) 

________________ (seconds) 

________________

© 2006 Dr. Carol Snellgrove 

© 

294
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 

EDUCATION

MEDICALLY-BASED ASSESSMENT, 

EDUCATION AND REFERRAL SPECIALIZED EVALUATION AND TRAINING

Program 

Type

Driver Safety 

Programs Driving School Driver Screen Clinical IADL Evaluation Driver Rehabilitation Programs (Includes Driver Evaluation)

Typical 

Providers 

and 

Credentials

Program specific 

credentials 

(e.g. AARP and 

AAA Driver 

Improvement 

Program).

Licensed Driving 

Instructor (LDI) 

certified by state 

licensing agency 

or Dept. of 

Education.

Health care professional 

(e.g., physician, social worker, 

neuropsychologist).

Occupational Therapy Practitioner 

(Generalist or Driver Rehabilitation 

Specialist#).

Other health professional degree 

with expertise in Instrumental 

Activities of Daily Living (IADL).

Driver Rehabilitation Specialist#, Certified Driver 

Rehabilitation Specialist*, Occupational Therapist with 

Specialty Certification in Driving and Community Mobility+.

Required 

Provider’s 

Knowledge

Program specific 

knowledge.

Trained in course 

content and 

delivery.

Instructs novice 

or relocated 

drivers, excluding 

medical or aging 

conditions that 

might interfere 

with driving, for 

purposes of 

teaching / training 

/ refreshing / 

updating driving 

skills.

Knowledge of relevant 

medical conditions, 

assessment, referral, and / or 

intervention processes.

Understand the limits and 

value of assessment tools, 

including simulation, as a 

measurement of fitness to 

drive.

Knowledge of medical conditions 

and the implication for community 

mobility including driving. 

Assess the cognitive, visual, perceptual, behavioral and 

physical limitations that may 

impact driving performance.

Knowledge of available services.

Understands the limits and value 

of assessment tools, including 

simulation, as a measurement of 

fitness to drive.

Applies knowledge of medical conditions with implications 

to driving. 

Assesses the cognitive, visual, perceptual, behavioral and 

physical limitations that may impact driving performance.

Integrates the clinical findings with assessment of on-road 

performance.

Synthesizes client and caregiver needs, assist in decisions 

about equipment and vehicle modification options available.

Coordinates multidisciplinary providers and resources, 

including driver education, health care team, vehicle choice 

and modifications, community services, funding / payers, 

driver licensing agencies, training and education, and 

caregiver support.

Typical 

Services 

Provided

1) Classroom 

or computer 

based 

refresher for 

licensed 

drivers: review 

of rules of the 

road, driving 

techniques,

driving strategies, state 

laws, etc.

2) Enhanced selfawareness, 

choices, and

capability to 

self-limit.

1) Enhance 

driving 

performance. 

2) Acquire driver 

permit or 

license. 

3) Counsel 

with family 

members for 

student driver 

skill development.

4) Recommend 

continued 

training and / 

or undergoing 

licensing test.

5) Remedial 

Programs 

(e.g., license 

reinstatement 

course for 

teens / adults,

license point 

reduction 

courses).

1) Counsel on risks associated 

with specific conditions 

(e.g., medications, fractures, 

post-surgery).

2) Investigate driving risk 

associated with changes 

in vision, cognition, and 

sensory-motor function.

3) Determine actions for the 

at-risk driver:

•	Refer to IADL evaluation, driver rehabilitation 

program, and / or other 

services.

•	Discuss driving cessation; 

provide access to counseling and education for 

alternative transportation 

options.

4) Follow reporting / referral 

structure for licensing 

recommendations.

1) Evaluate and interpret risks associated with changes in vision, 

cognition, and sensory-motor 

functions due to acute or chronic 

conditions. 

2) Facilitate remediation of deficits 

to advance client readiness for 

driver rehabilitation services.

3) Develop an individualized 

transportation plan considering 

client diagnosis and risks, 

family, caregiver, environmental 

and community options and 

limitations:

•	Discuss resources for vehicle 

adaptations (e.g., scooter lift). 

•	Facilitate client training on 

community transportation 

options (e.g., mobility 

managers, dementia-friendly 

transportation).

•	Discuss driving cessation. 

For clients with poor selfawareness, collaborate with 

caregivers on cessation 

strategies.

•	Refer to driver rehabilitation 

program.

4) Document driver safety risk and 

recommended intervention plan 

to guide further action.

5) Follow professional ethics on 

referrals to the driver licensing 

authority.

Programs are distinguished by complexity of evaluations, 

types of equipment, vehicles, and expertise of provider.

1) Navigate driver license compliance and basic eligibility 

through intake of driving and medical history.

2) Evaluate and interpret risks associated with changes in 

vision, cognition, and sensory-motor functions in the 

driving context by the medically trained provider.

3) Perform a comprehensive driving evaluation (clinical and 

on-road).

4) Advise client and caregivers about evaluation results, 

and provides resources, counseling, education, and / or 

intervention plan. 

5) Intervention may include training with compensatory 

strategies, skills, and vehicle adaptations or modifications 

for drivers and passengers. 

6) Advocate for clients in access to funding resources 

and / or reimbursement.

7) Provide documentation about fitness to drive to the 

physician and / or driver-licensing agency in compliance 

with regulations.

8) Prescribe equipment in compliance with state regulations 

and collaborate with Mobility Equipment Dealer^ for 

fitting and training.

9) Present resources and options for continued community 

mobility if recommending driving cessation or transition 

from driving.

Recommendations may include (but not restricted to): 

1) drive unrestricted; 2) drive with restrictions; 3) cessation 

of driving pending rehabilitation or training; 4) planned 

re-evaluation for progressive disorders; 5) driving cessation; 

6) referral to another program.

Outcome Provides 

education and 

awareness.

Enhances skills for 

healthy drivers.

Indicates risk or need for follow-up for medically at-risk drivers. Determines fitness to drive and provides rehabilitative services. 

#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

295
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. 

Program Type DRIVER REHABILITATION PROGRAMS

Determine fitness to drive and / or provide rehabilitative services. 

Levels of 

Program and 

Typical Provider 

Credentials

BASIC

Provider is a Driver Rehabilitation 

Specialist (DRS)# with professional 

background in occupational therapy, 

other allied health field, driver 

education or a professional team of 

CDRS or SCDCM with LDI**.

LOW TECH 

Driver Rehabilitation Specialist#, Certified Driver 

Rehabilitation Specialist*, Occupational Therapist 

with Specialty Certification in Driving and Community 

Mobility+, or in combination with LDI.

Certification in Driver Rehabilitation is recommended 

as the provider for comprehensive driving evaluation 

and training.

HIGH TECH

Driver Rehabilitation Specialist#, Certified Driver Rehabilitation 

Specialist*, Occupational Therapist with Specialty Certification in 

Driving and Community Mobility+.

Certification in Driver Rehabilitation is recommended as the 

provider for comprehensive driving evaluation and training with 

advanced skills and expertise to complete complex client and 

vehicle evaluation and training.

Program Service Offers driver evaluation, training 

and education.

May include use of adaptive driving 

aids that do not affect operation of 

primary or secondary controls (e.g., 

seat cushions or additional mirrors).

May include transportation 

planning (transition and options), 

cessation planning, and recommendations for clients as passengers.

Offers comprehensive driving evaluation, training and 

education, with or without adaptive driving aids that 

affect the operation of primary or secondary controls, 

vehicle ingress / egress, and mobility device storage / 

securement. May include use of adaptive driving aids 

such as seat cushions or additional mirrors.

At the Low Tech level, adaptive equipment for primary 

control is typically mechanical. Secondary controls may 

include wireless or remote access.

May include transportation planning (transition and 

options), cessation planning, and recommendations for 

clients who plan to ride as passengers only.

Offers a wide variety of adaptive equipment and vehicle options 

for comprehensive driving evaluation, training and education, 

including all services available in Low Tech and Basic programs. At 

this level, providers have the ability to alter positioning of primary 

and secondary controls based on client’s need or ability level.

High Tech adaptive equipment for primary and secondary controls 

includes devices that meet the following conditions: 

1) capable of controlling vehicle functions or driving controls, and

2) consists of a programmable computerized system that 

interfaces / integrates with an electronic system in the vehicle. 

Access to Driver’s 

Position

Requires independent transfer into 

OEM^ driver’s seat in vehicle. 

Addresses transfers, seating and position into OEM^ 

driver’s seat. May make recommendations for assistive 

devices to access driver’s seat, improved positioning, 

wheelchair securement systems, and / or mechanical 

wheelchair loading devices. 

Access to the vehicle typically requires ramp or lift and may 

require adaptation to OEM driver’s seat. Access to driver position 

may be dependent on use of a transfer seat base, or clients may 

drive from their wheelchair. Provider evaluates and recommends 

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 

Modification: 

Primary Controls: 

Gas, Brake, 

Steering

Uses OEM^ controls. Primary driving control examples: 

A) mechanical gas / brake hand control; 

B) left foot accelerator pedal; 

C) pedal extensions;

D) park brake lever or electronic park brake; 

E) steering device (spinner knob, tri-pin, C-cuff).

Primary driving control examples (in addition to Low Tech options): 

A) powered gas / brake systems; 

B) power park brake integrated with a powered gas / brake system; 

C) variable effort steering systems; 

D) reduced diameter steering wheel, horizontal steering, steering 

wheel extension, joystick controls;

E) reduced effort brake systems.

Typical Vehicle 

Modification: 

Secondary 

Controls

Uses OEM^ controls. Secondary driving control examples: 

A) remote horn button; 

B) turn signal modification (remote, crossover lever); 

C) remote wiper controls;

D) gear selector modification;

E) key / ignition adaptions. 

Electronic systems to access secondary and accessory controls. 

Secondary driving control examples (in addition to 

Low Tech options): 

A) remote panels, touch pads or switch arrays that interface 

with OEM^ electronics; 

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

296
9

4

8

19

10

7

3

5

2

15

13

25

12

6

11

Trail Making Test, Part A

Client Name: ______________________ Date: _____________

1

16

14 Start

24

17

18

20 22

21

23

297
9

4

B

8 D I

10

7

3

5

C

H

12

A

G

L

F

K

2

E

6

11

J

Trail Making Test, Part B

Client Name: ______________________ Date: _____________

1

13

Start

298
DOT HS 812 228

January 2016

12052-012916-v6a