Physician’s Guide to 

Assessing and Counseling

Older Drivers

 

2nd edition

physician’s guide to 

Assessing and Counseling 

Older Drivers 

2nd edition 

Physician’s Guide 

to Assessing and 

Counseling Older Drivers

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

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

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

commercial vehicles or to function as professional drivers involves more 

stringent criteria and is beyond the scope of this publication.

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

as a substitute for physicians’ clinical judgement. Rather, this guide reflects the 

scientific literature and views of experts as of December 2009, and is provided 

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

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

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

practice in their State.

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

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

comprehensive review by medical specialists and other experts in the field of 

older driver safety.

The American Medical Association is accredited by the Accreditation Council 

for Continuing Medical Education to provide continuing medical education 

(CME) for physicians. 

The American Medical Association designates this educational activity for a 

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

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

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

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

For further information about the guide, 

please contact:

Joanne G. Schwartzberg, MD 

Director, Aging and Community Health 

American Medical Association 

515 N. State Street 

Chicago, IL 60654

An AMA Continuing Education Program

First Edition Original Release Date–7/30/2003 

Second Edition–2/3/2010 

Expiration Date–2/3/2012

Accreditation Statement

The American Medical Association is accredited 

by the Accreditation Council for Continuing 

Medical Education to provide continuing medical 

education for physicians.

Designation Statement

The American Medical Association designates 

this educational activity for a maximum of 6.25 

AMA PRA Category 1 CreditsTM. Physicians 

should only claim credit commensurate with the 

extent of their participation in the activity.

Disclosure Statement

The content of this activity does not relate to 

any product of a commercial interest as defined 

by the ACCME; therefore, there are no relevant 

financial relationships to disclose.

Educational Activity Objectives

• Increase physician awareness of the safety risks 

of older drivers as a public health issue

• Identify patients who may be at risk for unsafe 

driving

• Use various clinical screens to assess patients’ 

level of function for driving fitness

• Employ referral and treatment options for 

patients who are no longer fit to drive

• Practice counseling techniques for patients who 

are no longer fit to drive

• Demonstrate familiarity with State reporting 

laws and legal/ethical issues surrounding 

patients who may not be safe on the road

Instructions for claiming AMA PRA 

Category 1 CreditsTM

To facilitate the learning process, we encourage 

the following method for physician participation: 

Read the material in the Physician’s Guide to 

Assessing and Counseling Older Drivers, complete 

the CME Questionnaire & Evaluation, and then 

mail both of them to the address provided. To 

earn the maximum 6.25 AMA PRA Category 1 

CreditsTM , 70 percent is required to pass and 

receive the credit.
 

 

Acknowledgements 

This Physician’s Guide to Assessing and 

Counseling Older Drivers is the product 

of a cooperative agreement between 

the American Medical Association and 

the National Highway Traffic Safety 

Administration. 

First edition: Primary Authors 

Claire C. Wang, MD 

American Medical Association 

Catherine J. Kosinski, MSW 

American Medical Association 

Joanne G. Schwartzberg, MD 

American Medical Association 

Anne Shanklin, MA 

American Medical Association 

Second edition: 

Principal Faculty Authors 

Editor: David B. Carr, MD 

Associate Professor of Medicine and 

Neurology Washington University at 

St. Louis Clinical Director 

Planning Committee: 

David B. Carr, MD; 

Associate Professor of Medicine and 

Neurology Washington University at 

St. Louis Clinical Director 

Joanne G. Schwartzberg, MD 

Director, Aging and Community Health, 

American Medical Association 

Lela Manning, MPH, MBA 

Project Coordinator, American Medical 

Association 

Jessica Sempek, MS 

Program Administrator, American Medical 

Asscoiation 

Citation 

Carr DB; Schwartzberg JG; Manning 

L; Sempek J; Physician’s Guide to 

Assessing and Counseling Older 

Drivers, 2nd edition, Washington, 

D.C. NHTSA. 2010. 

This guide benefited significantly 

from the expertise of the following 

individuals who served as reviewers 

in this project. 

Second edition: Content Consultants 

Lori C. Cohen 

AARP 

Senior Project Manager, Driver Safety 

Jami Croston, OTD 

Washington University at St. Louis 

T. Bella Dinh-Zarr, PhD, MPH 

Road Safety Director, FIA Foundation 

North American Director, MAKE 

ROADS SAFE–The Campaign for Global 

Road Safety 

John W. Eberhard, PhD 

Consultant, Aging and Senior 

Transportation Issues 

Camille Fitzpatrick, MSN, NP 

University of California Irvine 

Clinical Professor Family Medicine 

Mitchell A. Garber, MD, 

MPH, MSME 

National Transportation Safety Board 

Medical 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, MD 

VAMC 

Donald W. Reynolds Department of 

Geriatric Medicine 

Associate Professor 

Alice Pomidor, MD, MPH 

Florida State University College of 

Medicine 

Associate Professor, Department of 

Geriatrics 

Kanika Mehta Rankin 

Loyola University Chicago School of Law 

(2nd year) Juris Doctorate Candidate, 

2011 

Yael Raz, MD 

American Academy of Otolaryngology 

William H. Roccaforte, MD 

American Association for Geriatric 

Psychiatry 

Nebraska Medical Center 

Department of Psychiatry 

Gayle San Marco, OTR/L, CDRS 

Northridge Hospital Medical Center 

Project Consultation, Center for Injury 

Prevention Policy & Practice 

Freddie Segal-Gidan, PA-C, PhD 

American Geriatrics Society 

William Shea, OTR/L 

Fairlawn Rehabilitation Hospital 

IV acknowledgements 
Patricia E. Sokol, RN, JD 

Senior Poilcy 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 

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 

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 

acknowledgements V 
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 Moore, MD, MPH 

American Public Health Association 

David Geffen School of Medicine, 

University of California 

Anne Long Morris, EdD, OTR/L 

American Society on Aging 

Germaine Odenheimer, MD 

Center for Assessment and Rehabilitation 

of Elderly Drivers 

Eli Peli, M.Sc., OD 

Schepens Eye Research Institute 

Alice Pomidor, MD, MPH 

Society of Teachers of Family Medicine 

George Rebok, MA, PhD 

Johns Hopkins School of Hygiene and 

Public Health 

Selma Sauls 

Florida Department of Highway Safety and 

Motor Vehicles 

Susan Samson 

Pinellas/Pasco Area Agency on Aging 

Steven Schachter, MD 

Epilepsy Foundation 

Frank Schieber, PhD 

University of South Dakota 

Freddi Segal-Gidan, PA, PhD 

American Geriatrics Society 

Melvin Shipp, OD, MPH, DrPh 

University of Alabama at Birmingham 

Richard Sims, MD 

American Geriatrics Society 

Kristen Snyder, MD 

Oregon Health & Science University 

School of Medicine 

Susan Standfast, MD, MPH 

American College of Preventative Medicine 

Holly Stanley, MD 

American Geriatrics Society 

Loren Staplin, PhD 

Transanalytics and Texas Transportation 

Institute 

Wendy Stav, PhD, OTR, CDRS 

American Occupational Therapy 

Association 

Cleveland State University 

Donna Stressel, OTR, CDRS 

Association of Driver Rehabilitation 

Specialists 

Cathi A. Thomas, RN, MS 

Boston University Medical Center 

American Parkinson Disease Association 

John Tongue, MD 

American Academy of Orthopedic Surgery 

Patricia Waller, PhD 

University of Michigan 

Lisa Yagoda, MSW, ACSW 

National Association of Social Workers 

Patti Yanochko, MPH 

San Diego State University 

Richard Zorowitz, MD 

National Stroke Association 

VI acknowledgements 
Table of Contents 

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

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

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

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

Is the Patient at Increased Risk for Unsafe Driving? 

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

Assessing Functional Ability 

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

Physician Interventions 

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

The Driver Rehabilitation Specialist 

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

Counseling the Patient Who Is No Longer Safe to Drive 

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

Ethical and Legal Responsibilities of the Physician 

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

State Licensing and Reporting Laws 

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

Medical Conditions and Medications That May Affect Driving 

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

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

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

CPT® Codes 

table of contents VII 
Table of Contents(continued) 

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

Patient and Caregiver Educational Materials 

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

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

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

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

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

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

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

Continuing Medical Education Questionnaire and Evaluation 

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

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

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

VIII table of contents 
 

Preface
 

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

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

disease in the individual, while the science of public health is devoted to prevention of disease in the population. However, physicians can actualize public health 

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

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

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

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

that most people sustain a significant injury at some time during their lives. 

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

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

Highway Traffic and Safety Administration (NHTSA), to help physicians 

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

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

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

among 75- to 84-year-olds. While traffic safety programs have reduced the fatality rate for drivers under age 65, the fatality rate for older drivers has consistently 

remained high. Clearly, additional efforts are needed. 

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

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

a high level of 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 strategies outlined 

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

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

and when it becomes necessary. 

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

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

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

to forge a link between public health and medicine. 

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

from the National Highway Traffic Safety Administration (NHTSA) of the Department 

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

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

of NHTSA. 

preface IX 

chapter 1 

Safety and the Older Driver 


With Functional or Medical 


Impairments: An Overview
 

 

 

 

 

 

chapter 1 

Safety and the Older 

Driver With Functional 

or Medical Impairments 

An Overview 

Mrs. Simon, a 67-year-old woman 

with type 2 diabetes mellitus and 

hypertension, mentions during a 

routine check-up that she almost 

hit a car while making a left-hand 

turn when driving two weeks ago. 

Although she was uninjured, she 

has been anxious about driving since 

that episode. Her daughter has 

called your office expressing concern 

about her mother’s driving abilities. 

Mrs. Simons admits to feeling less 

confident when driving and wants 

to know if you think she should stop 

driving. What is your opinion? 

Mr. Evans, a 72-year-old man 

with coronary artery disease and 

congestive heart failure, arrives for 

an office visit after fainting yesterday 

and reports complaints of “lightheadedness” for the past two weeks. 

When feeling his pulse, you notice 

that his heartbeat is irregular. You 

perform a careful history and physical examination, and order some 

laboratory tests to help determine the 

cause of his atrial fibrillation. When 

you ask Mr. Evans to schedule a 

follow-up appointment for the next 

week, he tells you he cannot come 

at that time because he is about to 

embark on a two-day road trip to 

visit his daughter and newborn 

grandson. Would you address the 

driving issue and if so, how? 

What would you communicate to 

the patient? 

Patients like Mrs. Simon and Mr. Evans 

are becoming more common in physicians’ practices. Buoyed by the large 

ranks of “baby boomers” and increased 

life expectancy, the U.S. older adult 

population is growing nearly twice as 

fast as the total population.1,2 Within 

this cohort of older adults, an increasing 

proportion will be licensed to drive, and 

it is expected that these license-holders 

will drive more miles than older drivers 

do today.3 

As the number of older drivers with 

medical conditions expands, patients 

and their families will increasingly 

turn to physicians for guidance on safe 

driving. Physicians will have the challenge of balancing their patients’ safety 

against their transportation needs and 

the safety of society. 

This guide is intended to help you 

answer the questions, “At what level of 

severity do medical conditions impair 

safe driving?” “What can I do to help 

my patient drive more safely?”*

, and if 

necessary to help you counsel patients 

1.	 National Center for Statistics & Analysis. 

Traffic Safety Facts 2000: Older Population. 

DOT HS 809 328. Washington, DC: National 

Highway Traffic Safety Administration. 

2.	­ Population Projections of the United States by 

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

1999 to 2100. Population Projections Program, 

Population Division, Census Bureau Internet 

release date: January 13, 2000. Revised date: 

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

Census Bureau. 

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

International Association for Traffic and Safety 

Services Research. 20(1):29–37. 

about driving cessation and alternate 

means of transportation. Mobility 

counseling and discussing alternative 

modes of transportation need to take a 

more prominent role in the physician’s 

office. To these ends, we have reviewed 

the scientific literature and collaborated 

with clinicians and experts in this field 

to produce the following physician tools: 

• An office-based assessment of 

medical fitness to drive. This 

assessment is outlined in the 

algorithm, Physician’s Plan for 

Older Drivers’ Safety (PPODS), 

presented later in this chapter. 

• A functional assessment battery, 

the Assessment of Driving Related 

Skills (ADReS). This can be found 

in Chapter 3. 

• A reference table of medical 

conditions and medications that 

may affect driving, with specific 

recommendations for each, can 

be found in Chapter 9. 

In addition to these tools, we also 

present the following resources: 

• Information to help you navigate 

the legal and ethical issues regarding 

patient driving safety. Information 

*	 Please be aware that the information in this 

guide is provided to assist physicians in 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 

guide. 

chapter 1—Safety and the Older Driver With Functional or Medical Impairments: An Overview 1 
on patient reporting, with a State-byState list of licensing criteria, license 

renewal criteria, reporting laws, 

and Department of Motor Vehicles 

(DMV) contact information, can be 

found in Chapters 7 and 8. 

• Recommended Current Procedural 

Terminology (CPT®) codes for 

assessment and counseling procedures. 

These can be found in Appendix A. 

• Handouts for your patients and their 

family members. These handouts, 

located in Appendix B, include a selfscreening tool for driving safety, safe 

driving tips, driving alternatives, and 

a resource sheet for concerned family 

members. These handouts can be 

removed from the guide and photocopied for distribution to patients 

and their family members. 

We understand that physicians may 

lack expertise in communicating with 

patients about driving, discussing the 

need for driving cessation (delivering 

bad news), and being aware of viable 

alternative transportation options to 

offer. Physicians also may be concerned 

about dealing with the patient’s anger, 

or even losing contact with the patient. 

Driving is a sensitive subject, and the 

loss of driving privileges can be stressful. 

While these are reasonable concerns, 

there are ways to minimize the impact 

on the doctor-patient relationship when 

discussing driving. We provide sample 

approaches in subsequent chapters in 

the areas of driving assessment, rehabilitation, restriction, and cessation. 

We want this information to be 

readily accessible to you and your 

office staff. You can locate this guide 

on the Internet at the AMA Web site 

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

Additional printed copies may also 

be ordered through the Web site. 

Before you read the rest of the guide, 

you may wish to familiarize yourself 

with key facts about older drivers. 

Older drivers: Key facts 

Fact #1: The number of older adult 

drivers is growing rapidly and they 

are driving longer distances. 

Life expectancy is at an all-time high4 

and the older population is rapidly increasing. By the year 2030, the 

population of adults older than 65 will 

more than double to approximately 70 

million, making up 20 percent of the 

total U.S. population.5 In many States, 

including Florida and California, the 

population of those over age 65 may 

reach 20 percent in this decade The 

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

is anticipated to increase from about 3 

million this year to 8 to 10 million over 

the next 30 years. We can anticipate 

many older drivers on the roadways 

over the next few decades, and your 

patients will likely be among them. 

Census projections estimate that by 

the year 2020 there will be 53 million 

persons over age 65 and approximately 

40 million (75%) of those will be 

licensed drivers.6

 The increase in the 

number of older drivers is due to many 

factors. In addition to the general aging 

of the population that is occurring in 

all developed countries, many more 

female drivers are driving into advanced 

age. This will likely increase with aging 

cohorts such as the baby boomers. 

In addition, the United States has 

become a highly mobile society, and 

older adults are using automobiles for 

volunteer activities and gainful employment, social and recreational needs, 

and cross country travel. Recent studies 

suggest that older adults are driving 

4.	 Centers for Disease Control and Prevention. 

2008. National Center for Health Statistics. 

Accessed on December 14, 2008 at; 

www.cdc.gov/nchs/PRESSROOM/
 

07newsreleases/lifeexpectancy.htm 


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

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

gov/NCCdphp/publications/aag/aging.htm 

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

population by 5-year age groups and sex with 

special age categories; middle series, 2016–2020. 

Washington, DC: Population Projections 

Program, Population Division, U.S. Census 

Bureau; 2000. 

more frequently, while transportation 

surveys reveal an increasing number of 

miles driven per year for each successive 

aging cohort. 

Fact #2: Driving cessation is inevitable for many and can be associated 

with negative outcomes. 

Driving can be crucial for performing 

necessary chores and maintaining social 

connectedness, with the latter having 

strong correlates with mental and physical health.7

 Many 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 may be 

the sole means of transportation. Just as 

the driver’s license is a symbol of independence for adolescents, the ability to 

continue driving may mean continued 

mobility and independence for older 

drivers, with great effects on their quality of life and self-esteem.8 

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

86 percent of survey participants reported that driving was their usual mode of 

transportation. Within this group, driving was the usual method of transportation for 85 percent of participants 75 to 

79, 78 percent of participants 80 to 84, 

and 60 percent of participant’s 85 and 

older.9 This data also indicates that the 

probability of losing the ability to drive 

increases with advanced age. It is estimated that the average male will have 

6 years without the functional ability to 

drive a car and the average female will 

have 10 years.10 However, our society 

has not prepared the public for driving 

7.	­ Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. From social integration to health: 

Durkheim in the new millennium. Soc Sci Med. 

51:843–857. 

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

cognitive impairments drive less? J Am Geriatr 

Soc. 46(7):854–861. 

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

Understanding Senior Transportation: Report 

and Analysis of a Survey of Consumers Age 

50+. American Association for Retired Persons, 

Policy and Strategy Group, Public Policy 

Institute, p. 10–11. 

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

Brock, D. B. Driving life expectancy of persons 

aged 70 years and older in the United States. 

Am J Public Health. 92:1284–1289 

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

 

 

 

cessation, and patients and physicians 

are often ill-prepared when that time 

comes. 

Studies of driving cessation have noted 

increased social isolation, decreased 

out-of-home activities,11 and an increase in depressive symptoms.12 These 

outcomes have been well documented 

and represent some of the negative consequences of driving cessation. It is important for health care providers to use 

the available resources and professionals 

who can assist with transportation to 

allow their patients to maintain independence. These issues will be discussed 

further in subsequent chapters. 

Fact #3: Many older drivers 

successfully self-regulate their 

driving behavior. 

As drivers age, they may begin to 

feel limited by slower reaction times, 

chronic health problems, and effects 

from medications. Although transportation surveys over the years document 

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

reduce their mileage or stop driving 

altogether because they feel unsafe or 

lose confidence. In 1990, males over 70 

drove on average 8,298 miles, compared 

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

women, the figures were 3,976 miles 

and 11,807 miles, respectively.13 Older 

drivers are more likely to wear seat belts 

and are less likely to drive at night, 

speed, tailgate, consume alcohol prior 

to driving, and engage in other risky 

behaviors. 14 

Older drivers not only drive substantially less, but also tend to modify 

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

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

decreased out-of-home activity levels. J Gerontol 

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

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

K. E. Driving cessation and increased depressive 

symptoms J Gerontol Series A Bio Sci Med Sci. 

60:399–403. 

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

when they were younger? Am J Epidemiol. 

1993;137(7);769–775. 

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

related to driving difficulty and habits in older 

drivers. Accid Anal Prev. 33:413–421. 

when and how they drive. When they 

recognize loss of ability to see well after 

dark, many stop driving at night. There 

are data that suggest older women are 

more likely to self-regulate than men.15 

Others who understand the complex 

demands of left turns at uncontrolled 

intersections and their own diminished 

capacity forgo left-hand turns, and make 

a series of right turns instead. Selfregulating in response to impairments 

is simply a continuation of the strategy 

we all employ daily in navigating this 

dangerous environment—driving. Each 

of us, throughout life, is expected to 

use our best judgment and not operate 

a car when we are impaired, whether 

by fatigue, emotional distress, physical 

illness, or alcohol. Thus, self-awareness, 

knowledge of useful strategies, and 

encouragement to use them may be 

sufficient among cognitively intact 

older adults; however, this remains an 

important area for further study. 

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. Decreasing mileage, then, may 

not always proportionately decrease 

safety risks.16 In fact, the “low mileage” 

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

year) may actually be the group that is 

most “at-risk.”17 

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

driven begin to increase at age 65.18 On 

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

depends on whether each individual 

driver’s decreased mileage and behavior 

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

driving practices among older adults: health, age 

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

16.	 Janke, M. K. Accidents, mileage, and the exaggeration of risk. Accid Anal Prev. 1991;23:183– 

188. 

17.	 Langford, J., Methorst, R., & HakamiesBlomqvist, L. Older drivers do not have a high 

crash risk—a replication of low mileage bias.’ 

Accid Anal Prev. 38(3):574–578. 

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

the High Driver Death Rates per Vehicle-Mile 

of Travel in Older Drivers: Fragility versus 

Excessive Crash Involvement. Presented at the 

Insurance Institute for Highway Safety; August 

2001. 

modifications are sufficient to counterbalance any decline in driving ability. 

In some cases, decline—in the form of 

peripheral vision loss, for example— 

may occur so insidiously that the driver 

is not aware of it until he/she experiences a crash. In fact, a recent study 

indicated that some older adults do not 

restrict their driving despite having 

significant visual deficits.19 Reliance on 

driving as the sole available means of 

transportation can result in an unfortunate choice between poor options. In 

the case of dementia, drivers may lack 

the insight to realize they are unsafe 

to drive. 

In a series of focus groups conducted 

with older adults who had stopped 

driving within the past five years, about 

40 percent of the participants knew 

someone over age 65 who had problems 

with his/her driving but was still behind 

the wheel.20 Clearly, some older drivers 

require outside assessment and interventions when it comes to driving safety. 

Fact #4: The crash rate for older 

drivers is in part related to physical 

and/or mental changes associated 

with aging and/or disease.21 

Compared with younger drivers whose 

car crashes are often due to inexperience or risky behaviors,22 older driver 

crashes tend to be related to inattention 

or slowed speed of visual processing.23 

Older driver crashes are often multiplevehicle events that occur at intersections 

and involve left-hand turns. The crash is 

usually caused by the older driver’s failure 

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

At intersections with traffic signals, left19.	 Okonkwo, O. C., Crowe, M., Wadley, V. G., 

& Ball, K. Visual attention and self-regulation 

of driving among older adults. Int Psychogeriatr. 

20:162–173. 

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

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

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

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

risk for older drivers at intersections. Accid Anal 

Prev. 30(2):151–159. 

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

for graduated licensing and the risks it should 

address. Inj Prev. 8:ii9–ii16. 

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

Citizens. International Association for Traffic 

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

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

 

hand turns are a particular problem for 

the older driver. At stop-sign-controlled 

intersections, older drivers may not know 

when to turn.24 

These driving behaviors indicate that 

visual, cognitive, and/or motor factors 

may affect the ability to drive in older 

adults. Research has not yet determined 

what percentage of older adult crashes 

are due to driving errors that are also 

common among middle-aged drivers, 

what proportion are due to age-related 

changes in cognition (such as delayed 

reaction time), or how many could be 

attributed to age-related medical illnesses. However, it is believed that further 

improvements in traffic safety will likely 

result from improving driving performance or modifying driving behavior.

25 

The identification and management 

of diseases has a potential to maintain 

or improve driving abilities and 

road safety. 

Fact #5: Physicians can influence 

their patients’ decisions to modify 

or stop driving. They can also help 

their patients maintain safe 

driving skills. 

Although older drivers believe that 

they should be the ones to make the 

final decision about driving, they also 

agree that their physicians should advise 

them. In a series of focus groups conducted with older adults who had given 

up driving, all agreed that the physicians should talk to older adults about 

driving, if a need exists. As one panelist 

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

drive anymore, that’s definite. But when 

you decide for yourself, there might be 

questions.” While family advice had 

limited influence on the participants, 

most agreed that if their physicians 

advised them to stop and their family 

concurred, they would certainly retire 

from driving.26 This is consistent with a 

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

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

risk for older drivers at intersections. Accid Anal 

Prev. 30(2):151–159. 

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

Hum Factors. 50: 521–528. 

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

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

recent focus group study with caregivers of older drivers have focused on screenof demented drivers, who stated that ing methods to identify unsafe drivers 

physicians should be involved in this and restrict older drivers. Physicians are 

important decision-making process.27 in a position to identify patients at risk 

for unsafe driving or self-imposed drivPhysicians assist their older patients ing cessation due to functional impairto maintain safe mobility in two ways. ments, and address and help manage 

They provide effective treatment and these issues to keep their patients drivpreventive health care, and they play a ing safely for as long as possible. 

role in determining the ability of older 

adults to drive safely. Also, improved Physicians must abide by State reportcardiovascular and bone health has ing laws. While the final determination 

the potential to reduce serious injuries of an individual’s ability to drive lies 

and improve the rate of recovery in the with the driver licensing authority, 

event of a crash. physicians can assist with this determination. Driver licensing regulations 

In many cases, physicians can keep and reporting laws vary greatly by State. 

their patients on the road longer by Some State laws are vague and open to 

identifying and managing diseases, such interpretation; therefore, it is imporas cataracts and arthritis, or by discon­ tant for physicians to be aware of their 

tinuing sedating medications. Many responsibilities for reporting unsafe 

physicians are aware of the literature on patients to the local driver licensing 

fall prevention, and that clinicians can authority. Information on State laws is 

reduce future risks of falls and fractures provided in Chapter 8. 

by addressing certain extrinsic (environmental) and intrinsic factors.28 Driv- Thus, physicians can play a more active 

ing abilities share many attributes that role in preventing motor vehicle crashes 

are necessary for successful ambulation, by assessing their patients for medical 

such as adequate visual, cognitive, and fitness to drive, recommending safe 

motor function. In fact, a history of falls driving practices, referring patients to 

has been associated with an increased driver rehabilitation specialists, advising 

risk of motor vehicle crash.29 or recommending driving restrictions, 

and referring patients to State authoriBrief physician intervention on topics ties when appropriate. 

such as smoking and seat belt use has 

been shown to be effective. There is 

an assumption that doctors can and do 

make a difference by evaluating older 

individuals for medical fitness to drive. 

Furthermore, there is a crucial need to 

have this hypothesis studied systematically. To date, little organized effort in 

the medical community has been made 

to help older adults improve or maintain their driving skills. Research and 

clinical reviews on the assessment 

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

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

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

of the Alzheimer type: beliefs and cessation 

strategies among stakeholders. Gerontologist. 

45(5):676–685. 

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

N Engl J Med. 348(1):42–49. 

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

et al. Risk factors for motor vehicle crashes in 

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

57:M186–M191. 

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

 

To achieve these ends, primary care 

physicians can follow the algorithm, 

Physician’s Plan for Older Drivers’ Safety 

(PPODS) (see Figure 1.1), which 

recommends that physicians: 

•	Screen for red flags such as medical 

illnesses and medications that may 

impair driving safety; 

•	Ask about new-onset impaired 

driving behaviors (see Am I a Safe 

Driver and How to Help the Older 

Driver in the appendices); 

•	Assess driving-related functional 

skills in those patients who are at 

increased risk for unsafe driving; for 

the functional assessment battery, 

Assessment of Driver Related Skills 

(ADReS), see Chapter 3; 

•	Treat any underlying causes of 

functional decline; 

•	Refer patients who require a driving 

evaluation and/or adaptive training to 

a driver rehabilitation specialist; 

•	Counsel patients on safe driving 

behavior, driving restrictions, driving 

cessation, and/or alternate transportation options as needed; and 

•	Follow-up with patients who should 

adjust their driving to determine if 

they have made changes, and evaluate those who stop driving for signs of 

depression and social isolation. 

While primary care physicians may 

be in the best position to perform the 

PPODS, other clinicians have a responsibility to discuss driving with their 

patients as well. Ophthalmologists, 

neurologists, psychiatrists, physiatrists, 

orthopedic surgeons, emergency department and trauma center physicians, 

and other specialists all treat conditions, prescribe medications, or perform 

procedures that may have an impact on 

driving skills. When counseling their 

patients, physicians may wish to 

consult the reference list of medical 

conditions in Chapter 9. 

In the following chapters, we will guide 

you through the PPODS and provide 

the tools you need to perform it. Before 

we begin, you may wish to review the 

AMA’s policy on impaired drivers (see 

Figure 1.2).This policy can be applied 

to older drivers with medical conditions 

that impair their driving skills and 

threaten their personal driving safety. 

Fact #6: Traffic safety for older 

drivers is a growing public 

health issue. 

Older drivers are the safest drivers as 

an age group when using the absolute 

number of crashes per 100 licensed 

drivers per year.30 However, the crash 

rate per miles driven reveals an increase 

at about age 65 to 70 in comparison to 

middle-aged drivers.31 In 2000, 37,409 

Americans died in motor vehicle 

crashes.32 Of this number, 6,643 were 65 

and older.33 Accidental injuries are the 

seventh leading cause of death among 

older people and motor vehicle crashes 

are not an uncommon cause.34 As the 

number of older drivers continues to 

grow, drivers 65 and older are expected 

to account for 16 percent of all crashes 

and 25 percent of all fatal crashes.35 

Motor vehicle injuries are the leading 

cause of injury-related deaths among 

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

leading cause (after falls) among 75- to 

84-year-olds.36 Compared to other driv30.	 CDC. (1997). Behavioral Risk Factor Surveillance System Survey Data. Atlanta: Centers for 

Disease Control and Prevention 

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

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

functional impairment in older drivers. Accid 

Anal Prev. 30:313–322. 

32.	 NHTSA. FARS. Web-Based Encyclopedia. 

www-fars.nhtsa.dot.gov. 

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

Fatality Facts: Elderly (as of October 2001). 

(Fatality Facts contains an analysis of data from 

U.S. Department of Transportation Fatality 

Analysis Reporting System.) Arlington, VA: 

Insurance Institute for Highway Safety. 

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

Geriatrics. 63:12–17. 

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

dangerous. Insurance Institute for Highway Safety 

Status Report (Special Issue: Older Drivers). 

36(8):1–2. 

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

Deaths, United States, 1999, All Races, Both 

Sexes. Office of Statistics and Programming, 

National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Data source: National Center for Health 

Statistics Vital Statistics System. Atlanta: 

Centers for Disease Control and Prevention. 

ers, older drivers have a higher fatality 

rate per mile driven than any other age 

group except drivers under 25.37 On the 

basis of estimated annual travel, the 

fatality rate for drivers 85 and older is 

9 times higher than the rate for drivers 

25 to 69.38 By age 80, male and female 

drivers are 4 and 3.1 times more likely, 

respectively, than 20-year-olds to die 

as a result of a motor vehicle crash.39 

There is a disproportionately higher rate 

of poor outcomes in older drivers, due 

in part to chest and head injuries.40 Older adult pedestrians are also more likely 

to be fatally injured at crosswalks.41 

There may be several reasons for this 

excess in fatalities. First, some older 

drivers are considerably more fragile. 

For example, the increased incidence 

of osteoporosis, which can lead to 

fractures, and/or atherosclerosis of the 

aorta which can predispose individuals 

to rupture with chest trauma from an 

airbag or steering wheel. Fragility begins 

to increase at age 60 to 64 and 

increases steadily with advancing age.42 

A recent study noted that chronic 

conditions are determinants of mortality 

and even minor injury.43 As noted above, 

older drivers are also overrepresented in 

(Continues on page 7) 

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

Washington, DC: National Highway Traffic 

Safety Administration. 

38.	 NHTSA. National Center for Statistics & 

Analysis. Traffic Safety Facts 2000: Older 

Population. DOT HS 809 328. Washington, 

DC: National Highway Traffic Safety 

Administration. 

39.	 Evans, L. Risks older drivers face themselves 

and threats they pose to other road users. 

Int J Epidemiol. 29:315–322. 

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

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

associated with distinct injury patterns: analysis 

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

64:304–310. 

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

Countermeasres. PEDSAFE. 2007. Washington, 

DC: Federal Highway Administration. www. 

walkinginfo.org/pedsafe/crashstats.cfm. Accessed 

November 21, 2007. 

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

excessive crash involvement as determinants of 

high death rates per vehicle mile of travel for 

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

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

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

the role of comorbidities. Int J Inj Control Safety 

Prom. 15:25–31. 

chapter 1—Safety and the Older Driver With Functional or Medical Impairments: An Overview 5 
Figure 1.1 Physician’s Plan for Older Drivers’ Safety (PPODS) 

Is the patient at increased risk for unsafe driving? 

Perform initial screen— 

• Observe the patient 

• Be alert to red flags 

¤ Medical conditions

¤ Medications and polypharmacy

¤ Review of systems

¤ Patient’s or family member’s concern/ 

impaired driving behaviors 

At risk 

Formally assess function 

• Assess Driving Related Skills (ADReS) 

¤ Vision 

¤ Cognition

¤ Motor and somatosensory skills

Medical interventions 

• For diagnosis and 

treatment 

Counsel and follow up 

• Explore alternatives to driving 

• Monitor for depression and social isolation 

• Adhere to State reporting regulations 

Deficit not resolved 

Refer to Driver Rehabilitation Specialist: 

Is the patient safe to drive? 

No Yes 

Deficit resolved 

Not at risk 

Health maintenance 

• Successful Aging Tips 

• Tips for Safe Driving 

• Mature Driving classes 

• Periodic follow-up 

If screen is positive— 

• Ask health risk assessment/social history questions 

• Discuss alternatives to driving early in the process 

• Gather additional information 

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

 

 

 

 

 

 

left-hand-turn collisions, which cause 

more injury than more injury than 

rear-end collisions.44 Finally, preliminary 

data from a Missouri study of medically 

impaired drivers who were in crashes 

indicate that the average age of the 

vehicle was more than 10 years and the 

cars often did not have air bags (personal 

communication, Tom Meuser, University 

of St. Louis-Missouri). If this latter observation is a contributing factor, improvement should occur as future cohorts of 

aging drivers purchase newer vehicles 

with improved crashworthiness. 

Figure 1.2 

AMA ethical opinion 

E-2.24 Impaired drivers and their physicians 

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

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

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

does not address the reporting of medical information for the purpose of punishment or criminal prosecution. 

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

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

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

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

impairment (e.g., physicians who treat patients on a short-term basis). In making evaluations, physicians should consider the following factors: (a) the physician must be able to identify and document physical or mental impairments 

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

to public safety. 

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

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

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

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

such as substance abuse treatment or occupational therapy. Physicians also 

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

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

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

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

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

render reporting unnecessary. 

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

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

clear evidence of substantial driving impairment implies a strong threat to 

patient and public safety, and where the physician’s advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the Department of 

Motor Vehicles. 

4.	 The physician’s role is to report medical conditions that would impair safe driving as dictated by his or her State’s mandatory reporting laws and standards of 

medical practice. The determination of the inability to 

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

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

report. 

6.	 Physicians should protect patient confidentiality by ensuring that only the minimal amount of information 

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

information. 

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

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

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

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

December 1999. 

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

of November 2002. Arlington, Va: Insurance 

Institute for Highway Safety. 

chapter 1—Safety and the Older Driver With Functional or Medical Impairments: An Overview 7 

chapter 2 

Is the Patient at 

Increased Risk for 

Unsafe Driving? 

 

 

 

 

 

 

 

 

 

 

 

chapter 2 

Is the Patient at Increased 

Risk for Unsafe Driving? 

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

a history of hypertension, congestive 

heart failure, type 2 diabetes mellitus, macular degeneration, and 

osteoarthritis comes to your office for 

a routine check-up. You notice that 

Mr. Phillips has a great deal of trouble walking to the examination room, 

is aided by a cane, and has difficulty 

reading the labels on his medication 

bottles, even with his glasses. While 

taking a social history, you ask him 

if he still drives, and he states that 

he takes short trips to run errands, 

reach appointments, and meet 

weekly with his bridge club. 

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

no significant past medical history, 

presents at the emergency department 

with an acute onset of substernal 

chest pain. He is diagnosed with 

acute myocardial infarction. Following an uneventful hospital course, he 

is stable and ready to be discharged. 

On the day of discharge, he mentions 

that he had driven himself to the 

emergency department and would 

now like to drive himself home, but 

cannot find his parking voucher. 

This chapter discusses the first steps of 

the Physician’s Plan for Older Drivers’ 

Safety (PPODS). In particular, we 

provide a strategy for answering the 

question, “Is the patient at increased 

risk for unsafe driving?” This part of the 

evaluation process includes your clinical 

observation, identifying red flags such 

medical illnesses and medications that 

may impair safe driving, and inquiring 

about new onset driving behaviors that 

may indicate declining traffic skills. 

to answer this question, first— 

Observe the patient 

throughout the office visit. 

Careful observation is often an important step in diagnosis. As you observe 

the patient, be alert to: 

• Impaired personal care such as poor 

hygiene and grooming; 

• Impaired ambulation such as difficulty 

walking or getting into and out of 

chairs 

• Difficulty with visual tasks; and 

• Impaired attention, memory, language 

expression or comprehension. 

In the example above, Mr. Phillips 

has difficulty walking and reading his 

medication labels. This raises a question 

as to whether he can operate vehicle 

foot pedals properly or see well enough 

to drive safely. His physical limitations 

would not preclude driving, but may 

be indicators that more assessment 

is indicated. 

Be alert to conditions in the 

patient’s medical history, 

examine the current list of 

medications, and perform 

a comprehensive review 

of systems. 

When you take the patient’s history, be 

alert to “red flags,”45 that is, 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. Evans, as described in Chapter 1, 

presents with lightheadedness associated 

with atrial fibrillation. This is a red flag, 

and he should be counseled to cease 

driving until control of heart rate and 

symptoms that impair his level of consciousness have resolved. Similarly, Mr. 

Bales’ acute myocardial infarction is a 

red flag. Prior to discharge from the 

hospital, his physician should counsel 

him about driving according to the 

recommendations in Chapter 9 (see 

Figure 2.1). 

Mr. Phillips does not have any acute 

complaints, but his medical history 

identifies several conditions that place 

him at potential risk for unsafe driving. 

His macular degeneration may prevent 

him from seeing well enough to drive 

safely. His osteoarthritis may make it 

difficult to operate vehicle controls or it 

may restrict his neck range of motion, 

thereby diminishing visual scanning 

in traffic. Questions in regard to his 

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

Driving: A Review of the Literature (1960­

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

DC: National Highway Traffic Safety Administration. Accessed October 11, 2007. 

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

Medical_Condition_Driving/pages/TRD.html. 

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

 

 

 

 

 

 

 

 

 

 

diabetes include: Does he have any 

end-organ damage such as sensory neuropathies, chronic cognitive decline, or 

fluctuations from stroke that may affect 

his ability to operate a motor vehicle? 

Could any of his medications impair 

driving performance? 

Most older adults have at least one 

chronic medical condition and many 

have multiple conditions. The most 

common medical conditions in older 

adults include arthritis, hypertension, 

hearing impairments, heart disease, 

cataracts, dizziness, orthopedic impairments, and diabetes.46 Some of these 

conditions have been associated with 

driving impairment and will be discussed in more detail in subsequent 

chapters. Additionally, keep in mind 

that many prescription and nonprescription medications have the potential to impair driving skills, either 

by themselves or in combination with 

other drugs. (See Chapter 9 for a more 

in-depth discussion on medications and 

driving.) Older patients generally take 

more medications than their younger 

counterparts and are more susceptible 

to their central nervous system effects. 

Whenever you prescribe one of these 

medications or change its dosage, counsel your patient on its potential to affect 

driving safety. You may also recommend 

that your patient undergo formal 

assessment of function (see Chapter 3) 

while he/she is taking a new medication 

that may cause sedation. Concern may 

be heightened if there are documented 

difficulties in attention or visuospatial 

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

B test [see Chapters 3 and 4]). 

The review of systems can reveal 

symptoms that may interfere with the 

patient’s driving ability. For example, 

loss of consciousness, confusion, falling 

sleep while driving, feelings of faintness, 

memory loss, visual impairment, and 

muscle weakness all have the potential 

to endanger the driver. 

46. Health United States: 2002; Current Population 

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

At times, patients themselves or family 

members may raise concerns. If the family of your patient asks, “Is he or she safe 

to drive?” (or if the patient expresses 

concern), identify the reason for the 

concern. Has the patient had any recent 

crashes or near-crashes, or is he/she losing confidence due to declining 

functional abilities? Inquiring about 

specific driving behaviors may be more 

useful than asking global questions 

about safety. A list of specific driving 

behaviors that could indicate concerns 

for safety is listed in the Hartford guide, 

“At the Crossroads.”47 Physicians can 

request family members or spouses to 

monitor and observe skills in traffic 

with full disclosure and permission from 

the patient. Another tactic might be 

identifying a family member who refuses 

to allow other family members such 

as the grandchildren to ride with the 

patient due to traffic safety concerns. 

Please note that age alone is not a red 

flag! Unfortunately, the media often 

emphasize age when an older driver is 

involved in an injurious crash. This 

“ageism” is a well-known phenomenon 

in our society.48 While many people 

experience a decline in vision, cognition, 

or motor skills as they get older, people 

age at different rates and experience 

functional changes to different degrees. 

The focus should be on functional abilities and medical fitness-to-drive and 

not on age per se. 

Inquire about driving during 

the social history/health risk 

assessment. 

If a patient’s presentation and/or the 

presence of red flags lead you to suspect 

that he/she is potentially at risk for 

unsafe driving, the next step is to ask 

whether he/she drives. You can do this 

by incorporating the following questions into the social history or health 

risk assessment (see Figure 2.2): 

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

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

Accessed December 12, 2007. 

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

Prejudice Against Older Persons. Cambridge, 

MA: MIT Press. 

Figure 2.1 

Counseling the driver in the 

inpatient setting 

When caring for patients in the inpatient 

setting, it can be all too easy for physicians to forget about driving. In a survey 

of 290 stroke survivors who were interviewed 3 months to 6 years post-stroke, 

fewer than 35% reported receiving advice 

about driving from their physicians, and 

only 13% reported receiving any type of 

driving evaluation. While it is possible that 

many of these patients suffered such extensive deficits that both the patient and 

physician assumed that it was unlikely for 

the patient to drive again, patients should 

still receive driving recommendations from 

their physician. 

Counseling for inpatients may include 

recommendations for permanent driving 

cessation, temporary driving cessation, 

or driving assessment and rehabilitation when the patient’s condition has 

stabilized. Such recommendations are 

intended to promote the patient’s safety 

and, if possible, help the patient regain 

his/her driving abilities. 

Figure 2.2 

Health risk assessment 

A health risk assessment is a series of 

questions intended to identify potential 

health and safety hazards in the patient’s 

behaviors, lifestyle, and living environment. 

A health risk assessment may include 

questions about, but not limited to: 

•	 Physical activity and diet; 

•	Use of seat belts; 

•	 Presence of smoke detectors and fire 

extinguishers in the home; 

•	 Presence of firearms in the home; and 

•	 Episodes of physical or emotional 

abuse. 

The health risk assessment is tailored to 

the individual patient or patient population. 

For example, a pediatrician may ask the 

patient’s parents about car seats, while a 

physician who practices in a warm-climate 

area may ask about the use of hats and 

sunscreen. Similarly, a physician who sees 

older patients may choose to ask about 

falls, injuries, and driving. 

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

 

 

 

 

 

 

 

 

 

• “How did you get here today?” or 

“Do you drive?”; and 

• “Are you having any problems while 

operating a motor vehicle?”; 

• “Have others expressed concern 

about your driving?”; and 

• “What would you do if you had to 

stop driving?” 

If your patient drives, then his/her driving safety should be addressed. For acute 

illness, this generally involves counseling the patient. For example, Mr. Bales 

should be counseled to temporarily 

cease driving for a certain period of 

time after his acute myocardial infarction (see Chapter 9). If Mr. Phillips is 

started on a new medication, he should 

be counseled about the side effects and 

their potential to impair driving performance, if appropriate. 

For chronic conditions, on the other 

hand, driving safety is addressed by 

formally assessing the functions that are 

important for driving. This assessment 

will be discussed further in the 

next chapter. 

Please note that some chronic medical 

conditions may have both chronic and 

acute effects. For example, a patient 

with insulin-dependent diabetes may 

experience acute episodes of hypoglycemia, in addition to having chronic 

complications such as diabetic retinopathy and/or peripheral neuropathy. 

In this case, the physician should 

counsel the patient to avoid driving 

until acute episodes of hypoglycemia 

are under control and to keep candy 

or glucose tablets within reach in the 

car at all times. The physician should 

also recommend formal assessment of 

function if the patient shows any signs 

of chronic functional decline. (See 

Chapter 9 for the full recommendation 

on diabetes and driving.) 

If your patient does not drive, you may 

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

so, what the reason was for stopping. If 

your patient voluntarily stopped driving 

due to medical reasons that are potentially treatable, you may be able to 

help her or him return to safe driving. 

In this case, formal assessment of 

function can be performed to identify 

specific areas of concern and serve as 

a baseline to monitor the patient’s 

improvement with treatment. Referral 

to a driver rehabilitation specialist in 

these cases is strongly encouraged (see 

Chapter 5). 

Gather additional information. 

To gain a better sense of your patient as 

a driver, ask questions specific to driving. 

The answers can help you determine the 

level of intervention needed. 

If a collateral source such as a family 

member is available at the appointment 

or bedside, consider addressing your 

questions to both the patient and the 

collateral source with the patient’s 

permission. If this individual has had 

the opportunity to observe the patient’s 

driving, his/her feedback may be 

valuable. 

Questions to ask the patient and/or 

family member: 

• “How much do you drive?” (or 

“How much does [patient] drive?”) 

• “Do you have any problems when you 

drive?” (Ask specifically about day 

and night vision, ease of operating 

the steering wheel and foot pedals, 

confusion, and delayed reaction to 

traffic signs and situations.) 

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

• “Do you ever get lost while driving?” 

• “Have you received any traffic violations or warnings in the past two years?” 

• “Have you had any near-crashes or 

crashes in the past two years?” 

Understand your patient’s 

mobility needs. 

At this time you can also ask about your 

patient’s mobility needs and encourage 

him/her to begin exploring alternative 

transportation options before it becomes imperative to stop driving. even 

if alternative transportation options 

are not needed at this point, it is wise 

for the patient to plan ahead in case it 

ever becomes necessary. 

Some questions you can use to initiate 

this conversation include: 

• “How do you usually get around?” 

• “If your car ever broke down, how 

would you get around? Is there anyone who can give you a ride? Can you 

use a public train or bus? Does your 

community offer a shuttle service or 

volunteer driver service?” 

Encourage your patients to plan a safety 

net of transportation options. You might 

want to say, “Mobility is very important for your physical and emotional 

health. If you were ever unable to drive 

for any reason, I’d want to be certain 

that you could still make it to your appointments, pick up your medications, 

go grocery shopping, and visit your 

friends.” 

Sources for educational materials are 

listed in Appendix B like the Hartford insurance company’s “We need to 

talk,” AARP materials, or University 

of Michigan Transportation Research 

Institute’s materials49, which could be 

invaluable in planning for maintaining 

out-of-home activities.50 In the event 

that your patient must cease driving, 

the transition from driver to non-driver 

status will be less traumatic if he/she has 

already created a transportation plan. 

In addition the handout in Appendix B, 

Getting By Without Driving, can help 

your patient get started. 

49.	 University of Michigan Transportation 

Research Institute. UMTRI Library; 2007. 

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


Accessed November 21, 2007.
 

50.	 The Hartford. Family Conversations With 

Older Drivers. Hartford, CT. www.thehartford. 

com/talkwitholderdrivers/. Accessed October 11, 

2007. 

chapter 2—Is the Patient at Increased Risk for Unsafe Driving? 13 
Red Flags for Further Assessment
 

Acute events 

Prior to hospital or emergency department discharge, patients 

and appropriate caregivers should be counseled as needed 

regarding temporary driving cessation: 

• Acute myocardial infarction; 

• Acute stroke and other traumatic brain injury; 

• Arrhythmia; 

• Lightheadedness and pre-syncope; 

• Syncope and vertigo; 

• Seizure; 

• Surgery; 

• Delirium from any cause; and 

• New sedating medications. 

Patient’s or family member’s concern 

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

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

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

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

driving fitness—function, not age, is the determining factor. 

Ask for specific causes of concern, such as recent crashes, 

near-misses, traffic tickets, becoming lost, poor night vision, 

forgetfulness, and confusion. Evaluate for function using the 

Assessment of Driver Related Skills (ADReS) battery (Chapters 3 and 4). 

Medical history: Chronic medical conditions 

Patients may require formal assessment to determine the 

impact of these conditions on their level of function: 

•	Diseases affecting vision, including cataracts, diabetic retinopathy, macular degeneration, glaucoma, retinitis pigmentosa, field cuts, and low visual acuity even after correction; 

•	Cardiovascular disease, especially when associated with presyncope, syncope or cognitive deficits, including unstable 

coronary syndrome, arrhythmias, palpitations, congestive 

heart failure, hypertrophic obstructive cardiomyopathy, and 

valvular disease; 

•	Neurologic disease, including dementia, multiple sclerosis, 

Parkinson’s disease, peripheral neuropathy, brain injury, 

spinal cord injury, and residual deficits from stroke; 

•	Psychiatric disease, including mood disorders, depression, 

anxiety disorders, psychotic illness, personality disorders, 

and alcohol or other substance abuse; 

•	Metabolic disease, including type 1 and type 2 diabetes mellitus especially with hypoglycemic attacks or severe swings 

in blood sugars, and hypothyroidism; 

•	Musculoskeletal disabilities, including arthritis and foot 

abnormalities; 

•	Chronic renal failure; 

•	Respiratory disease, including chronic obstructive pulmonary 

disease and obstructive sleep apnea; and 

•	Cancer and chemotherapy. 

14 chapter 2—Is the Patient at Increased Risk for Unsafe Driving? 
Medical history: Medical conditions with 

unpredictable/episodic events 

The patient should be counseled not to drive during any of 

the following acute events until they have discussed this issue 

with their physician: 

• Pre-syncope or syncope; 

•

•

•

•

•

•

•

Angina; 

Seizure; 

Transient ischemic attacks; 

Hypoglycemic attacks; 

Vertigo; 

Alcoholism and hospitalization for detoxification; or 

Sleep attacks or cataplexy. 

Medications 

Many nonprescription and prescription medications have the 

potential to impair driving ability, either by themselves or 

in combination with other drugs. Combinations of drugs may 

affect drug metabolism and excretion, and dosages may need 

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

each medication class.) Medications with strong potential to 

affect the patient’s driving ability include: 

• Anticholinergics; 

• Anticonvulsants; 

• Antidepressants; 

• Antiemetics; 

• Antihistamines; 

• Antihypertensives; 

• Antiparkinsonians; 

• Antipsychotics; 

• Benzodiazepenes and other sedatives/anxiolytics; 

• Muscle relaxants; 

• Narcotic analgesics; and 

• Stimulants. 

Review of systems 

The review of systems can reveal symptoms or conditions 

that may impair driving performance. In addition to further 

work-up, driving safety should be addressed. 

•	general: fatigue, weakness; 

•	head ears eyes nose throat (heent): headache, head 

trauma, double vision, visual changes, vertigo; 

•	respiratory: shortness of breath, use of oxygen; 

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

sudden loss of consciousness; 

•	Musculoskeletal: muscle weakness, muscle pain, joint 

stiffness or pain, decreased range of motion; 

•	neurologic: loss of consciousness, feelings of faintness, 

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

numbness, tingling; and 

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

psychosis, mania. 

Assessment and plan 

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

medical conditions, remember to address driving safety as 

needed. You may need to counsel your patients about driving 

when you: 

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

current medication; and 

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

unstable medical condition. This includes many of the 

medical conditions listed above. 

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

Dobbs, B. M. (2005) Medical Conditions and Driving: A Charlton, J., Koppel, S., O’Hare, M., Andrea, D., Smith, G., 

Review of the Literature (1960-2000). Report # DOT HS Khodr, B., Langford, J., Odell, M., & Fildes, B. (2004) Influ809 690. Washington, DC: National Highway Traffic Safety ence of chronic illness on crash involvement of motor vehicle 

Administration. www.nhtsa.dot.gov/people/injury/research/ drivers, Monash University Accident Research Centre, ReMedical_Condition_Driving/pages/TRD.html. port No. 213. www.monash.edu/muarc/reports/muarc213.html 

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

chapter 3
 

Assessing Functional 

Ability 

 

 

 

chapter 3 

Assessing Functional 


Ability
 

Mr. Phillips, whom you met in 

Chapter 2, has been accompanied 

to the clinic by his son, who is in 

the examination room with him. 

Mr. Phillips tells you that he is a 

safe driver. You request and obtain 

permission to interview the son who 

voices his concern. Four months ago, 

Mr. Phillips was involved in a minor 

car crash, in which he was found to 

be at fault. He has also had several 

near-crashes in the past two years. 

However, he has never gotten lost 

while driving. 

In discussing Mr. Phillips’ 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 around? Besides, I don’t want 

to impose on my family or friends.” 

As revealed in the PPODS algorithm 

(Figure 1.1), the next step to managing 

Mr. Phillips’ driving safety is a formal 

assessment of the key functional abilities 

related to driving. Specific information 

in Mr. Phillips’ driving history—namely, 

the crash, moving violations, or near 

crashes—in addition to his medical 

conditions, further support the need for 

an assessment. 

In this chapter, we discuss the functions 

related to driving and present a brief 

office test battery, the Assessment of 

Driving Related Skills (ADReS). Each 

test in ADReS assesses a key area of 

function. Although not all functional 

domains that are necessary or relevant 

to driving are tested by the ADReS 

battery, many key areas are and have 

been validated with driving outcomes. 

How do you broach the issue 

of a driving assessment to 

your patient? 

Your patient may feel defensive about 

being assessed and may even refuse 

assessment for fear of being told that 

he/she can no longer drive. After all, 

driving is not only the primary form 

of transportation for most Americans, 

it also represents freedom and 

independence. 

In suggesting assessment to your patient, 

it is best to use a direct but nonconfrontational approach. Reassure your patient 

that you have his/her safety in mind 

and emphasize that you would like to 

assist him/her to drive safely for as long 

as possible. If your patient expresses 

fear that you will “take away my driver’s 

license,” you may find it helpful to offer 

reassurance that physicians do not have 

that type of legal authority. Explain that 

you may advise evaluation of driving if 

needed and/or refer him/her to a driver 

rehabilitation specialist or the Department of Motor Vehicles (DMV). 

here is an example of how you could 

suggest an evaluation to Mr. phillips: 

“Mr. Phillips, I’m concerned about your 

safety when you drive. Your son tells me 

that you were in a car crash recently and 

that you’ve had several near crashes in the 

past two years. Even though your medical 

conditions are well managed, they can still 

cause problems that can affect your driving 

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

me, such as walking down the hall while I 

time you. These tests will help me decide 

if there are areas we need to work on to 

improve your driving safety. 

“This is how it works: Based on what I 

know about your health and how you do on 

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

potential treatable or reversible conditions. 

For example, if you’re not seeing as well 

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

to improve your vision. If there’s something 

we can’t improve, then we can consult a 

driver rehabilitation specialist. This type 

of instructor, typically an occupational 

therapist, will go out on the road with you 

to watch you drive, then recommend ways 

to make your driving safer. The goal is to 

keep you on the road for as long as you are 

safe to drive.” 

19 
 

 

 

What do you do if your patient 

refuses assessment? 

Despite your best efforts, your patient 

may refuse to have his/her functional 

abilities that are key to driving assessed. 

If this occurs, you have several options: 

• Encourage your patient to complete 

the self-screening tool (Am I a Safe 

Driver?) found in Appendix B. This 

may help raise your patient’s level of 

awareness and make him/her more 

open to ADReS. 

• Counsel your patient on the Successful Aging Tips and Tips for Safe 

Driving, both found in Appendix B. 

These may raise your patient’s level 

of awareness and encourage safe 

driving habits. 

• Suggest enrolling in a driving course 

designed to improve traffic safety, 

such as the Traffic Safety Course 

offered by AARP51 or those offered 

by the AAA.52 Roadwise Review is 

a CD available from the AAA that 

assesses important functional abilities for driving and provides feedback 

to older adults on the presence of 

impairment.53 Roadwise Review does 

require the older adult to have a 

computer and an assistant during the 

playing of the CD. Give the patient a 

copy of the Driving Decisions Workbook. Developed by the University 

of Michigan Transportation Research 

Institute, this is a paper-and-pencil 

workbook that provides users with 

individualized feedback based on how 

they answer questions. Research has 

shown that workbook scores are positively correlated with on-road driving 

scores and several clinical tests of 

functional ability. The workbook can 

be downloaded free of charge at: 

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

2027.42/1321/2/94135.0001.001.pdf. 

51.	 AARP Traffic Safety Course. www.aarp.org/ 

families/driver_safety/driver_safety_online_course. 

html. Accessed October 14, 2007. 

52.	 AAA Foundation for Traffic Safety Senior 

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

index.cfm. Accessed October 14, 2007. 

53.	 AAA Exchange. Checking Your Driving Abilities. www.aaapublicaffairs.com/Main/Default.as 

p?SectionID=&SubCategoryID=38&CategoryID 

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

2007. 

• Suggest that the patient take the 

SAFER Driving survey. Also developed at the University of Michigan 

Transportation Research Institute, 

this is a Web-based tool (available at 

um-saferdriving.org) that requires users 

to answer questions about the severity 

of health concerns they are experiencing due to medical conditions 

and medications. The Web site then 

calculates the effects of these health 

concerns on critical driving skills and 

gives users individualized feedback on 

how their driving may be declining; 

what to do to continue driving safely 

given these declines; and, if appropriate, 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.54 

• In the patient’s chart, document your 

concern regarding his/her driving 

ability, and support this with relevant 

information from the patient’s presentation, medical history, medications, 

and reported driving history. Document the patient’s refusal for further 

assessment, along with any counseling 

you have provided. (Current Procedural Terminology [CPT®] codes for 

counseling can be found in Appendix 

A.) Not only will this remind you 

to follow-up at the next visit, but 

it could potentially protect you in 

the event of a lawsuit. (A detailed 

medicolegal discussion can be found 

in Chapter 7.) In cases where the risk 

is very high and the patient drives 

despite your recommendations, you 

might consider referral of the patient 

to the DMV for further testing. 

54.	 Eby, D. W., Molnar, L. J., Shope, J.T., & Dellinger, A.M. Development and pilot testing of 

an assessment battery for older drivers. J Safety 

Res 38: 535-43. 

• Follow-up at the patient’s next appointment: Would he/she be willing 

to complete the self-screening? Has 

the patient put any of the tips into 

practice? Does the patient have any 

questions or concerns? Would he/she 

be willing to undergo ADReS? 

• If family members are concerned 

about the patient’s driving safety, 

you can give them a copy of How 

to Assist the Older Driver, found in 

Appendix B. Especially if the patient 

has dementia, he/she will probably 

lack insight and it will likely not 

be fruitful to belabor the point. It is 

important here to enlist family members and obtain their aid in creating 

a transportation plan for the patient 

and encouraging the patient to be 

evaluated by ADReS. 

• If you are urgently concerned about 

your patient’s driving safety, you may 

wish to forego ADReS and refer your 

patient directly to a driver rehabilitation specialist (see Chapter 5) or to 

your State DMV for a focused driving assessment. Depending on your 

State’s reporting laws, you may be 

legally responsible for reporting 

“unsafe” drivers to the DMV. (A 

detailed discussion of the physician’s 

legal responsibilities can be found in 

Chapter 7. A reference list of reporting laws is provided in Chapter 8.) 

In any case, the patient should be 

referred with his/her knowledge. 

At this point, the patient and/or 

family might relent and be willing 

to consider an evaluation from a 

driving rehabilitation specialist. 

Assessment of Driving-Related 

Skills (ADReS) 

The three key functions for safe driving 

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

motor/somatosensory function. ADReS 

assesses some aspects of these three 

important functions to help you identify 

specific areas of concern. 

Please note that ADReS does not predict crash risk! While many researchers 

are working to create an easy-to-use 

test battery that predicts crash risk, 

further research is needed. However, 

20 chapter 3—Assessing Functional Ability 
 

 

 

 

 

 

 

 

 

until physicians are able to test their 

patients directly for crash risk, they can 

test them indirectly by assessing the functions that are necessary for safe driving. 

Any impairment in these functions has 

the potential to increase the patient’s 

risk for crash. Once they are identified, 

the physician is in a good position to 

determine if the patient requires referral 

to a specific subspecialist (e.g., ophthalmologist). Although cut-off scores are 

provided for these tests (see Chapter 4), 

the ADReS battery is a tool for identifying areas of concern that require additional evaluation. The physician should 

use his/her clinical judgment regardless 

of the scores by utilizing all available 

information (driving history, medical 

history, and functional assessment). In 

addition, not all important functions 

are tested on the ADReS battery; rather 

specific items were chosen for their 

applicability and feasibility in the office 

setting, along with their correlates with 

impaired driving outcomes. 

The tests in ADReS were selected by a 

consensus panel of driving safety experts 

who worked with the AMA, and were 

chosen from among the many available 

functional tests based on their ease of 

use, availability, amount of time required 

for completion, and quality of information provided by the patient’s test performance. The individual tests in ADReS 

have been validated as measures of their 

particular function and in some cases 

have been studied with relation to driving. Although we are still awaiting more 

evidenced-based medical studies to link 

these tests with crash risk, these screens 

can detect new-onset visual, cognitive, 

or motor problems that may be amenable 

to an intervention. 

The tests are presented below by 

function, following a discussion of the 

function and how it relates to driving. 

An accompanying score sheet on pages 

28–29 can be photocopied and placed 

in the patient’s chart. On the score 

sheet, the tests are presented in the 

recommended order of execution. CPT® 

codes for components of ADReS are 

provided in Appendix A, and the score 

sheet can serve as documentation for 

these codes. 

To perform ADReS, you will need a 

Snellen chart, tape to mark distances 

on the floor, a stopwatch, and a pencil. 

There are two paper-and-pencil tests in 

ADReS, one of which requires a preprinted form. This is included on pages 

28–29 and may be photocopied. 

Vision 

Vision is the primary sense utilized in 

driving in comparison to other modalities like hearing and proprioception, 

and it is responsible for the majority 

of driving-related sensory input.55 

In most States, candidates are required 

to undergo vision testing to obtain 

a driver’s license. Several States (see 

Chapter 8) also require vision testing 

at the time of license renewal. 

Aspects of vision that are important for 

safe driving and can be readily assessed 

by a physician include: 

• Visual acuity, and 

• Visual fields. 

Numerous studies show that visual 

acuity declines between early and late 

adulthood, although no consensus exists 

on the rate of decline or decade of 

onset. Decline in acuity is related to 

physiologic changes of the eye that 

occur with age and the increased 

incidence of diseases such as cataracts, 

glaucoma, and macular degeneration.56 

While far visual acuity is crucial to 

many driving-related tasks, declines 

in near visual acuity may be associated with difficulty seeing or reading 

maps, or gauges and controls inside the 

vehicle. In ADReS, far visual acuity is 

measured with a Snellen chart. 

Visual fields may decline as a result of 

the natural aging process and medical 

conditions such as glaucoma, retinitis 

pigmentosa, and stroke. In addition, 

upper visual fields may be obstructed by 

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

requirements for safety and mobility of older 

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

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

physical and cognitive impairment. Geriatrics. 

1993;48(5):46-51. 

ptosis, which is more common in the 

older population. Drivers with loss of 

peripheral vision (e.g., glaucoma) may 

have trouble noticing traffic signs or 

cars and pedestrians that are about to 

cross their path. Although earlier studies examining the relationship between 

visual field loss and driving performance 

were equivocal, more recent studies 

have found significant relationships.57 

In ADReS, visual fields are measured 

through confrontation testing. 

Aspects of vision that are important for 

safe driving58 but are not included in 

ADReS are: 

•	contrast sensitivity: Older adults 

require about three times more contrast than young adults to distinguish 

targets against their background. This 

deficit in contrast sensitivity is further 

exacerbated by low light levels. Thus, 

older drivers may have problems 

distinguishing cars or pedestrians 

against background scenery, and this 

may be much worse at night or during 

storms.59 While contrast sensitivity 

has been found to be a valid predictor 

of crash risk among older drivers,60 

most vision care specialists are not 

familiar with measures of contrast 

sensitivity, nor is it routinely measured in eye examinations. Further 

research must be performed to produce 

standardized, validated cut-off points 

for contrast sensitivity, and further 

work must be done to introduce 

this concept to professionals in 


eye care centers.
 

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

Driving: Current Knowledge. Association for 

the Advancement of Automotive Medicine/ 

National Highway Traffic Safety Administration, p. 24 Project DTNH22-94-G-05297. 

Washington, DC: National Highway Traffic 

Safety Administration 

58.	 Walgreens. https://webapp.walgreens.com/cePharmacy/programsHTML/transportation-tech.pdf. 

Accessed October 14, 2007. 

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

function in the older driver. Clin Geriatr Med. 

1993;9(2):389–401. 

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

Current Knowledge. Association for the Advancement of Automotive Medicine/ National 

Highway Traffic Safety Administration, Project 

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

National Highway Traffic Safety Administration. 2001: p. 15–16. 

chapter 3—Assessing Functional Ability 21 
Assessment of Driving-Related Skills (ADReS) 

Snellen E chart 

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

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

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

printed on the reverse. 

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

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

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

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

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

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

sinister). 

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

mark a distance of 20 feet. 

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

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

meters (20 feet).1 

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

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

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

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

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

include—but are not limited to—the different number of letters per line, different spacing between lines, the specific use of letters, and the spacing between 

letters.2

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

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

diseases appears to be more accurate.3 The ETDRS chart improves on the Snellen 

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

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

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

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

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

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

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

Administration. 

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

October 14, 2007. 

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

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

Ophthalmology. 10:319–23. 

•	accommodation and adaptation: 

Accommodation is the change in 

the shape of the lens that assists with 

bringing objects into focus. This is 

an important skill for reading the 

instrument panel in a car or viewing 

objects in the mirror. Adaptation is 

the ability to perceive objects when 

levels of illumination are changing, as 

might occur during nighttime driving 

or in parking garages. Older adults 

require more time than young adults 

to adjust to abrupt changes in light 

or darkness. As a result, older drivers 

often report difficulties dealing with 

the sudden onset of bright lights, such 

as the headlights of an oncoming car. 

Glare may also play a role in their 

visual difficulties.61 

•	angular movement, dynamic visual 

acuity, and depth perception. Older 

adults must be able to detect objects 

in motion such as judging the speed 

of cars coming across their path during left hand turns. This ties in with 

the concept of dynamic visual acuity, 

which may also require the detection 

of letters or images (such as reading 

traffic signs) while in motion. Depth 

perception is important for near objects, but apparently becomes less of 

an issue at further distances. A more 

pertinent task is the ability to detect 

changes in visual image size, such 

as judging the speed of approaching 

vehicles. 

•	color. Many reviews on visual 

abilities that are necessary for driving 

tend to downplay the importance of 

color detection, based on the current 

level of evidence. Traffic lights in the 

United States typically have mixed 

colors embedded in the lights to 

compensate for the small percentage 

of the population that is red-green 

color blind. However, the ability 

to recognize traffic signs, which are 

given specific colors based on a specific regulatory area, is important. In 

addition, vehicle color may enhance 

or diminish detection under certain 

traffic conditions (e.g., a white car in 

snowy weather, or a grey car in rainy 

or foggy conditions). 

61.	 Owsley, C., & Ball, K. Assessing visual function in the older driver. Clin Geriatr Med. 

1993;9(2):389–401. 

22 chapter 3—Assessing Functional Ability 
 

 

 

 

 

 

Cognition 

Driving is a complex activity that 

requires a variety of high-level cognitive 

skills. Among the cognitive skills that 

are useful for driving62 are: 

• Memory—short-term, long-term, 

and working memory; 

• Visual perception, visual processing, 

visual search, and visuospatial skills; 

• Selective and divided attention; 

• Executive skills (sequencing, planning, judgment, decision making); 

• Language; and 

• Vigilance. 

Both crystallized memory and working 

memory are necessary for driving. Not 

only must drivers remember how to 

operate their vehicle and what signs and 

signals mean, they must also remember 

their current destination and how to 

get there.63 In addition, drivers must be 

able to retain certain information while 

simultaneously processing other information—a skill called working memory. 

Working memory (and the other cognitive skills to which it contributes) tends 

to decline with age, while crystallized 

memory remains relatively intact across 

the life span. It is unclear at present 

whether age-related memory impairments reflect only preclinical forms of 

age-related diseases or whether these 

occur independent of disease processes.64 

Visual perception, visual processing, 

and visuospatial skills are necessary for 

the driver to organize visual stimuli into 

recognizable forms and know where 

they exist in space. Without these skills, 

the driver would be unable to recognize 

a stop sign and determine its distance 

from the car. In general, visual process62.	 Walgreens. https://webapp.walgreens.com/ 

cePharmacy/programsHTML/transportation-tech. 

pdf. Accessed October 14, 2007. 

63.	 Colsher, P. L., & Wallace R. B. Geriatric assessment and driver functioning. Clin Geriatr Med. 

1993;9(2):365–375. 

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

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

Company. 

ADReS (continued) 

Visual fields by confrontation testing 

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

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

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

The examiner then holds up a hand in each visual field simultaneously with a 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/she has a visual 

field defect. 

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

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

of defect on a visual field representation. 

Trail-making test, part B 

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

visual processing, visuospatial skills, selective and divided attention, and psychomotor coordination. In addition, numerous studies have demonstrated an association between poor performance on the Trail-Making Test, Part B, and poor driving 

performance.1 (See Chapter 4 for further discussion.) 

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

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

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

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

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

3 to 4 minutes to administer. 

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

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

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

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

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

Go.” The examiner records time-to-complete.2 

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

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

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

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

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

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

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

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

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

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

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

of the ADReS battery. 

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

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

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

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

Administration. 

chapter 3—Assessing Functional Ability 23 
 

 

 

 

 

ADReS (continued) 

Clock drawing test 

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

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

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

skills. Preliminary research indicates an association between specific scoring 

elements of the clock drawing test and poor driving performance.1 

(See Chapter 4 for a further discussion.) 

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

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

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

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

amount of time to complete the drawing. The examiner scores the test by examining the drawing for each of seven specific elements found on the ADReS score 

sheet (see page 28 for score sheet).2 

Rapid pace walk 

This is a measure of lower limb strength, endurance, range of motion, and balance. A 10-foot path is marked on the floor with tape. The subject is asked to 

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

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

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

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

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

total number of seconds it takes for the patient to walk 10 feet and back.3 

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

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

increased risk of at-fault motor vehicle tasks.4 

1.	­ Freund, B., Gravenstein, S., & Ferris, R. 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; and Personal correspondence with B. Freund dated September 16, 17 and 19, 2002. 

2.	 Ibid. 

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

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

Administration. 

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

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

ing may slow65 and complex visuospatial 

skills may decline with age, while visual 

perception remains stable.66 

During driving, many demands are 

made on attention. In particular, drivers 

must possess selective attention—the 

ability to prioritize stimuli and focus 

on only the most important—in order 

to attend to urgent stimuli (such as 

traffic signs) while not being distracted 

by irrelevant ones (such as roadside 

ads). In addition, drivers must possess 

divided attention in order to focus on 

the multiple stimuli required by most 

driving tasks. Attentional functioning 

may decline with age,67 with divided 

attention showing more pronounced 

changes than selective attention.68 

The most widely studied instrument 

for detection of impairment in divided 

attention and selective attention that 

has been correlated with crash risk in 

older adult drivers has been the Useful 

Field of View (UFOV).69 This test is 

available for purchase and information is 

available on the Visual Awareness Web 

site.70 Cost, time, and ability to bill, 

as well as limited studies in a primary 

care setting, might be potential barriers 

to utilization in a physician’s office. 

Another computerized set of tests that 

assesses key functional abilities for driving is the Driving Health© Inventory 

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

function in the older driver. Clin Geriatr Med. 

1993;9(2):389–401. 

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

Merck Manual of Geriatrics. Section 4, Chapter 

32: Aging and mental health. Whitehouse 

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

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

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

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

Erlbaum. 

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

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

E. (1997). Selective and divided visual attention: age-related changes in regional cerebral 

blood flow measured by H215O PET. Hum Brain 

Mapp. 5:389–409. 

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

(2006). Can high-risk older drivers be identified 

through performance-based measures in a 

Department of Motor Vehicles setting? J Am 

Geriatr Soc. 54:77–84. 

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

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

2007. 

24 chapter 3—Assessing Functional Ability 
 

 

 

 

 

(DHI).71 Similar to the ADReS battery, 

the program has not yet been validated 

in a large cohort of older adult drivers, 

but the subcomponents have been 

found to correlate with at-fault crash 

risk.72 Furthermore, the DHI did appear 

to discriminate drivers with a history of 

a crash from those without crashes in a 

small cohort of drivers. In addition, this 

battery of tests appears feasible and 

acceptable to older drivers as a screen 

for functional impairments.73 

Additional cognitive domains that have 

been linked with driving impairment 

include vigilance or sustained attention. 

Although many older drivers may make 

only short trips, some illnesses such as 

untreated obstructive sleep apnea cause 

persistent sleepiness or impaired attention. This risk would be present in this 

example regardless of the duration of 

the driving episode. In addition, many 

older adults travel long distances for 

vacations and to visit relatives, making 

the ability to sustain attention over 

time critical. 

Language skills are necessary to read 

traffic signs and are critical in knowing 

the speed limit, identifying construction zones, and comprehending other 

important informational cues along the 

roadway. Geographic orientation refers 

to the skill of finding unfamiliar routes 

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

or knowing the way to familiar places. 

This skill likely involves executive 

function, short- and long-term memory, 

and language abilities. Impairment in 

these cognitive domains have not been 

well studied in regard to driving outcomes, but could play a role in accident 

causation in selected groups of medically 

impaired drivers. 

71.	 DrivingHealth.com. DrivingHealth Inventory. 

www.drivinghealth.com/screening.htm, Accessed 

October 14, 2007. 

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

(2006). Can high-risk older drivers be identified 

through performance-based measures in a 

Department of Motor Vehicles setting? J Am 

Geriatr Soc. 54:77–84. 

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

et al. (2008). Acceptability and validity of 

older driver screening with the DrivingHealth, 

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

ADReS (continued) 

Manual test of range of motion 

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

requested motions bilaterally: 

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

do the same thing for the other side.” 

•	 Shoulder and elbow flexion: “Pretend you’re holding a steering wheel. Now 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 towards your body.” 

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

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

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

Manual test of motor strength 

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

patient’s limbs, and asking him/her to resist the examiner’s movements. The examiner should test bilateral: 

•	 Shoulder adduction, abduction and flexion; 

•	 Wrist flexion and extension; 

•	 Hand-grip strength; 

•	 Hip flexion and extension; and 

•	 Ankle dorsiflexion and plantar flexion.1
 

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


 Grade Definition

 5/5 

4/5 

Normal strength: movement against gravity with full resistance

Movement against gravity and some resistance

 3/5 Movement against gravity only

 2/5 Movement with gravity eliminated

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

 0/5 No contraction2 

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

be recorded as 5–

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

still less than 5/5 may be recorded as 4+/5. This applies to all other grades 

of strength as well. 

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

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

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

Company, Inc. 

chapter 3—Assessing Functional Ability 25 
 

 

 

Executive skills are required to analyze 

driving-related stimuli and formulate 

appropriate driving decisions. Executive 

skills allow a driver to appropriately 

make the decision to stop at a red light 

or at a green light if a pedestrian is in 

the path of the vehicle. The capacity 

for this kind of logical analysis tends to 

decline with age.74 

Dementia and some medications’ side 

effects in the older population may 

impact cognition. The fact that crashes 

involving older drivers commonly occur 

in complex situations in which task 

demand exceeds performance suggests 

that cognitive limitations may play a 

significant role in crash causation.75 

In the ADReS battery, cognition is 

measured through the Trail-Making 

Test, Part B, and the Clock Drawing 

Test using Freund Scoring Criteria. 

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

Merck Manual of Geriatrics. Section 4, Chapter 

32: Aging and mental health. Whitehouse 

Station, NJ: Merck & Co., Inc. 

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

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

of some cognitive functions are common in 

crash-involved older drivers. Accid Anal Prev. 

30(3):371–377. 

Motor and Somatosensory Function 

Driving is a physical activity that 

requires motor and somatosensory 

abilities such as: 

• Muscle strength and endurance; 

• Range of motion of the extremities, 

trunk, and neck; and 

• Proprioception.76 

Motor abilities are necessary for operating vehicle controls appropriately and 

consistently and turning to view traffic. 

Even before driving, motor abilities are 

needed to enter the car safely and fasten 

the seat belt. The natural process of 

aging may involve a decline in muscle 

strength, muscle endurance, flexibility, 

and joint stability. (Whether proprioception changes appreciably with age 

has not been solidly established.77) 

Furthermore, osteoarthritis and other 

musculoskeletal problems are common 

in the elderly. Patients who suffer pain 

and limitations from these conditions 

may not only experience direct effects on 

their driving ability, but also decrease 

their physical activity, causing further 

decline in motor function. 

Most of the difficulty in driving an 

automobile for patients with muscle 

or arthritic disorders involves difficulties with the use of seat belts and keys, 

adjusting seats and mirrors, using the 

pedals, steering, and transferring in and 

out of the car.78 Several efforts have 

been made to correlate functional abili76.	 Marottoli, R. A., & Drickamer M. A. (1993). 

Psychomotor mobility and the elderly driver. 

Clin Geriatr Med. 9(2):403–411. 

77.	 Ibid. 

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

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

361–364. 

ties, such as range of motion and muscle 

function, with driving. Driving impairment has been associated with the 

inability to reach above the shoulder.79 

Older adults with physical frailty may 

be at increased risk for a motor vehicle 

crash,80,81 and studies have indicated 

they appear to be more vulnerable to 

injury.82 Walking less than one block a 

day, impaired left knee flexion, and foot 

abnormalities have been associated with 

an adverse driving event.83 Another 

study revealed that more difficulty 

walking one-quarter mile in comparison 

to a control group was associated with 

increase crash risk.84 In ADReS, motor 

function is measured through the Rapid 

Pace Walk, Manual Test of Range of 

Motion, and Manual Test of Motor 

Strength measures. 

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

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

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

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

al. (2000). Exploratory study of incident vehicle 

crashes among older drivers. J Gerontol Series A 

Bio Sci Med Sci. 55: M22–27. 

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

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

and moving violations among elderly drivers. 

Ann Intern Med; 121:842–846. 

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

future trends in societal aging, air bag availability, seat belt use, and fleet composition will 

affect serious injury risk and occurrence in the 

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

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

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

and Moving Violations Among Elderly Drivers. 

Annals of Internal Medicine, 121, 842–846. 

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

(2001). Mobility Impairments in Crash 

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

26 chapter 3—Assessing Functional Ability 
ADReS score sheet 

When administering the ADReS 

battery, you may find it helpful to use 

the ADReS Score Sheet which can be 

found at the end of this chapter. This 

form may be photocopied, filled out, 

and placed in the patient’s chart. The 

ADReS Score Sheet presents the tests in 

the simplest order of administration and 

provides space for recording test results. 

We also recognize that these tests may 

not necessarily be performed by the 

physician but assigned to office staff 

such as the nurse or physician extender. 

CPT

® codes for components of the 

ADReS battery are provided in Appendix A, and the ADReS Score Sheet can 

serve as documentation for these codes. 

Although you may administer the tests 

in the order you prefer, we recommend 

the following sequence: 

• Visual Fields by Confrontation Testing; 

• Snellen E Chart—If your office has 

a long hallway, hang the chart at the 

end of the hallway and mark a 20-foot 

distance on the floor with tape. Have 

the patient stand at the tape. 

• Rapid Pace Walk—Mark a 10-foot 

distance on the floor. With the 

patient already standing at the 

20-foot mark, have him/her walk 

to the 10-foot mark, then back. 

• Manual Test of Range of Motion— 

This is performed when the patient 

has returned to the examination 

room. 

• Manual Test of Motor Strength; 

• Clock Drawing Test—Ask the patient 

to turn over the Trail Making Test 

sheet and draw a clock on the 

blank side. 

• Trail Making Test, Part B. 

A discussion of these tests’ efficacy, 

scoring, and recommended interventions based on performance is included 

in the next chapter. 

chapter 3—Assessing Functional Ability 27 
 

Assessing Driving Related Skills (ADReS) Score Sheet 

patient’s name:______________________________________________________ date: __________________________ 

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

Patient’s L	 R 

2.	 Visual acuity: _________OU __________ OS _________OU 

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

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

3.	 rapid pace walk:____________ seconds 

(>9 secs, abnormal and consider referral for driving evaluation and/or evaluation of gait disorder) Was this performed with 

a walker or cane? If yes, please specify: __________________________________________________________________ 

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

right Left 

Neck rotation 

Finger curl 

Shoulder and elbow flexion 

Ankle plantar flexion 

Ankle dorsiflexion 

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

clinic for vehicle modification) 

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

right Left 

Shoulder adduction 

Shoulder abduction 

Shoulder flexion 

Wrist flexion 

Wrist extension 

Hand grip 

Hip flexion 

Hip extension 

Ankle dorsiflexion 

Ankle plantar flexion 

Plan for any deficiencies: (consider referral to OT/PT or driving clinic for vehicle modification) 

28 chapter 3—Assessing Functional Ability 
 

 

ADReS Score Sheet (continued) 

patient’s name:______________________________________________________ date: __________________________ 

6. trail-Making test, part B:____ seconds 

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

cognitive/visual/motor impairment ) 

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

yes no 

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

The numbers are drawn inside the clock circle 

The numbers are spaced equally or nearly equally from each other 

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

One clock hand correctly points to 2 

There are only two clock hands 

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

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

motor impairment) 

Assessment/Plan: 

chapter 3—Assessing Functional Ability 29 
Trail-Making Test, Part B patient’s name:_________________________ date: __________________________ 

13

8 9 I

4 B

D

10

End 

3

1

5

C

H

12

G

7 Begin 

A J

F

2

L 6

E

11 K

30 
chapter 4 

Physician Interventions
 

 

 

chapter 4 

Physician Interventions
 

Despite your encouragement, Mr. 

Phillips (introduced in Chapter 2) 

hesitates to take the assessment 

of driver related skills (ADReS) 

battery because he says, “I don’t 

see the need for it.” You reiterate 

your concerns for his safety, and 

give him a copy of the am i a safe 

driver? self-assessment handout to 

take home. In addition, you counsel 

Mr. Phillips on the successful aging 

tips and tips for safe driving handouts. Mr. Phillips agrees to allow 

his son to observe his driving, and 

you give the son the how to assist 

the older driver handout (see Appendices). You document all of this 

in Mr. Phillips’ chart and schedule 

a follow-up visit. Alternatively, the 

Hartford guide “at the crossroads” 

has a driving behavior checklist that 

could be filled out by family members 

(p.11).85 Although not systematically studied, this type of objective 

evaluation could also be revealing. 

At Mr. Phillips’ next visit, you ask 

him if he has tried putting any of the 

tips for safe driving into practice. 

He admits that he had another close 

call, and his son states he observed 

several driving errors. These motivated Mr. Phillips to complete the 

self-assessment. He claims that the 

self-assessment was an eye-opening 

experience, and he is now willing to 

undergo ADReS. 

85.	 The Hartford. Alzheimers, Dementia & 

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

alzheimers/brochure.html. Accessed October 

24, 2007. 

On the ADReS battery, Mr. Phillips 

takes 11 seconds to perform the 

Rapid Pace Walk. His visual acuity is 20/50 OD and 20/70 OS. His 

motor strength is 4-/5 in both lower 

extremities, and 4/5 in both upper 

extremities. He has limited range 

of motion on neck rotation; ankle 

plantar flexion and dorsiflexion are 

within normal limits. It takes him 

182 seconds to complete the TrailMaking Test, Part B, and his clock 

drawing is scored as “normal” for 

all seven criteria. 

Now that Mr. Phillips has undergone 

ADReS, what does his performance 

indicate? In this chapter, we help you 

interpret your patient’s test performance 

by providing you with scoring cut-offs.86 

We have also provided examples of 

interventions to help you manage and 

treat any functional deficits that are 

identified through ADReS. Recently, the 

ADReS battery has been shown to have 

high levels of inter-rater reliability.87 

As you review the recommended interventions, remember that the goal of 

physician evaluation is to identify, correct, or stabilize any functional deficits 

that may impair the patient’s driving 

performance and refer to a driver rehabilitation specialist (DRS), if appropriate (for more details, see Chapter 5). 

86.	 Please be aware that the recommendations 

stated in this chapter are subject to your State’s 

reporting laws and DMV requirements. 

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

(2006). A pilot study of interrater reliability of 

the assessment of driving-related skills: Older 

Driver Screening Tool. Top Geriatr Rehab The 

Older Driver, Part 2. 22: 113–120. 

Visual acuity 

Although many States currently require 

far visual acuity of 20/40 for an unrestricted license, there is a paucity of 

evidence that links static visual acuity 

to crash risk. In fact, studies undertaken 

in some States have demonstrated that 

there is no increased crash risk between 

20/40 and 20/70, resulting in several 

new State requirements.88 However, 

some studies have found that those 

States that require visual testing during 

license renewal for older adults have 

lower crash rates.89, 90 

General recommendations on visual 

acuity and driving are stated below. 

Please note that these recommendations are subject to each State’s 

licensing requirements. 

For visual acuity greater than 

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

physician should: 

• Ensure that the underlying cause of 

vision loss is adequately treated, if 

treatment is possible. If the patient 

is not currently under the care of an 

ophthalmologist or optometrist, 

referral is recommended. 

• Recommend that the patient has and 

uses the appropriate glasses or contact 

lenses. Again, if the patient is not 

currently under the care of a specialist, referral is recommended. 

88.	 American Academy of Ophthalmology. Policy 

Statement: Vision Requirements for Driving. 

Approved by Board of Trustees, October 2001. 

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

and State license renewal policies to driving 

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

90.	 Shipp, M. D. (1998). Potential human economic cost-savings attributable to vision testing 

policies for driver license renewal, 1989–1991. 

Optom Vis Sci. 75:103–118. 

chapter 4—Physician Interventions 33 
 

 

 

• Recommend that the patient 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). 

• Be aware that the patient may require 

more frequent (e.g., yearly) assessment 

of visual acuity to detect further 

visual decline caused by chronic, 

progressive diseases. 

For visual acuity less than 

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

the physician should: 

• Follow the recommendations stated 

above, and 

• Recommend an on-road assessment 

performed by a DRS to evaluate the 

patient’s performance in the actual 

driving task, where permitted and 

available (see Chapter 5). 

For visual acuity less than 

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

the physician should: 

• Follow the recommendations stated 

above, and 

• Recommend that the patient not 

drive unless safe driving ability can be 

demonstrated in an on-road assessment performed by a DRS, where 

permitted and available. 

Visual fields 

Research shows that visual field loss 

can significantly affect driving safety. In 

examining 10,000 volunteer California 

license applicants, Johnson and Keltner 

found significant deterioration in visual 

fields among drivers over age 60. In 

addition, they found that drivers with 

binocular visual field loss had driving 

crash and conviction rates more than 

twice as high as age- and gendermatched drivers with normal fields.91 

Recently, studies focused on a more 

homogenous group of older adults with 

a specific disease (e.g., glaucoma) that 

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

Incidence of visual field loss in 20,000 eyes 

and its relationship to driving performance. 

Arch Ophthalmol. 101:371–375. 

is known to impair visual fields have 

found correlation with increased crash 

risk in patients with moderate to severe 

field defects.92, 93 

While it is known that an adequate 

visual field is important for safe driving, there is no conclusive evidence 

to define what is meant by “adequate.” 

Most likely, this varies widely from 

patient to patient and may depend on 

the presence of other co-morbidities. 

For example, a driver with a restricted 

visual field but excellent scanning 

ability may drive as safely as a driver 

with an unrestricted visual field but 

poor neck rotation.94 

General recommendations on visual 

field and driving are stated below. Physicians should be aware of their States’ 

specific visual field requirements, if any, 

and adhere to them. 

For visual field defects noted on 

clinical examination, the physician 

should: 

• Ensure that the underlying cause of 

visual field loss is adequately treated, 

if treatment is possible. If the patient 

is not currently under the care of an 

ophthalmologist or optometrist, 

referral is recommended. 

• Automated visual field testing may 

help define the extent of the defect, 

and ophthalmologists have a number 

of useful instruments for measuring 

visual fields. 

• For binocular visual field of questionable adequacy (as deemed by clinical 

judgment), an on-road assessment 

performed by a DRS is strongly recommended. Through driving rehabilitation, the patient may learn how to 

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

(2005). Driving performance of glaucoma 

patients correlates with peripheral visual field 

loss. J Glaucoma. 14:145–150. 

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

(2004). Is glaucoma associated with motor 

vehicle collision involvement and driving 

involvement and driving avoidance? Invest 

Ophthalmol Vis Sci. 45: 3934–3939. 

94.	 American Academy of Ophthalmology. Policy 

Statement: Vision Requirements for Driving. 

Approved by Board of Trustees, October 2001. 

compensate for decreased visual fields. 

In addition, the DRS may prescribe 

enlarged side- and rear-view mirrors 

as needed and train the patient in 

their use. 

• Be aware that the patient may require 

re-testing of visual fields in the future 

for visual field defects caused by 

chronic, progressive diseases. 

Cognition 

Although the following cognitive tests 

are scored separately, interventions are 

recommended if the patient reaches 

designated cut-off values (as described 

below) on either of them. 

Trail-Making Test, Part B 

A time for completion of greater than 

3 minutes (180 seconds) signals a need 

for intervention,95 such as a review of 

causes for the abnormal result (e.g., 

dementia, sedating medication) and/or 

referral to a DRS. 

Numerous studies have demonstrated 

an association between performance on 

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

and cognitive function and/or driving 

performance. In a study of 1,700 drivers 

65 and older who were applying for 

renewal of their North Carolina driver’s 

license, TMT-B test results were strongly associated with recent prior crash 

involvement.96 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).97 

Most recently, data from the Maryland 

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

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

and evaluation program & Maryland pilot older 

driver study. NHTSA Report Number DOT HS 

809 581. Washington, DC: National Highway 

Traffic Safety Administration. 

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

(1998). Cognitive test performance and 

crash risk in an older driver population. 

Accid Anal Prev. 30(3):337–346. 

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

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

with driving performance of older drivers. 

Transportation Res Record. 1405:64–71. 

34 chapter 4—Physician Interventions 
 

 

 

 

 

 

 

 

 

Pilot Older Driver Study98 demonstrated 

a significant correlation between TMTB performance and future at-fault crash 

in the license renewal sample. 

Clock Drawing Test, Freund Clock 

Scoring for Driving Competency 

Any incorrect or missing element on 

the Freund Clock Scoring Criteria 

signals a need for intervention, such 

as a review of causes for the abnormal 

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

to a DRS. 

Clock Drawing Tests (CDT) have been 

found to correlate significantly with 

traditional cognitive measures, and to 

discriminate healthy individuals from 

those with dementia.99 Of all the measures that have correlated with impaired 

driving performance in older adults 

with dementia, tests of visuospatial 

skill ability have had the highest level 

of prediction.100 Several versions of the 

CDT are available, each varying slightly 

in the method of administration and 

scoring.101 The Freund Clock Scoring is 

based on seven “principal components” 

(as outlined on the ADReS Score 

Sheet), which were derived by analyzing the clock drawings of 88 drivers 65 

and older against their performance on 

a driving simulator.102 Errors on these 

principal components correlated significantly with specific hazardous driving 

errors, signaling the need for formal 

driving evaluation. 

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

(2006). Can high-risk older drivers be identified 

through performance-based measures in a 


Department of Motor Vehicles setting? 


J Am Geriatr Soc. 54:77–84.
 

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

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

J Neurol Neurosurg Psychiatry. 64:588–594. 

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

(2004). The relationship between neuropsychological functioning and driving ability in 

dementia: a meta-analysis. Neuropsychology. 

18:85–93. 

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

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

executive control: a comparison of six methods. 

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

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

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

Intern Med. 20:240–244. 

It is again emphasized that these tests 

should not be the sole determinant as 

to whether an older adult should drive, 

and this was the conclusion of a recent 

review on this subject.103 However, 

impairments on these tests are associated 

with increased risk, and referral for 

further evaluation, such as performancebased road testing, should be considered. In addition, it is unlikely that 

future fitness-to-drive evaluations will 

rely on one test but likely will employ 

a battery of tests.104 

If the patient’s performance 

warrants interventions, the 

physician should: 

• Gather (or refer for) more 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; 

• Identify the cause of the 

cognitive decline; 

¤	 Check for reversible causes 

of cognitive decline;105
 

¤	 Screen for depression;106 

¤	 Review the patient’s medication 

regimen and the side effects of 

the medications, and question the 

patient about the onset of cognitive 

decline in conjunction with new 

medications or dosage changes. 

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

screening tests to licensing authorities when 

assessing older driver fitness to drive. Traffic Inj 

Prev. 9:328–335. 

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

al. (2008). Predictability of clinical assessments 

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

105. Based on history, examination, and cognitive testing, order laboratory tests as needed 

to evaluate for causes of cognitive decline: 

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 the prior 

probability, noncontrast CT or MRI scan. 

106. 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. 

Your patients may be unaware of the 

potential effects of polypharmacy on 

cognitive ability and driving. 

• If possible, treat the underlying 

disorder and/or adjust the medication regimen as needed. Remember, 

it is critical that every patient have a 

complete evaluation to identify the 

underlying cause or causes and receive 

proper treatment. 

• Refer the patient to a neurologist, 

psychiatrist, or neuropsychologist 

for diagnosis or treatment as needed. 

If the patient has a degenerative 

dementia, such as Alzheimer’s disease, 

begin treatment with appropriate 

medications as indicated. 

• Recommend an on-road assessment 

performed by a DRS to assess the 

patient’s performance in the actual 

driving task. An initial comprehensive 

on-road assessment with retesting at 

regular intervals is particularly useful 

for progressive dementing illnesses. 

Strongly recommend that the patient 

begin exploring alternative forms of 

transportation now, and encourage 

him/her to involve family members/ 

caregivers in these discussions. 

chapter 4—Physician Interventions 35 
 

 

 

Motor ability 

Although the following tests are scored 

separately, interventions are recommended if the patient reaches designated 

cut-off values (as described below) on 

any of the individual tests. 

Rapid Pace Walk 

A time for completion of greater than 9 

seconds signals a need for intervention,107 

such as determination of the cause for 

slowed gait speed (e.g., Parkinson’s disease) and/or referral to a DRS. 

The Rapid Pace Walk assesses lower 

limb mobility, trunk stability, and 

balance. In a prospective cohort study 

of 283 drivers 72 and older, subjects 

who took longer than 7 seconds to 

complete the test were twice as likely 

to experience an adverse traffic event 

(crash, violation, or being stopped by 

the police) in the year following the 

test.108 More recently, data from the 

Maryland Pilot Older Driver Study—a 

study of almost 2,000 drivers over age 

55 who were license renewal applicants­

-demonstrated a correlation between 

performance on the Rapid Pace Walk 

and future at-fault crash in the license 

renewal sample (odds ratio 1.70).109 

Manual Test of Motor Strength 

Less than grade 4/5 strength in either 

upper extremity or the right lower extremity signals a need for intervention, 

such as vehicle modification. (If the 

patient drives a vehicle with manual 

transmission or reports using both feet 

to operate the brake and accelerator 

pedals,110 this applies to the left lower 

extremity as well.) 

(Continues on next page) 

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

(2003). MaryPODS revisited: updated crash 

analysis and implications for screening program 

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

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

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

of automobile crashes and moving violations among elderly drivers. Ann Intern Med. 

121(11):842–846. 

109. Ibid. 

110. Although this is not considered the recommended way of driving, many older drivers 

initially learned to drive using both feet to 

operate the pedals. 

Figure 4.1: Dementia and driving 

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

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

persons in the United States.1 However, it is frequently unrecognized and undocumented by primary care physicians2

—a situation that is particularly unfortunate 

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

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

With regard to driving, patients with progressive dementia ultimately become 

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

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

members and caregivers to enforce driving cessation and arrange alternative 

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

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

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

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

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

on this topic also may be helpful to the clinician.3, 4) 

Figure 4.2: The copilot phenomenon 

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

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

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

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

passengers to alert them to traffic signs and signals. 

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

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

still driving relied on copilots.5

 Patients should be advised to not continue driving 

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

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

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

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

other passengers. Furthermore, the use of copilots to meet standards for 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.6 

Patients who are not safe to drive should be recommended to stop driving, regardless of their need or use of a copilot. Copilots should never be recommended to 

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

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

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

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

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

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

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

assistance is an acceptable and advisable practice. 

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

Station, NJ: Merck & Co., Inc. 

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

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

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

Neurol. 17:232–240. 

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

Am Fam Physician. 73:1029–1034. 

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

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

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

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

36 chapter 4—Physician Interventions 
 

 

 

The manual test of motor strength 

evaluates separate muscle groups in 

both the upper and lower limbs. The 

U.S. Public Health Service guidelines 

on musculoskeletal ability and driving 

state that a driver should have at least 

grade 4/5 strength in the right lower 

extremity and both upper extremities.111 

The physician should also be aware 

that the amount of strength required for 

safe driving may depend on the vehicle 

driven by the patient. For example, a 

patient who drives an older car that 

does not have power steering or operates a large vehicle (e.g., a school bus, 

which is not uncommon for retirees) 

may require greater strength to safely 

drive the vehicle. 

Manual Test of Range of Motion 

If the patient’s range of motion is not 

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

has a good range of motion with excessive hesitation/pain or a very limited 

range of motion), this signals the need 

for intervention. Recently, the inability 

to recognize an object that is presented 

directly behind a patient (e.g., intact 

cervical range of motion) was correlated 

with increased risk of a motor vehicle 

crash.112 

Scoring for range of motion is based on 

simple dichotomous outcomes (normal 

vs. impaired), and this is due to several 

reasons: (1) Physicians are not usually 

trained in use of goniometers nor have 

the devices in the office setting; (2) 

range of motion requirements vary with 

automobile design, and thus it is difficult to specify exact requirements; 

(3) as discussed in the visual fields 

section, the impact of limited range of 

motion on driving safety also depends 

on other functions; and (4) as with all 

the other tests in the ADReS battery, 

a patient’s poor performance should be 

a stimulus for optimization of func111. Marottoli, R. A., & Drickamer, M. A. (1993). 

Psychomotor mobility and the elderly driver. 

Clin Geriatr Med. 9(2):403–411. 

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

(2006). Can high-risk older drivers be identified 

through performance-based measures in a 

Department of Motor Vehicles setting? J Am 

Geriatr Soc. 54:77–84. 

tion, rather than for immediate driving 

restrictions. 

If the patient’s performance on this 

test is not within normal limits, the 

physician should be certain to elicit 

the reason: Do these movements cause 

muscle or joint pain? Does the patient 

complain of tight muscles or stiff joints? 

Do these movements cause a loss of 

balance? Patients with a history of falls 

have been noted to be at increased risk 

of motor vehicle crashes.113 Knowing 

the answers to these questions will help 

in the management of the patient’s 

physical limitations. 

If the patient’s performance warrants interventions, the physician 

should: 

• Encourage the patient to drive a 

vehicle with power steering and 

automatic transmission, if he/she 

does not already do so. 

• Recommend that the patient 

maintain or commence a consistent 

regimen of physical activity, including 

cardiovascular exercise, strengthening 

exercises, and stretching. (Successful 

Aging Tips, in Appendix B, suggests 

some exercises.) 

• Refer the patient to a physical 

therapist or occupational therapist 

as needed for training and exercises 

to improve strength and/or range of 

motion. 

• Provide effective pain control if the 

patient’s range of motion and mobility are limited by pain. This may 

include prescribing analgesics or medications that treat the underlying disorder (e.g., a urate-lowering drug for 

gout), or changing when the patient 

takes pain medications so that relief is 

achieved prior to driving. Please note 

that many analgesics (including narcotics and skeletal muscle relaxants) 

have the potential to impair driving 

ability, and may be more deleterious to driving performance than the 

instigating pain. These medications 

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

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

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

Sci. 57:M186–191. 

should be avoided, if possible, or 

prescribed in the lowest effective dose 

possible. Patients should be advised to 

refrain from driving when first taking 

these medications until they know 

whether they are tolerated. 

• Refer the patient to a specialist for 

management of any joint disease, 

podiatry issues, or neuromuscular 

problems. Post-stroke patients with 

residual deficits that interfere with 

the patient’s handling of car controls 

should also be referred. 

• Recommend an on-road assessment, 

performed by a DRS, to assess the 

patient’s performance in the actual 

driving task. A comprehensive onroad assessment is particularly useful 

for assessing the impact of physical 

fatigue on the patient’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 patient 

in their use. 

What do you do next? 

After administering ADReS, you can 

follow one of three courses of action. 

(See also the Physician’s Plan for Older 

Drivers’ Safety, Figure 1, Chapter 1.) 

If the patient performs well on all three 

sections of the ADReS battery, you may 

advise him/her that there are no medical 

contraindication to safe driving and no 

need for further work-up or treatment. 

Counsel the patient on health maintenance by providing the Successful Aging 

Tips and Tips for Safe Driving handouts, 

and periodically follow-up on the 

patient’s driving safety. However, if 

there is evidence of a new onset of 

impaired driving behaviors (e.g., a 

decline from baseline) as described by 

the patient and/or family, further 

evaluation may be warranted despite 

a normal score. 

If the patient performs poorly on any 

section of ADReS, but the causes of 

poor performance are medically correctable, pursue medical treatment until the 

chapter 4—Physician Interventions 37 
patient’s function has improved to the 

fullest extent possible. The patient may 

need to be counseled to limit driving as 

treatment proceeds. Assess the patient’s 

level of improvement with repeat 

administration of ADReS. If the patient 

now performs well on all three sections 

of the ADReS battery, counsel him/her 

on health maintenance as above. 

If the patient’s poor performance on the 

ADReS battery cannot be medically 

corrected, or if the patient’s function 

shows no further potential for improvement with medical interventions, refer 

him/her to a DRS. 

The ADReS battery is useful as an 

in-office assessment, but it does not 

evaluate the patient’s performance in 

the actual driving task, and the results 

even if abnormal are not sufficient to 

recommend driving cessation. For this, 

an on-road assessment performed by 

a DRS is needed. The DRS can more 

specifically determine the patient’s 

level of driving safety and correct his/ 

her functional impairments, if possible, 

through adaptive techniques or devices. 

The role of the DRS is discussed in the 

next chapter. 

38 chapter 4—Physician Interventions 
chapter 5 

The Driver 

Rehabilitation Specialist 

 

 

 

chapter 5 

The Driver 

Rehabilitation Specialist 

After scoring Mr. Phillips’ (introduced 

in previous chapters) performance 

on the ADReS battery, you discuss 

the results with him. You assure him 

that he scored well on the cognitive 

tests, but that his performance on 

the visual and motor tasks indicates 

a need for further evaluation and 

treatment. 

You recommend that Mr. Phillips 

make an appointment with his 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 afterwards. His son, who is 

present at the clinic visit, offers to 

exercise with him several times a 

week. You schedule Mr. Phillips to 

return to your clinic in one month. 

When Mr. Phillips arrives for his 

follow-up appointment, he is wearing new glasses. His vision with the 

new glasses is 20/40 OU. You retest 

his motor skills, and he is now able 

to complete the Rapid Pace Walk 

in 8.0 seconds. His lower extremity 

strength has improved to 4+/5, but 

his range of motion on finger curl 

and neck rotation remain restricted. 

With Mr. Phillips’ agreement, you 

refer him to a driver rehabilitation 

specialist (DRS) for an evaluation 

and adaptive equipment, if necessary. 

Despite your medical interventions, 

your patients will sometimes continue 

to demonstrate functional impairments 

that may impair their driving performance. In these cases, a DRS is an 

excellent resource. A DRS can perform 

a more in-depth functional assessment 

and evaluate performance with an actual driving task. Based on the patient’s 

performance, the DRS can recommend 

that he/she continue driving with or 

without further restrictions or interventions, recommend adaptive techniques 

and devices to overcome functional 

deficits, or recommend that the 

patient cease driving and offer 

mobility counseling. 

This chapter provides you with 

information you should have when 

you refer your patient to a DRS. 

What is a driver rehabilitation 

specialist? 

A DRS is one who “plans, develops, 

coordinates and implements driving services for individuals with disabilities.”114 

DRSs are often occupational therapists 

who undergo additional training in 

driver rehabilitation. Aside from occupational therapy, DRSs also come from 

backgrounds such as physical therapy, 

kinesiotherapy, psychology, and driver 

education. 

Many DRSs receive certification from 

the Association for Driver Rehabilita114. Association of Driver Rehabilitation Specialists: 

Driver Rehabilitation Specialist Certification 

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

index.cfm?Cat=10). 

tion Specialists (ADED)115 by 

fulfilling education and experience 

qualifications116 and passing a certification examination.117 Certified driver 

rehabilitation specialists (CDRSs) 

renew their certification every three 

years by fulfilling a minimum amount 

of contact hours. While many DRSs 

either hold certification or are in the 

process of obtaining the necessary 

education and experience to sit for 

the examination, certification is not 

required to practice driver rehabilitation nor for ADED membership. 

115. The acronym ADED was retained when the 

association changed its name from the Association of Driver Educators for the Disabled to its 

current name. 

116. Candidates must fulfill one of the following 

requirements: A. An undergraduate degree or 

higher in a health-related area of study with 

one year full time experience in degree area 

of study and an additional one year full time 

experience in the field of Driver Rehabilitation; 

B. Four year undergraduate degree or higher 

with a major or minor in Traffic Safety and/or a 

Driver and Traffic Safety Endorsement with one 

year full time experience in Traffic Safety and 

an additional two years of full time experience 

in the field of Driver Rehabilitation; C. Two 

year degree in health-related area of study with 

one year experience in degree area of study and 

an additional three years full time experience 

in the field of Driver Rehabilitation; D. Five 

years of full time work experience in the field 

of Driver Rehabilitation. Association of Driver 

Rehabilitation Specialists: Driver Rehabilitation 

Specialist Certification Exam fact sheet (www. 

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

117. Examination content includes (1) program 

administration, (2) the pre-driving assessment, 

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

evaluation, (5) interpretation of assessment 

results, and (6) planning and implementation 

of recommendations. Association of Driver 

Rehabilitation Specialists: Driver Rehabilitation 

Specialist Certification Exam fact sheet 

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

chapter 5—The Driver Rehabilitation Specialist 41 
What do driver rehabilitation 

specialists do? 

A DRS evaluates the client’s driving 

skills, recommends rehabilitation as 

needed, and can suggest vehicle and/or 

route modifications (e.g., such as avoiding left hand turns) to enable the person to resume or continue driving safely. 

Although driver rehabilitation programs 

vary, most typically include the following elements in their evaluation: 

Driver Evaluation 

• Clinical assessment, including review 

of driving history, driving needs, and 

license status; review of medical history and medications; visual/perceptual assessment; assessment of range 

of motion, motor strength, coordination, sensation, and reaction time; 

and cognitive assessment. 

• Functional (on-road) assessment, 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 client: 

¤	 Return to driving, with or without 

adaptive driving equipment. 

¤	 Limit driving with restrictions 

placed on either the geographic 

areas or conditions in which the 

client drives. 

¤	 Attend a remedial driving course to 

establish/maintain defensive driving skills. 

¤	 Receive adaptive driving instruction or driver retraining using a 

vehicle matched to the client’s 

individual needs. 

¤	 Stop driving. This is advised when 

a client does not demonstrate the 

necessary skills to resume driving, 

and the potential for improvement 

with retraining is poor. In these 

cases, alternative transportation options are reviewed with the client. 

¤	 Re-evaluation. This option is 

indicated if a client’s function is 

expected to improve, or if a client 

demonstrates adequate skills to 

drive at present but has a progressive disorder that may cause future 

decline. 

Passenger Vehicle Evaluation 

• Assessment of vehicle, vehicle 

modifications, and equipment needed 

for the client’s safe transport as a 

passenger. 

• Consideration of the needs of the 

patient’s family (for example, certain 

lifts or tie-down systems may be 

recommended due to an assisting 

family member’s physical limitations). 

Treatment and Intervention 

• Adaptive driving instruction or driver 

retraining, with or without vehicle 

modifications. 

• Coordination of vehicle modifications: 

¤	 Vehicle consultation: The DRS 

serves as a consultant to clients 

who are purchasing a new vehicle 

to ensure that the vehicle will accommodate the necessary adaptive 

equipment. 

¤	 Vehicle modification recommendations: The DRS provides written 

recommendations for all vehicle/ 

equipment needs to the client, 

third party payer, and vehicle/ 

equipment dealer. 

¤	 Vehicle inspection: The DRS is 

involved with the client and adaptive equipment dealer in a final 

fitting to ensure optimal functioning of the recommended vehicle/ 

equipment. 

An initial driver evaluation can last 

one to four hours, depending on the 

client’s presenting disabilities and 

driving needs. Following the clinical 

assessment, clients undergo an on-road 

assessment if they meet the minimum 

State standards for health and vision, 

and the client holds a valid driver’s 

license or permit. The on-road assessment is performed in a driver rehabilitation vehicle equipped with dual brakes, 

a rear-view mirror and eye-check mirror 

for the DRS, and any necessary adaptive 

equipment. 

Please note that clients who perform 

poorly on the clinical assessment may 

still undergo on-road assessment. In 

these cases, the DRS may recommend 

on-road assessment for one of two 

reasons: (1) clients who perform poorly 

on individual components of the clinical assessment may still demonstrate 

safe driving due to over-learning the 

driving task; and (2) clients and family 

members may need concrete evidence 

of unsafe driving, which can only be 

documented through observation of 

behind-the-wheel performance. 

Who can driver rehabilitation 

specialists help? 

Driver assessment and rehabilitation 

are appropriate for a broad spectrum of 

visual, physical, and/or cognitive disabilities. DRSs work with clients 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 client in their use. 

It can also be as complex as working 

with a client with dementia and his/her 

caregivers to determine the individual’s 

driving needs, plan driving routes for 

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

or busy intersections), supervise practice 

drives, and provide close and extended 

follow-up. 

42 chapter 5—The Driver Rehabilitation Specialist 
What is the cost of driver 

assessment and rehabilitation? 

While the cost of driver assessment and 

rehabilitation varies between programs 

and according to the extent of services 

provided, the range is typically $300 

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

full assessment and $100 an hour for 

rehabilitation. If adaptive equipment 

is required, the cost is approximately 

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

$500 for a left foot accelerator, $700 to 

$900 for hand controls, and thousands 

of dollars for reduced-effort steering systems, wheelchair lifts, and raised roofs 

and dropped floors on vans. 

Two programs that may pay for driver 

assessments, driver rehabilitation, and 

vehicle modifications are each State’s 

workers compensation and vocational 

rehabilitation programs. However, 

not all drivers—and often many older 

drivers—will not qualify for either 

program, and insurance coverage from 

Medicare, Medicaid, and private insurance companies is variable. To date, 

these expenses are usually out of pocket. 

In general, Medicare does not reimburse 

for driving services, and private insurance companies—basing their coverage 

on Medicare’s covered services—tend 

to follow suit. However, some driver 

rehabilitation programs have successfully pursued insurance reimbursement 

from Medicare and other providers. 

(Note that while Medicare may provide 

partial or full reimbursement for driver 

assessment and rehabilitation, it does 

not cover the cost of adaptive equipment.) At present, the American 

Occupational Therapy Association 

(AOTA) is actively lobbying for consistent Medicare coverage of occupational 

therapy-performed driver assessment 

and rehabilitation, with the assertions 

that these services fall under the scope 

of occupational therapy practice and 

that driving is considered an instrumental activity of daily living. 

Because rates and extent of insurance 

reimbursement vary among driver 

rehabilitation programs, patients should 

be encouraged to inquire about program 

rates, insurance coverage, and payment 

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

and is reimbursed when insurance payments are received, or payment is collected directly from insurance provider). 

Where can I find a driver 

rehabilitation specialist? 

Driver rehabilitation programs and 

DRSs are still fairly rare, but in private 

practice they are often affiliated with 

hospitals, rehabilitation centers, driving 

schools, and State departments of motor vehicles. DRS services may also be 

found through area agencies on aging, 

universities, and area departments of 

education. Before referring patients to 

driving schools for driver assessment 

and rehabilitation, physicians are urged 

to determine that the staff has training 

and experience in driver rehabilitation. 

A background in driver education 

alone may be insufficient for appropriate 

assessment of medically impaired drivers 

and correct interpretation of 

the assessment. 

To locate a DRS in your area, you 

may wish to start by calling the occupational therapy departments in your 

local hospitals or rehabilitation centers. 

The ADED’s online directory is another 

good source of information. The directory, which can be found by clicking the 

Directory button at www.driver-ed.org or 

www.ADED.net, lists all 553 ADED 

members (as of December 2006), 

including 251 certified DRSs. You can 

search the directory by State, county, 

type of facility, program services offered, 

and professional background of the 

DRS, as well as by name of the DRS 

or name of the driver rehabilitation 

program. Please note that not all ADED 

members provide direct assessment 

and rehabilitation services; some are 

involved solely in vehicle modification, 

as indicated in their “program services” 

field. Many local chapters of the 

Alzheimer’s Association (www.alz.org) 

also provide lists of area driving 

evaluation programs. 

When selecting a DRS or driver 

rehabilitation program, the patient 

and family may want to ask: 

• How many years of experience does 

the DRS (or program) have? 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 both the 

clinical assessment and on-road assessment? A DRS who provides both 

components of the evaluation (or a 

program whose specialists perform 

both components as a team) is ideal. 

Referral to two separate specialists 

or centers is inconvenient for the 

physician and the patient, and often 

presents a greater insurance reimbursement challenge. In addition, 

some programs utilize a driving simulator program, which has strengths of 

reliability, but weaknesses of validity, 

lack of standardization, paucity of 

evidence that correlates it with other 

important outcomes, and possibly 

sickness induced by the simulator. 

• Does the DRS provide rehabilitation 

and training? A good DRS (or program) should be experienced in both 

assessment and rehabilitation, and 

should be able to prescribe adaptive 

devices or vehicle modifications and 

train the patient in their use. 

• How much can the patient expect to 

pay out-of-pocket for assessment, rehabilitation and adaptive equipment? 

• Who will receive a report of the 

assessment outcome? In most cases, 

reports are sent to the patient and to 

the physician and/or referring agency 

(e.g., workers compensation or office 

of retirement services) Some DRSs 

also send reports to family members, 

at the request of the family and with 

the client’s consent. Whether or not 

the DRS reports to the State DMV 

is highly variable: In States with 

mandatory reporting laws, the DRS 

and/or physician may send a report; if 

reporting is not legally required, some 

DRSs will still send a report in the 

interest of public safety. The policy of 

the DRS should be discussed with all 

parties prior to the evaluation. 

• If the patient receives recommendations to cease driving, does the DRS 

chapter 5—The Driver Rehabilitation Specialist 43 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

provide any counseling or aid in identifying alternative forms of transportation? Please note that DRS counseling does not preclude the need for 

physician follow-up. Many times, the 

patient may be too distressed at the 

time of DRS counseling to absorb 

information. Mobility counseling is 

crucial for reinforcement of this information, and it demonstrates to the 

patient the physician’s involvement 

and support. 

CarFit is an educational program created 

by the American Society on Aging and 

developed in collaboration with AAA 

(American Automobile Association), 

AARP, and the American Occupational 

Therapy Association. CarFit offers older 

adults the opportunity to check out how 

well their personal vehicles “fit” them. 

An evaluation, typically performed by 

an occupational therapist or a trained 

volunteer, employs a checklist for correct 

positioning of the seat, use of mirrors, 

and so forth. Information and materials 

for community-specific resources and activities that could make drivers personal 

vehicles fit better, enhance their safety as 

drivers, or increase their mobility in the 

community are available. More information on referring your patients to this 

service can be found at www.car-fit.org. 

Making the referral 

Prior to making the referral, let your patient know why he/she is being referred, 

what the assessment and rehabilitation 

will accomplish, what these will consist 

of, and how much he/she can expect to 

pay out-of-pocket for these services. 

For example, you could tell 

Mr. phillips: 

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

better with your new glasses, and that your 

physical fitness has improved with your 

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

work. However, I’m still concerned about 

your hands and your neck. I’m concerned 

about your poor grip on the steering wheel, 

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

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

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. 

“This person, who’s called a driver 

rehabilitation specialist, will ask you some 

questions about your medical history and 

test your vision, strength, range of motion, 

and thinking skills—similar to what we did 

the last time you were here. He/she will 

also take you out on the road and watch 

your driving, and might recommend some 

accessories or 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 

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 to ever get into 

a serious car crash, your medical bills or 

the costs for someone you injured could end 

up costing you more money. We should try 

to prevent that from happening.” 

Most programs will require a written 

physician prescription. When writing 

the driving evaluation prescription, try 

to list a specific cause for assessment 

and rehabilitation. Assessment that is 

ordered the patient is “an older adult,” 

“debilitated,” or “frail” does not provide 

adequate guidance to the DRS and can 

complicate insurance reimbursement. 

On the other hand, “OT driver evaluation for hand weakness such as poor 

finger flexion or limited neck rotation 

secondary to arthritis,” “DRS evaluation 

for hemianopia secondary to stroke,” 

and “DRS evaluation for cognitive 

impairments secondary to Alzheimer’s 

disease” provide more guidance for 

the DRS and are more likely to be 

reimbursed by insurance. In addition, 

most DRS programs will send the 

physician a referral form that includes 

space for a list of current diagnoses 

and medications. 

Remind your patient to schedule a 

follow-up appointment with you after 

he/she undergoes evaluation. If your 

patient is safe to drive (with or without 

restrictions, adaptive devices, and/or 

rehabilitation), reinforce any recommendations made by the DRS. When 

applicable, family and caregivers should 

be informed of these recommendations. 

Also remember to counsel your patient 

on the Successful Aging Tips and Safe 

Driving Tips handouts, and encourage 

him/her to start planning alternative 

forms of transportation in case they 

ever become necessary. If your patient 

is not safe to drive, then you will 

need to counsel him/her on driving 

cessation. This is discussed in the 

following chapter. 

Special mention is made of other rehabilitation specialists who may be helpful 

for impairments that are not uncommon 

in older adults. For instance, physical 

therapists may be able to improve muscle 

weakness, range of motion or physical frailty. Visual rehabilitation may be 

available in some specialized centers. 

Neurophthalmologists or optometrists 

may provide vision training, especially 

for patients with neurological insults that 

affect convergence, alignment, nystagmus, 

eye apraxia, and/or visual neglect from 

stroke, head injury, brain tumors, 

and trauma. 

What if driver assessment is 

not an option? 

Unfortunately, driver assessment and 

rehabilitation may not always be feasible 

options for your patients. In some areas, 

DRSs simply are not available. Even if 

a DRS is available, your patient may 

refuse further assessment, or may 

be unable to afford it. 

• If driver assessment through a driver 

rehabilitation specialist is not an 

option, you have several choices: 

• Some occupational therapists are 

“generalists” and still may be able to 

perform off-road tests and/or mobility 

counseling. Referral to these types 

of health professionals may actually 

be a more common option in your 

community. 

44 chapter 5—The Driver Rehabilitation Specialist 
• Driving educational specialists are 

often based at high schools or affiliated with programs for novice drivers. 

Yet, some of these specialists have 

developed experience in assessing 

and counseling medically impaired 

drivers and may be a resource in your 

community. 

• Advise your patient to continue, 

restrict, or cease driving based on 

the medical history, the results of 

ADReS, and your clinical judgment. 

As always, document your recommendation in the patient’s chart. Some 

physicians have the patient sign a 

document for the file acknowledging 

the doctor’s recommendation to 

cease driving. 

• You might consider the evaluation 

of another health professional 

such as a geriatrician, neurologist, 

psychiatrist, or neuropsychologist 

for a patient who has a chronic 

disease such as Alzheimer’s. 

• If there are changes in driving behavior that you feel are likely to improve 

your patient’s driving safety (e.g., 

avoiding driving at night, rush hour, 

adverse weather conditions, etc.), 

make these recommendations to your 

patient and follow up for compliance. 

• Private driving schools and driving 

education programs may be available 

in your area; however, they may not 

have expertise in assessing older 

adults with medical impairments. 

• If you are urgently concerned about 

your patient’s driving safety, you may 

wish to refer your patient to your 

State DMV for a driving assessment. 

Depending on your State’s reporting 

laws, you may be legally responsible 

for reporting “unsafe” drivers to the 

DMV. (A detailed discussion of the 

physician’s legal and ethical responsibilities can be found in Chapter 7; 

a reference list of reporting laws is in 

Chapter 8.) The patient should be 

referred with his/her knowledge, and 

this should be documented in the 

chart. Many States will require the 

physician to fill out forms that require 

medical information and vision testing results, and provide an opinion 

on whether the driver should undergo 

visual and/or on-the-road testing. 

• If there are no medical contraindications to continued driving, remember 

to counsel your patient on Successful 

Aging Tips and Safe Driving Tips and 

encourage him/her to start planning 

alternative forms of transportation. 

chapter 5—The Driver Rehabilitation Specialist 45 

chapter 6 

Counseling the Patient 

Who Is No Longer Safe 

to Drive 

chapter 6 

Counseling the Patient 


Who Is No Longer Safe 


to Drive
 

Mr. Phillips returns for follow-up 

after undergoing driver assessment. 

From the driver rehabilitation specialist (DRS) report, you know that 

the DRS recommends that Mr. Phillips resume driving after his car has 

been fitted with wide-angle rear-view 

mirrors. At the visit, Mr. Phillips 

states that he is driving more comfortably with this adaptive device. 

You counsel him on the tips for safe 

driving and successful aging tips, 

advise him to continue walking, and 

encourage him to start planning 

alternate transportation options. His 

daughter is recruited to assist with 

these discussions and interventions. 

You continue to provide care for Mr. 

Phillips’ chronic conditions and 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 due to 

the fixed nature of his deficits (more 

than six 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 feels 

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. 

Your next patient is Mrs. Allen an 

82-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 each time. The daughter 

would like to know how to manage 

her mother’s long-term safety and 

health, and would especially like to 

know how to address the driving 

issue. What do you tell her? 

For most of us, driving is a symbol of 

independence and a source of self-esteem. When an individual retires from 

driving, he/she not only loses a form of 

transportation, but all the emotional 

and social benefits derived from driving. 

For various reasons, physicians may be 

reluctant to discuss driving cessation 

with their patients. Physicians may fear 

delivering bad news or be concerned 

that the patient will lose mobility and 

all its benefits. Physicians may avoid 

discussions of driving altogether because 

they believe that a patient will not 

heed their advice or become angry. The 

physician may also be concerned about 

losing a patient to another practice. 

These concerns are all valid. However, 

physicians have an ethical responsibility to protect their patients’ safety 

through assessment of driving-related 

functions, exploration of medical and 

rehabilitation options to improve their 

patients’ driving safety, and—when all 

other options have been exhausted— 

recommendations for driving restriction 

or driving cessation. Physicians are 

influential in a patient’s decision to stop 

driving; in fact, advice from a doctor is 

the most frequently cited reason that a 

patient stops driving.118 

In this chapter, we discuss the key 

points to address when counseling a 

patient to stop driving and provide 

strategies for managing challenging 

cases. When counseling a patient to 

stop driving, the following steps may 

be useful: 

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

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

49 
Figure 1 

Transportation alternatives 

•	 Walking 

•	 Train/subway 

•	 Bus 

•	 Taxi 

•	 Friends/family 

•	 Paratransit 

•	 Community transportation services 

•	 Hospital shuttles 

•	 Medi-car 

•	Delivery services 

•	 Volunteer drivers (church, synagogue, 

community centers) 

•	 Private for-profit elderly care services 

Explain to your patient 

why it is important to 

stop driving. 

If your patient has undergone the 

ADReS battery (see chapters 3 and 4) 

or assessment by a driver rehabilitation 

specialist, explain the results of the 

assessment in simple language. Clearly 

explain what the results tell you about 

his/her level of function, and then 

explain why this function is important 

for driving. State the potential risks of 

driving, and end with the recommendation that your patient stop driving. 

This might be a good time to discuss the 

patient’s thoughts or feelings, especially 

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

should not drive, you might discuss issues related to injury, public safety, and/ 

or liability. This discussion should be 

put in writing and if the patient lacks 

decision-making capacity, involve a 

family member or caregiver. 

For example, you could say to 

Mr. phillips: 

“Mr. Phillips, the results of your eye exam 

show that your vision isn’t as good as it 

used to be. Good vision is important for 

driving, because you need to be able to 

see the road, other cars, pedestrians, and 

traffic signs. With your impaired vision 

due to underlying eye disease and now a 

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

car crash. Since your vision cannot be 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 

and you do not meet those any longer. “ 

Your patient may become upset or angry 

at your recommendation to stop driving. Acknowledge your patient’s feelings 

and be empathetic to any emotional 

responses. While you should be sensitive to the practical and emotional 

implications of driving cessation, it 

is also necessary to be firm with your 

recommendation. At this time, it is 

best to avoid engaging in disputes or 

long explanations. Rather, you should 

focus on making certain your patient 

understands your recommendation and 

understands that this recommendation was made for his/her safety. If the 

patient is competent but will allow the 

presence of a spouse or family member, 

having this person present may be helpful when communicating this sensitive 

information. All discussions should be 

documented in the chart. 

Discuss transportation 

options. 

Once you have recommended that 

your patient stop driving, you need to 

explore possible transportation alternatives. Unfortunately, driving cessation 

has been associated with a decrease 

in social integration.119 Discuss with 

your patient the fact that there may be 

alternative ways to reach destinations. 

Encourage your patient to take control 

of his/her future by creating a transportation plan. (Please note: If your patient 

does not have the cognitive capabilities for these tasks, see the section on 

patients who lack decision-making 

capacity later in this chapter.) 

Give your patient resources to explore 

options (see Appendix B handout 

sheets). By providing this information, 

you empower your patient to formulate a personal plan for transportation. 

Special mention is made of The Hartford insurance company’s educational 

brochures “We Need to Talk” and “At 

the Crossroads.” These guides provide 

excellent worksheets for defining pertinent out-of-home activities, initiating 

discussions between patients and their 

families, and assisting the patient and 

the family member on deciding how 

specific trips will be accomplished.120 

This process will help your patient preserve a sense of self-determination and 

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

integration and social support among older 

adults following driving cessation. J Gerontol 

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

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

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

alzheimers/brochure.html. Accessed October 24, 

2007. 

50 chapter 6—Counseling the Patient Who Is No Longer Safe to Drive 
independence. While older adult nondrivers usually prefer rides from friends 

and family, they are often uncomfortable with the accompanying feelings 

of dependency.121 Using alternative 

transportation options such as buses, 

trains, cabs, or even walking, offers patients independence from having to rely 

on others. However, these may not be 

a reasonable alternative for those with 

physical frailty and/or dementia. 

To begin a discussion on driving alternatives, ask if your patient has made 

plans to stop driving or how he/she currently finds rides when driving is not an 

option. Offer alternative transportation 

methods for your patient to use (Figure 

6.1). Explore any barriers your patient 

foresees to these methods (i.e., financial 

constraints, limited service and destinations, and required physical skills for 

accessibility). 

Help your patient identify his/her 

most feasible transportation options, as 

there often are necessary cognitive and 

physical skills required to access certain 

transportation alternatives. Stress the 

importance of planning ahead for social 

activities—which contribute to quality 

of life. Your patients can contact their 

Area Agency on Aging and/or Alzheimer’s Association for information on local 

resources such as taxis, public transportation services, and senior-specific 

transportation services. To find contact 

information for your local area, call the 

nationwide Eldercare Locator at 

800-677-1116. This might be a good 

time to refer to a social worker or a 

gerontological care manager who may 

be aware of alternate modes of transportation and/or can deal with the patient’s 

feelings of social isolation or depression. 

The Federal Government has recognized the limited transportation 

alternatives that are currently available 

(especially in rural areas) for an aging 

country with an increasing number of 

older adults who will no longer be able 

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

Older Persons: Perceptions and Preferences. 

AARP Public Policy Institute Issue Paper. 

to operate an automobile. To that end, 

legislation has been enacted to support funding of novel programs to assist 

seniors with transportation to needed 

destinations. To find more information 

on transportation options, please go 

to www.unitedweride.com. 

Encourage your patient to involve family members in creating a transportation 

plan. Obtain your patient’s permission 

when involving family or caregivers, 

and encourage them to offer rides and 

formulate a weekly schedule for running 

errands. They can also help arrange for 

delivery of prescriptions, newspapers, 

groceries and other services (See Figure 

6.2 for more tips). However, do not 

ignore your patient while including the 

caregiver in the discussion. 

Reinforce driving cessation. 

The message to cease driving is essential to ensure your patient’s safety, yet 

also presents a significant demand on 

your patient to change his/her current 

behavior. Therefore, you will need to 

ensure that your patient understands 

the reasons (legal, health and safety) 

why you have recommended driving 

discontinuation. Your patient may become argumentative or emotional during the office visit. He/she may not fully 

comprehend your recommendations and 

may not remember all the information 

you provide. To help re-enforce your 

message: 

• Ask your patient if he/she has any 

questions regarding the assessment 

and your recommendation. Reassure 

your patient that you are available 

should he/she have questions or need 

further assistance. 

• Ask your patient to reiterate to you, 

why he/she must not drive. Stress this 

recommendation is for personal safety 

and the safety of others on the road. 

• Your patient may benefit from the 

visual reinforcement of a prescription with the words “Do Not Drive.” 

Ensure that your patient understands 

why he/she is receiving this prescription, so as to avoid feelings of anxiety 

or anger. See Figure 3 for further reFigure 6.2 

Encourage family/caregiver 

assistance 

•	 Encourage family to promote the 

health and safety of their loved one 

by endorsing your recommendation 

and assisting in securing needed 

transportation. 

•	 Include them in the mobility 

counseling process. 

•	 Provide resources to caregivers. 

•	 Give copies of the How to Assist the 

Older Driver resource sheet (see 

Appendix B). 

•	 Refer caregivers to the National 

Family Caregivers Association (NCFA) 

at 800-896-3650 or www.nfcacares. 

org to find resources and tips on 

caring for loved ones. 

•	 Look for signs of caregiver burnout. 

•	 Keep the communication door open 

to the family. 

•	 In the case of cognitive impairment 

where it is believed the patient does 

not have decision-making capacity 

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

with a family member to reinforce 

recommendations is imperative. 

•	 Recognize that if the caregiver has 

depended on the patient for transportation, the situation may require 

more time, counseling, and support 

to meet the needs of the family. 

chapter 6—Counseling the Patient Who Is No Longer Safe to Drive 51 
Figure 6.3 

Tips to reinforce driving cessation 

Tip 1: Give the patient a prescription 

on which you have written “Do Not 

Drive, For Your Safety and the Safety 

of Others.” This acts as a reminder for 

your patient and also emphasizes the 

strength of your message. 

Tip 2: Remind your patient this recommendation is for his/her safety and for 

the safety of other road users. 

Tip 3: Ask the patient how he/she 

might feel if they were to get in a crash 

and injure themselves or someone else. 

Tip 4: Use economic arguments. Point 

out rising gas and oil prices, expense 

of car maintenance (tires, tune-ups, 

insurance), registration/license fees, 

financing expenses and depreciation 

of car value. Web sites are available 

to demonstrate the financial burden of 

owning and operating a car, and it may 

be useful to perform this exercise with 

the older adult.1

 Also, some physicians 

will state that the patient’s life savings 

may be at stake if they drive against 

medical advice and injure someone. 

Tip 5: Have a plan in place that involves 

family member support for alternative 

transportation. 

1.	 The Real Cost of Car Ownership Calculator. 

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

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

Accessed December 13, 2007. 

enforcement tips. 

• Send your patient a follow-up letter 

(see Figure 6.6). Place a copy of this 

letter in the patient’s chart as documentation and another visual tool for 

re-enforcement. The letter should be 

written in simple language to ensure 

your patient understands your recommendation. You can use the sample 

letter in Figure 6.6 as a template. 

• Discuss State reporting requirements 

with your patient (see Chapter 7 and 

Chapter 8 for more details). In the 

case of mandatory reporting laws, 

inform your patient that you are 

required by law to inform your local 

DMV of medical conditions that 

could affect a patient’s safe operation 

of a vehicle. Let your patient know 

the DMV will follow up, and what to 

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

review of driving record, required 

road test). In States with voluntary 

laws, a referral to the DMV could still 

be appropriate and patients may need 

to hear they will be reported if they 

drive against medical advice. 

• Help facilitate family members’ assistance in encouraging driving cessation, and if necessary, encourage your 

patient to self-report his/her impairment to the DMV. It may be helpful 

to enlist other trusted allies, such as 

clergy, friends, or the family attorney. 

• Ask your patient to return to you in 

one month for a follow-up assessment. (See next section for details of 

this visit.) 

Follow-up with your patient. 

At your patient’s follow-up appointment, you will want to assess: 

• Your patient’s ability to comply with 

the stop driving recommendation. 

• Transportation resources your patient 

has identified and has or has not utilized, looking especially at viability. 

• Signs of isolation or depression. 

Start the assessment by asking the 

patient how he/she got to the appointment that day. This will help you determine whether your patient has been 

able to plan for and schedule transportation to and from necessary appointments. Ensure that your patient has 

secured reliable and sufficient transportation resources to meet his/her needs. 

Consider referral to a social worker or 

gerontological care manager. 

As an example of a follow-up conversation with Mr. Phillips in your office, you 

could state the following; 

Physician: Here is a prescription for your 

medicines, you’ll need to refill this at your 

pharmacy after our appointment ... now 

how did you get here to the office today? 

Mr. Phillips: Oh, my son dropped 

me off. 

Physician: I see, has he been driving 

you lately? 

Mr. Phillips: Yes, ever since I stopped 

driving, he and his wife have been taking 

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

me up in 15 minutes. 

Physician: How has that been working 

for you? 

Mr. Phillips: This has worked quite well. 

Physician: Will he be able to take you to 

the pharmacy? 

Mr. Phillips: Yes, that will not be a 

problem. 

Physician: It’s wonderful that you have 

found them to be a reliable source for rides. 

What do you do when one of them is 

unable to drive you where you need to go? 

Be alert to signs of depression, neglect, 

and social isolation (see Figures 6.4122 

and 6.5 for details). Older adult who 

stop driving are at increased risk for 

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

of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric 

Association. 

52 chapter 6—Counseling the Patient Who Is No Longer Safe to Drive 
decreasing out-of-home activities.123 

Driving cessation has also been associated with an increase in depressive symptoms in the elderly124 125 in 

addition to an increased risk of nursing 

home placement.126 Because depressive symptoms have also been linked to 

physical decline and mortality in the 

elderly,127 it is important to continue 

to monitor your patient for any signs of 

decompensation. Ask your patient how 

he/she is managing without driving. 

Educate family members and caregivers 

on signs of depression and inquire about 

any concerns they may have. 

Continue to assess and treat your 

patient’s functional or cognitive impairments. If they improve to the extent 

that the patient is safe to drive again, 

notify the patient and give him/her the 

resource sheet on Tips for Safe Driving 

(see Appendix B). 

Situations that require 

additional counseling. 

It may be necessary to provide additional counseling to encourage driving retirement or to help your patient 

cope with this loss. Below, we provide 

potential situations (e.g., new patient 

scenarios) that may arise with patients 

who have difficulty coping or adhering 

to the recommendation to stop driving. 

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

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

decreased out-of-home activity levels. J Gerontol 

B Psychol Sci Soc Sci. 55:S334–340. 

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

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

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

depressive symptoms: prospective evidence 

from the New Haven EPESE. J Am Geriatr Soc. 

45:202–210. 

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

Changes in driving patterns and worsening 

depressive symptoms among older adults. 

J Gerontol. 56(6):S343–351. 

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

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

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

Health. 96:1254–1259. 

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

(1986). Depressive symptoms in relation to 

physical health and functioning in the elderly. 

Am J Epidemiol. 124:372–388. 

Situation #1: 


The resistant patient.
 

If your patient is belligerent or refuses to 

stop driving, it is important for you to 

understand why. Knowing this will help 

you address your patient’s concerns. 

Listen to your patient. Use supportive 

statements when addressing your patient’s concerns. Let your patient know 

you are there as an advocate for his/her 

health and safety. 

Physician: Mr. Adams, I understand you 

drove yourself to the appointment today. 

This worries me. At our last visit, I recommended that you retire from driving. I am 

wondering why you chose to drive yourself 

here today? 

Mr. Adams: Well, doctor, I don’t understand it. I’ve never gotten into an accident. 

My driving is fine and frankly, I don’t think 

you have any right to tell me not to drive. 

Physician: 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 physician, that is 

my primary concern. I want to help make 

this easier for you. Let’s talk about some 

of your concerns regarding retiring from 

driving. 

Remember driving cessation can have 

severe emotional and practical implications for your patients, and they may 

have a difficult time adjusting. 

•	have the patient define when a 

person would be unfit to drive. This 

will better help your patient recognize 

impairment in his/her own driving 

capabilities and will help you assess 

your patient’s judgment and insight. 

In addition, it might open up discussion where you can each reach some 

common ground. 

Physician: Mr. Adams, when do you 

think it’s an appropriate time for a person 

to stop driving? 

Mr. Adams: I suppose when they 

drive unsafely or are a threat to others 

on the road. 

Physician: That is an excellent 

observation; and I would agree with you. 

Mr. Adams: Well, a friend of mine 

doesn’t drive very well. He drives all over 

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

the car with him anymore because I worry 

about what may happen. 

Physician: That can be a scary situation 

for your friend and others on the road as 

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

potential danger and that you know how to 

ensure your own safety. I am wondering, 

is there someone whom you trust, and who 

would tell you when they thought it was 

unsafe for you to continue driving? 

Many older drivers are able to identify peers whose driving they consider 

unsafe, yet may not have the insight 

to recognize their own unsafe driving 

habits. Ask your patients if they have 

friends with whom they are afraid to 

drive and why. It’s important to have 

your patients begin to think about what 

they can expect when their driving abilities begin to decline. Let your patients 

know they are not alone and that many 

people make the decision to restrict 

or cease driving when safety becomes 

a concern. Encourage your patients to 

obtain a second opinion if they feel additional consultation is necessary. 

•	have your patient identify support 

systems. Ask your patient to list family members, church groups, neighbors, etc. who are able and willing to 

help with transportation decisions. 

This will help your patient become 

aware of a supportive network and 

feel more at ease when searching for 

alternative transportation. 

chapter 6—Counseling the Patient Who Is No Longer Safe to Drive 53 
Figure 6.4 

Questions to assess for major 

depression (adapted from the DSMIV-TR)1 

•	 Has your mood been down lately 

on a consistent basis? 

•	 Have you lost interest or pleasure in 

all or most activities? 

•	 Have you noticed any changes in 

appetite or weight? 

•	 Have you noticed any changes in 

sleeping habits or in concentration? 

•	 Have you noticed feelings of 

worthlessness or recurrent 

thoughts of death? 

Figure 6.5 

Signs of neglect or self-neglect 

The patient has: 

•	 An injury that has not been properly 

treated 

•	 Symptoms of dehydration and/or 

malnourishment 

•	 Weight loss 

•	 Soiled clothing 

•	 Recurrent falls with or without injuries 

•	 Evidence of inadequate or inappropriate administration of medications 

•	 Spoiled or outdated food in the 

refrigerator 

•	 Loss of income from difficulty with 

finances 

1.	 146 American Psychiatric Association (APA) 

2000. Diagnostic and Statistical Manual IV-R. 

(Fourth Edition-Text Revision). Washington: 

American Psychiatric Association. 

• Help your patient view 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; 

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

up freedom.” Help your patients view 

this as a step in health promotion 

and safety for themselves and others. 

Use phrases such as “it’s time to retire 

from driving” and point out that he/ 

she may still request rides from family 

and utilize community services, and 

will have lower costs and responsibility for maintaining an automobile. 

• Refer patient to social worker. Your 

patient may need additional help in 

securing resources and transitioning 

to a life without driving. Social workers can provide supportive counseling 

to patients and families, assess your 

patient’s psychosocial needs, assist in 

locating and coordinating community services and transportation, and 

enable your patient 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 social workers 

in your area who have met national 

verified professional standards for 

education, experience and supervision. Order information or access the 

on-line Register at www.socialworkers.org (see Appendix B for more 

details)Another resource for social 

workers may be your local hospital 

and a referral source may be the Area 

Agency on Aging or the Alzheimer’s 

Association. 

Situation #2: Your patient presents 

with symptoms of depression. 

This results from a combination of 

factors such as diminished health, 

social isolation, or feelings of loss. 

If you suspect your patient may be 

depressed (see Figure 6.4128), conduct a 

full assessment to determine the most 

appropriate treatment. Talk with your 

patient and appropriate family members 

about symptoms of depression and available treatment options. Consider referring your patient to individual therapy 

or group therapy, and social/recreational 

activities. Also consider treatment with 

medications if appropriate, or referral to 

a mental health professional. Normalize 

this experience for your patient— 

acknowledge they have suffered a loss— 

and recognize this may be an especially 

difficult time for them. 

Situation #3: Your patient lacks 

decision-making 

capacity. 

When your patient presents with significant cognitive impairment, or lacks 

insight or decision-making capacity 

as in certain cases of dementia, it is 

imperative that you employ the help of 

the appointed guardian, caregiver, or 

surrogate decision-maker to encourage 

your patient to stop driving. Let family 

and caregivers know they play a crucial 

role in helping the patient find alternatives to driving. Inform the family that 

you will be available to support and 

assist in any way you can. In rare instances, it may be necessary to appoint 

a legal guardian for the patient. In turn, 

the guardian may forfeit the patient’s 

car and license on behalf of the safety of 

the patient. These actions should only 

be used as a last resort. From a practical 

standpoint, hiding, donating, dismantling, or selling the car may also be 

useful in these difficult situations. 

128. APA. (2000). Diagnostic and Statistical 

Manual of Mental Disorders, Fourth Edition, 

Text Revision. Washington, DC: American 

Psychiatric Association. 

54 chapter 6—Counseling the Patient Who Is No Longer Safe to Drive 
Situation #4: Your patient shows signs 

of self-neglect or neglect. 

Your patient may be unable to secure 

resources for him/herself and may be 

isolated, lacking sufficient support 

from family, friends or an appointed 

caregiver. If your patient does not have 

the capacity to care for him/herself, or 

family and caregivers lack the ability 

to adequately care for your patient, be 

alert for signs of neglect or self-neglect 

(see Figure 6.5). If you suspect neglect 

or self-neglect, involve adult protective 

services (APS). Neglect is the failure of 

a caregiver to fulfill his/her caregiving 

responsibilities, whether due to willful neglect or an inability as a result of 

disability, stress, ignorance, lack of maturity, or lack of resources. Self-neglect 

is the failure to provide for one’s own 

essential needs. APS will investigate 

for neglect, self-neglect or abuse of the 

elderly person. APS can secure services 

such as case planning, monitoring, and 

evaluation; and can arrange for medical, 

social, economic, legal, housing, law 

enforcement and other emergency or 

supportive services. To obtain contact 

information for your State office, call 

the Eldercare Locator at 800-677-1116. 

chapter 6—Counseling the Patient Who Is No Longer Safe to Drive 55 
 

Figure 6.6 

July 1, 2009 

Clayton Phillips 

123 Lincoln Lane 

Sunnydale, XX 55555 

Dear Mr. Phillips: 

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

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

health problems and medicines. I recommended that you stop driving due to your slowed reaction time, poor vision and muscle weakness. 

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

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

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

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

two can discuss this plan together. 

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

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

plan is working for you. 

For a mandatory reporting State considering adding: 

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

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

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

For a voluntary reporting State consider adding: 

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

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

your license. 

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

Sincerely, 

Your Physician 

Enc: How to Assist the Older Drive 

cc: Your son 

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

56 chapter 6—Counseling the Patient Who Is No Longer Safe to Drive 
chapter 7 

Ethical and Legal 

Responsibilities of the 

Physician 

 

 

 

 

 

 

 

chapter 7 

Ethical and Legal 

Responsibilities of 

the Physician 

This chapter is intended to provide a general overview of a questions that may arise with an individual patient. The 

physician’s ethical and legal responsibilities as related to cases cited in this chapter are provided as examples of the 

reporting unsafe drivers to their State’s DMV. While some range of opinions in attempting to fairly define the scope of 

sections of this chapter address issues that are inherently legal, the physician’s responsibility to report impaired drivers. The 

the chapter is not intended to provide legal advice. The views, cases additionally demonstrate society’s efforts to provide safe 

discussion, conclusions and legal analysis are those of the environments for its citizens. 

authors and do not represent the opinions, policies or official 

positions of NHTSA. This chapter conveys the current For your reference, we have compiled a State-by-State list 

environment at the time of publication and compiles general of reporting laws, licensing requirements, license renewal 

knowledge to assist physicians in understanding the reporting information, and DMV contact information in Chapter 8. 

process. Laws, regulations and policies vary not only by State Please note that information may have changed since the 

but also by local jurisdiction, and are subject to change. There- publication of this guide. You are encouraged to contact 

fore, it is important for physicians to seek out legal advice your State DMV for the most up-to-date information. 

from a licensed attorney in their States on specific issues or 

Upon further evaluation, you 

diagnose Mrs. Allen (see Chapter 

6) with Alzheimer’s disease. It is 

readily apparent that her condition 

has progressed to the extent that she 

is no longer safe to drive and that 

rehabilitation is not likely to improve 

her driving safety. You tell Mrs. 

Allen that she must stop driving 

for the sake of her safety and the 

safety of others on the road. You 

also explain that the State physician 

reporting law requires you to notify 

the Department of Motor Vehicles 

(DMV) of your diagnosis. Initially, 

Mrs. Allen does not comprehend, 

but when you 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 DMV, but is now 

concerned that she will encounter 

legal problems if her mother attempts 

to drive without a license. She asks 

if it is absolutely necessary for you to 

report her mother. What do you say? 

Driving is a difficult topic to address, 

particularly when there is the risk of 

damaging the patient-physician relationship, violating patient confidentiality, 

and potentially losing patients. To 

complicate matters, many physicians are 

uncertain of their legal responsibility, 

if any, to report unsafe drivers to their 

State DMV.129,130 As a result, physicians 

are often faced with a dilemma: should 

they report the unsafe driver to the 

State DMV at the expense of breaching 

confidentiality and potentially damaging 

the patient-physician relationship, or 

should they forego reporting and risk 

being liable for any potential patient or 

third-party injuries for failing to report? 

Furthermore, should they engage the 

family in taking the responsibility for 

driving restriction or cessation? 

The Physician’s Ethical Duties 

Current legal and ethical debates high129. Kelly, R., Warke, T., & Steele, I. (1999). Medical 

restrictions to driving: the awareness of patients 

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

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

physicians toward elderly drivers and driving 

policy. J Am Geriatr Soc. 40:722–724. 

light duties of the physician that are 

relevant to the issue of driving. 

These include: 

“Duty to Protect” 

The Patient 

Protecting the patient’s physical and 

mental health is considered the physician’s 

primary responsibility. This includes not 

only treatment and prevention of illness, but also caring about the patient’s 

safety. With regard to driving, physicians should advise and counsel their 

patients about medical conditions and 

possible medication side effects that 

may impair one’s ability to drive safely. 

Certain States have enacted mandatory 

reporting requirements, which place the 

physician in danger of both civil and 

criminal liability for failure to report.131 

Wording in the Pennsylvania law has 

led the Pennsylvania DMV to state that 

physicians who do not report “could be 

held responsible as a proximate cause of 

an accident resulting in death, injury or 

property loss caused by your patient; the 

Pennsylvania statute further states that 

131. OR. REV. STAT.§ 807.710 (2001) 

59 
 

providers who do not comply with 

their legal requirement to report may 

be convicted of a summary criminal 

offense”.132 Some cases illustrate that a 

physician’s failure to advise the patient 

about such medical conditions and 

medication side effects can be considered 

negligent behavior.133 

The Public 

In addition to caring for their patients’ 

health, physicians may, in certain 

circumstances and jurisdictions, have 

some responsibility for protecting the 

safety of the public.134,135 In certain 

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

Code (stating physicians are immune from 

any civil or criminal liability if they do report 

patients 15 years of age or older who have been 

diagnosed as having a condition that could 

impair his/her ability to safely operate a motor 

vehicle; but, if the physician does not report 

could, then, possibly be held responsible as a 

proximate cause of an accident resulting in 

death, injury, or property loss caused by the 

physician’s patient. Also, physicians who do 

not comply with their legal requirement to 

report may be convicted of a summary criminal 

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

pdotforms/fact_sheets/fs-pub7212.pdf 

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

Texas court case that physicians have a duty 

to warn patients that medications may impair 

driving but that physicians do not have a duty 

to control a patient’s behavior). 

Wilschinsky v. Medina, 108 NM 511 (stating in 

a New Mexico court case the physician owed 

a duty of care to an individual harmed by the 

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

duty 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). 

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

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

ruling per se, upon which the principles of 

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

originally applied only in the State of California 

and now applies only in certain jurisdictions. 

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

involving these principles. Many States have 

adopted statutes to help clarify steps that are 

considered reasonable when a physician is presented with someone making a threat of harm to 

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

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

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

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

89 (defining factors applied in a Pennsylvania 

court case in determining the existence of a 

duty: (1) the relationship between the parties; 

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

the nature of the risk imposed and foreseeability 

of the harm incurred; (4) the consequences of 

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

public interest in the proposed solution). 

States, physicians have been found 

liable for third-party injuries because 

they failed to advise their patients 

about medication side effects,136 medical 

conditions,137 and medical devices138 

that may impair driving performance 

thus causing harm to those other than 

the patient. 

Maintaining patient 

confidentiality 

Patient confidentiality is the right of an 

individual to have personal, identifiable medical information kept private; 

these protections are enumerated in the 

federal statute, the Health Insurance 

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

Suburban Transportation System, 65 Wn. 2d 

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

State case, that a physician could be held liable 

due to the fact that a patient took medication 

completely unaware that it would have any 

adverse effect on him because the physician 

failed to warn his patient, whom he knew to 

be a bus driver, of the dangerous side effects of 

drowsiness or lassitude that may be caused by 

taking this particular medication). 

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

Kansas court case that that the doctor had no 

duty to protect bicyclists - a third party- from 

his patient’s actions because the patient who 

had a sleep disorder was aware of the problem 

and admitted to knowing that she should have 

stopped driving). 

Duvall v. Goldin, 362 NW 2d 275 (finding 

in a Michigan court case that the physician 

was liable to third persons injured as it was 

foreseeable that a doctor’s failure to diagnose or 

properly treat an epileptic condition could have 

created a risk of harm to a third party and that 

as a result of the patient’s medical condition, 

caused an automobile accident involving the 

third persons). 

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

(finding in a California court case that if a 

physician knows or should know a patient’s 

condition will impair the patient’s mental 

faculties and motor coordination, a comparable 

warning is appropriate). 

Schuster v. Alternberg, 424 NW 2d 159 (finding 

in a Wisconsin court case that if it was 

ultimately proven that it could have been 

foreseeable to a psychiatrist, exercising due care, 

that by failing to warn a third person or failing 

to take action to institute detention or commitment proceedings someone would be harmed, 

negligence could be established). 

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

1364 (finding in a Maine court case that when 

the doctor knew, or reasonably should have 

known that his patient’s ability to drive has been 

affected by treatment that the doctor provided, 

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

the patient to warn his patient of that fact). 

Portability and Accountability Act of 

1996, or HIPAA.139 Patient confidentiality is defined as the physician’s ethical 

obligation to keep information about 

the patient and his/her care unavailable 

to those—including the patient’s family, 

the patient’s attorney, and the government 

—who do not have the authorization to 

receive or review this information.140,141 

Patient confidentiality is crucial within 

the physician-patient relationship 

because it encourages the free exchange 

of information, allowing the patient to 

describe symptoms for diagnosis and 

treatment.142 Without belief in the 

patient confidentiality of their care, 

individuals may be less likely to seek 

treatment, disclose information for 

effective treatment, or trust the health 

care professional.143 

The need for patient confidentiality 

cannot be considered absolute; a 

patient is entitled to freely disclose his 

or her symptoms and condition to his 

or her physician in confidence except 

where the public interest or the private 

interest of the patient so demands, and 

thus a patient possesses a limited right 

to patient confidentiality in extrajudicial disclosures subject to exceptions 

prompted by the supervening interest of 

society.144 Thus, patient confidentiality 

does not necessarily protect the physi139. Health Insurance Portability and Accountability 

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

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

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

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

Rules and Regulations; page 82811. Available 

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

privacyrule/prdecember2000all8parts.pdf 

140. Justice J. Patient confidentiality and pharmacy 

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

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

nov/patient.html. 

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

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

Saunders Company; 1997: p. 1808. 

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

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

296. 

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

(deliberating in a South Carolina court case 

the benefits and risks of physician disclosing 

confidential patient information when that 

confidential information may protect patients 

and society from possible harm). 

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

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

Philadelphia: W. B. Saunders Company. 

60 chapter 7—Ethical and Legal Responsibilities of the Physician 
cian in the impaired driver situation.145 

Reporting Facts and Trends 

Medically Impaired Driver Reports 

National Highway Traffic Safety 

Administration (NHTSA) provides 

some information on State reporting for 

medically impaired drivers.146 Data from 

Oregon in 1993 suggested that close 

to 5,300 reports were submitted each 

year. About 55% were for drivers over 

age 65 years, and surprisingly one-third 

of reports were self-referral. Health 

care providers accounted for 37% of 

all reports. The two leading reasons for 

referral were epilepsy (19%) and stroke 

(15%). Few people had their license 

suspended. In 1995 Florida reported 

that 11.7% of referred drivers had their 

license suspended.147 

Pennsylvania requires health professionals to report any medical condition 

that can impair the ability to control 

or safely operate a motor vehicle.148 

In 2008, Pennsylvania received over 

27,000 reports, and 22% of these 

individuals have impairments serious 

enough to merit recall of their driving privilege. An additional 21% of 

reports result in restrictions placed on 

the individual’s driving privilege. Half 

of the recalls were attributed to seizure 

disorders, while 16% were attributable 

to other neurological disease.149 

A recent Missouri report by Meuser, 

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

146. National Highway Traffic Safety Administration. Family and Friends Concerned about 

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

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

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

Eby; Medical Fitness to Drive & A Voluntary 

Reporting Law: The AAA Foundation for 

Traffic Safety (2008). 

147. National Highway Traffic Safety Administration. Family and Friends Concerned about an 

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

olddrive/FamilynFriends/state.htm. Accessed 

11/12/07. 

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

Code. 

149. PENNSYLVANIA DEPARTMENT OF 

TRANSPORTATION; PHYSICIAN REPORTING FACT SHEET; March 2008. Available 

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

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

et al. on medically impaired drivers 

who are referred for fitness-to-drive 

evaluations found that very few older 

adults retain their license (<3%) when 

referred by any source.150 Notably, very 

few (<30%) of referrals came from physicians- most reports were submitted 

by police officers- indicating a need 

to educate health professionals in this 

area. The mean age of the study group 

was 80 and had an elevated crash risk 

prior to license referral when compared 

to controls. The majority of the referrals 

were due to an underlying cognitive 

impairment such as dementia (45%), 

although visual impairment was present 

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

individuals, 144, (3.5%) retained a 

driver’s license after the process. 

Missouri has a voluntary reporting law 

and further study is required to determine the benefits between mandatory 

reporting States and those that allow 

voluntary reporting.151 

Differences in referral rates, laws, and 

procedures probably account for variations among States. The information 

from the various States suggests that 

more research is needed on the sources 

of referral, barriers for reporting and the 

medical conditions of these drivers to 

determine whether referral is useful or 

whether other common conditions are 

underreported. 

Limitations of Reports: Most States 

require that physicians fill out their 

State’s forms when assessing fitness to 

drive. Physicians may experience problems or barriers to providing the State 

with accurate information. Taylor and 

colleagues found that patients, in fact, 

may not inform their doctor of relevant 

medical history that could pertain to 

driving.152 Older drivers may have a 

poor understanding of the laws in their 

150. Meuser T, Carr DB, & Ulfarsson GF. Motor-Vehicle Crash History and Licensing Outcomes for 

Older Drivers Reported as Medically Impaired 

in Missouri. Accident Analysis and Prevention. 

Accepted November 2008 (in press). 

151. Ibid. 

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

Accident experience and notification rates 

in people with recent seizures, epilepsy or 

undiagnosed episodes of loss of consciousness. 

Q J Med. 88:733-740. 

own State and/or have poor insight into 

their own driving abilities,153 or simply 

cannot face voluntarily giving up their 

freedom to drive. Although the authors of this guide are not aware of any 

supporting studies, there are concerns 

about “doctor shopping,” failure to 

disclose pertinent information in order 

to secure more favorable opinions, or 

approaching a new clinician who is unaware of the pertinent medical diagnoses. Physicians may be unaware of what 

functional battery or tests to perform 

to determine fitness-to-drive.154 Interrater reliability has been reported to be 

low when different physicians filled out 

the same type of medical report on the 

same patient.155, 156 However, physicians 

will continue to play an integral role 

in these types of evaluations and will 

require education in this area.157 Thus, a 

comprehensive approach such as identifying medical conditions or red flags, 

and using the ADReS battery should 

assist physicians in addressing some of 

the concerns. 

Physicians Concerns about Reporting 

A study of 523 Canadian physicians’ 

attitudes on medical fitness to drive 

found that most physicians would 

report unfit drivers, but at the same 

time believed this reporting could 

adversely affect the confidentiality 

expectations within the patientphysician relationship.158 Physicians 

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

Medical restriction to driving: the awareness 

of patients and doctors. Postgrad Med J, 

75:537-539. 

154. Ibid. 

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

(2003). Are medical reports on fitness to drive 

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

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

Assessment of older drivers: relationships among 

on-road errors, medical conditions and test 

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

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

Evaluation of fitness to drive: the physician’s 

role in assessing elderly or demented patients. 

Postgrad Med J. 107:229-236. 

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

Saskatchewan physicians’ attitudes and knowledge regarding assessment of medical fitness 

to drive. Canadian Medical Association Journal. 

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

Fitness to Drive & A Voluntary Reporting 

Law: The AAA Foundation for Traffic Safety, 

pg 30 (2008). 

chapter 7—Ethical and Legal Responsibilities of the Physician 61 
 

 

 

have raised concerns about mandatory 

reporting, stating it can violate privacy, 

compromise the ability to counsel 

patients, and negatively impact the 

doctor-patient relationship.159 Some 

physicians have suggested that mandatory reporting has the potential to 

discourage patients from seeking 

health care.160 

Six States have mandatory reporting 

requirements: California, Delaware, 

Nevada, New Jersey, Oregon, and 

Pennsylvania. In California, physicians 

are required to report specific conditions 

such as seizure disorders or Alzheimer’s 

disease, among other conditions. Cable 

et al. found that physicians practicing 

in mandatory reporting States are more 

likely to report impaired drivers to the 

licensing agency.161 Thus, physicians 

may choose not to report in certain situations unless they are required by law to 

do so. We are not aware of any studies 

that examine the efficacy of mandatory 

or voluntary reporting laws, or any that 

have drawn comparisons between States 

with differing approaches. But, physicians are required to follow the law of 

their particular State as it now stands. 

We urge you to become familiar with 

your State’s laws. 

Immunity and Confidentiality: Of the 43 

States with voluntary reporting laws, 

18 currently do not protect reporting 

health professionals from liability for 

civil damages.162 The National Com159. Molnar & Eby; Medical Fitness to Drive & A 

Voluntary Reporting Law: The AAA Foundation for Traffic Safety, pg 30 (2008). 

160. Kelly R, Warke T, Steele I. Medical restrictions to driving: the awareness of patients and 

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

West et al., The Mandatory Reporting of Adult 

Victims of Violence: Perspectives from the 

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

161. Cable G, Reisner M, Gerges S, & Thirumavalavan V. Knowledge, attitudes, and practices of 

geriatricians regarding patients with dementia 

who are potentially dangerous automobile 

drivers: a national survey. J Am Geriatr Soc. 

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

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

Advisory Board Practices in the United States. 

Task Report Prepared Under NHTSA Contract 

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

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

ProgramPracticesRecommendationsAndModelLaws 

.htm 

mittee on Uniform Traffic Laws and 

Ordinances (NCUTLO) reporting of a 

“Model Driving Impairment Law” has 

suggested that physician immunity from 

civil liability should be an important 

component of any law.163,164 Physicians 

have concerns about breach of confidentiality; however, several exceptions 

to maintaining confidentiality exist. For 

example, information may be released 

if the patient gives his/her consent, 

or may be released without patient 

authorization in order to comply with 

reporting statutes (such as child abuse 

reporting statutes) and court orders. 

The Health Insurance Portability and 

Accountability Act (HIPAA) has a 

regulation that allows for reporting 

information that includes a patient’s 

protected health information when it is 

in the public interest.165 In some cases, 

the act of reporting itself may help 

protect the physician from damages 

sought by third parties. 

Adhering to State Reporting Laws 

Because each State has its own reporting laws, we have provided a State-byState reference list in the following 

chapter. Please note that information 

may have changed since the publication 

of this guide. You should contact your 

State DMV for the most up-to-date 

information. 

Please note that in States where there 

are no laws authorizing physicians to 

163. Reporting of Driver Impairment Model Law; 

The National Committee on Uniform Traffic 

Laws and Ordinances, at www.ncutlo.org/ 

impairment.htm Accessed Sept 24th, 2009. 

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

to Identify Best Practices for Licensing Drivers 

with Medical and Functional Impairments and 

Barriers to their Implementation. #DTNH22­

02-P-05111; National Highway Traffic Safety 

Administration; 2004. 

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

to the State when the situation is significant 

enough to put public safety at risk. Source: 

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

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

specific requirements related to preemption of 

State law, “Permitted uses and disclosures 5. 

Public interest and benefit activities” Available 

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

summary/index.html 

report patients to the DMV, physicians 

should have patient authorization in 

order to disclose medical information. 

In these States, physicians who disclose 

medical information without patient 

authorization may be liable for breach 

of confidentiality. Nevertheless, this 

should not dissuade physicians from 

reporting when it is necessary and justified to protect the patient and/or public. 

The AMA recognizes that the safety of 

older drivers is a growing public health 

concern that is best addressed through 

multi-sector efforts to optimize vehicle 

design, the driving environment, and 

the individual’s driving capabilities.166 

Please refer to chapter 1 in this guide to 

review AMA Ethical Opinion E-2.24 

“Impaired Drivers and Their Physicians.” 

Putting it all together 

How can you fulfill these competing 

legal and ethical duties? In this section, 

we provide recommendations for 

achieving this balance. 

Counsel your patient and if indicated, 

include the family. 

Patients should be advised of medical 

conditions, procedures and medications 

that may affect driving performance. 

(A reference table of medical conditions 

and medications that may affect driving 

performance, with recommendations for 

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

can get the patient’s permission, involve 

the family in the counseling process 

whenever it seems appropriate. If the 

patient does not have decision-making 

capacity (e.g., due to Alzheimer’s 

disease), this information should be 

given to a cognitively intact surrogate 

decision-maker. 

Recommend driving cessation 

as needed. 

As discussed in the previous chapters, 

you should recommend that a patient 

cease driving if you believe that he/ 

166. AMA policy H-15.954 Older Driver Safety; 

(CSA Rep. 6, A-03). 

62 chapter 7—Ethical and Legal Responsibilities of the Physician 
 

 

she may be an unsafe driver and that 

his/her driving cannot be made safe 

by any available medical treatment, 

adaptive device, or adaptive technique. 

As always, base your clinical judgment 

on the patient’s driving abilities rather 

than the patient’s age. This recommendation should be documented in 

the chart and there should be a system 

in the office setting to check on future 

compliance with recommendations. 

Know and comply with your State’s 

reporting laws. 

You must know and comply with your 

State’s reporting laws (see Chapter 8). 

If you fail to follow these laws, you may 

be liable for patient and third-party 

injuries. 

If your State has a mandatory medical reporting law, report the required 

medical condition(s) using the DMV’s 

official form. If your State has a voluntary physician reporting law, report the 

information using the DMV’s official 

form and any other reporting guidelines. 

If the DMV’s guidelines do not indicate what patient information must be 

reported, provide only the minimum 

information necessary to show that your 

patient may be an unsafe driver. 

Reduce the impact of breaching 

patient confidentiality 

In adhering to the State’s reporting laws, 

it may be necessary for the physician to 

breach their patient’s confidentiality. 

However, you can do several things 

to reduce the impact of this on the 

patient-physician relationship. 

Providing Notice to the DMV 

Before reporting to the DMV, tell 

your patient what you are about to do. 

Explain that it is your ethical, and in 

some cases legal, responsibility to refer 

him/her to the State DMV, and describe 

what kind of follow-up can be expected 

from the DMV. Assure your patient 

that out of respect for his/her privacy, 

you will disclose only the minimum 

information required and hold all other 

information confidential. Even in 

States that offer anonymous reporting 

or reporter confidentiality, it is a good 

idea to be open with your patients. 

You may wish to remind the patient 

that ultimately the physician does not 

determine driver licensing. This is the 

responsibility of the State. Thus, the 

State has the final decision on determining whether the patient should still 

be allowed to drive. 

When submitting your report, provide 

only the information necessary or 

required to establish that your patient 

may be unsafe. Consider giving your 

patient a copy of his/her report. By 

providing your patients with as much 

information as possible, you can involve 

them in the process and give them a 

greater sense of control. 

Before contacting your patient’s family 

members and caregivers, request the 

patient’s permission to speak with these 

parties and document this in the chart. 

If your patient maintains decisional 

capacity and denies permission for you 

to speak with these parties, you must 

respect the patient’s wishes. 

Document diligently. 

Through documentation, you provide 

evidence of your efforts to assess and 

maintain your patient’s safety. In the 

event of a patient or third-party crash 

injury, good documentation may protect 

you against a judgment from a lawsuit. 

To protect yourself legally, you should 

document your efforts, conversations, 

recommendations, and any referrals for 

further testing in the patient’s chart.167 

In other words, you should document 

all the steps of Physician Plan for Older 

Drivers’ Safety (PPODS) (see page 6) 

that you have performed, including: 

• Any direct observations of your 

patient’s functional status, red flags 

as described in PPODS, or driving 

history that lead you to believe that 

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

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

your patient may be potentially at risk 

for 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 your patient’s 

driving-related functions (e.g., 

documenting that the patient has 

undergone the ADReS battery and 

including the ADReS scoring sheet 

in the chart). 

• Any medical interventions and 

referrals you have made to improve 

the patient’s function and any repeat 

testing to measure improvement. 

• A copy of the DRS report, if the 

patient has undergone driver 

assessment and/or rehabilitation. 

• Your recommendation on whether 

the patient should continue driving 

or cease driving. If you recommend 

that the patient cease driving, include 

a summary of your interventions (e.g., 

“sent letter to patient to reinforce 

recommendation,” “discussed transportation options and gave copy of 

‘Patient Resource Sheet’,” “contacted 

family members with patient’s permission,” and “reported patient to DMV 

with patient’s knowledge”). Include 

copies of any written correspondence 

in the chart or electronic record. 

• Follow-up for degree of success in 

using alternate transportation options 

and any signs of social isolation and 

depression. Document any further 

interventions, including referral to a 

social worker, geriatric care manager, 

or mental health professional. 

Additional legal and ethical 

concerns 

What should you do if you find yourself 

in a particularly challenging situation? 

In this section, we offer recommendations for several potential situations: 

Situation 1: My patient threatens to sue 

me if I report him/her to the DMV. 

A patient’s threat to sue should by no 

means deter you from complying with 

chapter 7—Ethical and Legal Responsibilities of the Physician 63 
 

 

 

 

 

 

 

 

 

your State’s reporting laws. If a patient 

threatens to sue, there are several steps 

you can take to protect yourself in the 

event of a lawsuit: 

• Know if your State has passed legislation specifically protecting health 

care professionals against liability 

for reporting unsafe drivers in good 

faith.168 (This information can be 

found in the following chapter.) 

• Even if your State has not passed 

such legislation, physicians generally 

run little risk of liability for following mandatory reporting statutes in 

good faith. Consult your attorney 

or malpractice insurance carrier to 

determine your degree of risk. 

• Make certain you have clearly documented your reasons for believing 

that the patient is an unsafe driver. 

Be aware that physician-patient privilege 

does not prevent you from reporting your 

patient to the State DMV. Physicianpatient privilege, which is defined as the 

patient’s right to prevent disclosure of 

any communication between the physician and patient by the physician, does 

not apply in cases of required reporting. 

Remind the patient that ultimately the 

physician does not determine licensing. 

This is the responsibility of the State. 

Thus, the State has the final decision 

on determining whether the patient 

should still be allowed to drive. 

Situation 2: Should I report an unsafe 

driver even if my State does not have 

any reporting laws? 

In this situation, the physician’s 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 DMV. 

Before reporting your patient, you may 

address the risk of liability for breaching 

patient confidentiality by following the 

steps listed under Situation 1. 

However, if your patient refuses to 

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

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

Saunders Company; 1997; p. 1809. 

stop driving despite your best efforts, 

then you must consider which is more 

likely to cause the greatest amount of 

harm: breaching the patient’s confidentiality versus allowing the patient to 

poten-tially injure himself/herself and 

third parties in a motor vehicle crash. 

According to AMA Policy E-2.24 (see 

Chapter 1), “in situations where clear 

evidence of substantial driving impairment implies a strong threat to patient 

and public safety, and where the physician’s advice to discontinue driving 

privileges is ignored, it is desirable and 

ethical to notify the Department of 

Motor Vehicles.” 

Situation 3: My patient has had his/ 

her license suspended by the DMV for 

unsafe driving, but I am aware that he/ 

she continues to drive. 

This patient is clearly violating the law, 

and several questions are raised: Is the 

physician responsible for upholding the 

law at the expense of breaching patient 

confidentiality? Since the license 

has been revoked by the DMV, is the 

driving safety of the patient now the 

responsibility of the DMV, the physician, or both? 

There are several steps you can take in 

this situation: 

• Ask your patient why he/she continues 

to drive. Address the specific causes 

brought up by your patient (see the 

previous chapter for recommendations). 

With your patient’s permission, the 

family should be involved in finding 

solutions such as alternative methods 

of transportation. 

• Ask your patient if he/she understands 

that he/she is breaking the law. 

Reiterate your concerns about the 

patient’s safety, and ask how he/she 

would feel about causing a crash and 

potentially being injured or injuring 

someone else. Discuss the financial 

and legal consequences of being 

involved in a crash without a license 

or auto insurance. Many clinicians 

will remind the patient and/or family 

that the patient could have financial 

liability for any injuries caused by 

driving. 

• Discuss the financial and emotional 

burden a car collision would cause 

them, their family, and all others 

involved. 

• If your patient is cognitively impaired 

and lacks insight into this problem, 

the issue must be discussed with the 

individual who holds decision-making 

authority for the patient and with any 

other caregivers. These parties should 

understand their responsibility to 

prevent the patient from driving. 

• If your patient continues to drive and 

your State has a physician reporting 

law, adhere to the law by reporting 

your patient as an unsafe driver (even 

if you have already done so previously, resulting in the revocation of 

your patient’s license). If your State 

does not have a physician reporting 

law, base your decision to report as in 

Situation 2 (see above). The DMV, 

as the agency that grants and revokes 

the drivers license, will follow-up as it 

deems appropriate. 

Situation 4: My patient threatens to 

find a new doctor if I report him/her to 

the DMV. 

This situation, while unfortunate, 

should not prevent you from adhering 

to your State’s reporting laws. As a 

physician, it is your responsibility to 

care for your patients’ health and safety, 

regardless of such threats. 

Several strategies may help you diffuse 

this situation: 

• Reiterate the process and information 

used to support your recommendation 

that the patient stop driving. 

• Reiterate your concern for the safety 

of your patient, his/her passengers, 

and those sharing the road. 

• Remind your patient that you try to 

provide the best possible care for 

his/her health and safety. State that 

driving safety is as much a part of 

patient care as encouraging patients 

to wear a seat belt, keep a smoke 

detector in the house, floss their 


teeth, and have regular physical 


check-ups. 

64 chapter 7—Ethical and Legal Responsibilities of the Physician 
 

 

• Encourage your patient to seek a 

second opinion. A DRS may evaluate 

the patient if this has not already 

been done, or the patient may consult 

another physician. 

• If your State DMV follows up on 

physician reports with driver retesting, 

inform the patient that just as it is 

your responsibility to report him/ 

her to the DMV, it is the patient’s 

responsibility to prove his/her driving 

safety to the DMV. Emphasize that 

the DMV makes the final decision, 

and that only the DMV can legally 

take away the license. Remind your 

patient that you have done everything medically possible to help him/ 

her pass the driver test. 

• As always, maintain professional 

behavior by remaining unemotional 

and not expressing hostility toward 

your patient even if he/she ultimately 

makes the decision to seek a new 

physician. 

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

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

Glossary of Terms 

anonymity and Legal protection: Several States offer anonymous reporting 

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

maintain the confidentiality of the reporter, unless otherwise required by a court 

order.169 

driver rehabilitation programs: These programs, run by driver rehabilitation 

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

adaptive devices and compensatory techniques. Clients typically receive a clinical evaluation, driving evaluation, and—if necessary—vehicle modifications and 

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

Chapter 5.) 

duty to protect: In certain jurisdictions State physicians have a legal duty to 

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

identifiable third parties.170 With respect to driving, mandatory reporting laws 

and physician reporting laws provide physicians with guidance on their duty 

to protect. 

good Faith: Honest and respectful in all professional interactions171 

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

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

DMV beforehand. 

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

report patients who have specific medical conditions (e.g., epilepsy, dementia) 

to their State DMV. These States provide specific guidelines and forms that can 

be obtained through the DMV. 

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

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

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

MABs specify mitigation that would permit continued licensure. MABs vary 

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

physician reporting Laws: Some States require physicians to report “unsafe” 

drivers to the State DMV, with varying guidelines for defining “unsafe.” The 

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

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

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

172 

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

About an Older Driver. NHTSA Report No. DOT HS 809 307. “State Reporting Practices.” Washington, DC: National Highway Traffic Safety Administration. 

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

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

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

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

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

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

chapter 7—Ethical and Legal Responsibilities of the Physician 65 
Glossary of Terms (continued) 

physician Liability: Previous cases have illustrated situations in which the 

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

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

prior to the incident.173 

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

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

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

renewal by mail; require specific vision, traffic law and sign knowledge; and/or 

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

renewal.174 

restricted drivers License: Some States offer the restricted license as an 

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

night driving, limiting driving to a certain distance from home, requiring adaptive devices, and shortening the renewal interval. To our knowledge, the efficacy 

of these types of restrictions has not been tested. 

third (3rd) party: The generic legal term for any individual who does not 

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

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

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

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

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

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

66 chapter 7—Ethical and Legal Responsibilities of the Physician 
chapter 8
 

State Licensing and 

Reporting Laws 

 

 

 

 

chapter 8 

State Licensing and 


Reporting Laws
 

Each State has its own licensing and 

license renewal criteria for drivers of 

private motor vehicles. In addition, 

certain States require physicians to 

report unsafe drivers or drivers with 

specific medical conditions to the 

driver licensing agency. 

This chapter contains licensing agency 

contact information, license renewal 

criteria, reporting procedures and medical advisory board information, listed 

by State. These materials are intended 

to guide physicians in understanding 

their legal responsibilities and managing 

the driving safety of their patients. The 

information in this chapter should not 

be construed as legal advice nor used to 

resolve legal problems. If legal advice is 

required, please consult an attorney who 

is licensed to practice in your State. 

Please note that information may have 

changed since the publication of this guide. 

You should contact your State DMV for 

the most up-to-date information. 

License renewal practices 

among States 

Practices vary among States for license 

renewal based on age. A recent review 

summarized some of these nuances, and 

are reviewed in this paragraph.175 Many 

States require renewal every four to five 

years, and one State requires no renewals until age 65 (Arizona). Fourteen 

States require some type of accelerated 

renewal for older drivers, ranging from 

age 60 to 80, with the length of the 

accelerated renewal cycle ranging from 

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

at driver license renewal policies in the United 

States. Public Policy and Aging Report. National 

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

one year (Illinois at age 87) to five years 

(Arizona, Colorado, South Carolina). 

Surprisingly, one State actually has a 

decelerating renewal for older drivers, 

with no renewal required after age 65 

(Tennessee). Over time, there has been 

a trend toward lengthening the period 

of license renewal. Seventeen States 

have special renewal provisions for older 

drivers, including in-person renewal, 

vision tests, written tests, road tests, a 

medical certification of fitness, or some 

combination of these. Thus, a minority 

of States have requirements for morefrequent testing for adults over 65.176 

A variety of options can apply due to 

the special renewal provisions of older 

drivers. These include license renewal, 

revocation or suspension, restriction, 

or shortening of the renewal cycle. 

A recent review indicates that in some 

jurisdictions in Australia age-based 

assessment has not been associated with 

safety benefits.177 Some of the literature 

supports vision testing during license 

renewal for older adults. One investigator compared occupant motor vehicle 

fatalities for those over age 60 in States 

with and without a vision-related relicensing laws and concluded there would 

be a 12.2-percent reduction in fatalities 

over the period of study if the majority of 

States without such laws were to adopt 

one.178 Another study examined the 

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

State motor vehicle laws and older drivers. 

Health Econ. 14(4):407–419. 

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

(2008). An Australian model license reassessment procedure for identifying potentially 

unsafe drivers. Traffic Inj Prev. 9:350–359. 

178. Shipp, M. D. (1998). Potential human economic cost-savings attributable to vision testing 

policies for driver license renewal 1989–1991. 

Optom Vis Sci. 75:103–118. 

effects of license renewal timing, and 

tests of visual acuity, knowledge and 

road examinations on older driver fatalities. The researchers concluded that 

tests of visual acuity were associated 

with a lower fatal crash risk for older 

drivers.179 Another study investigated 

the effect of renewal testing by comparing the crash rates of older adults in 

Indiana and Illinois (which at the time 

required vision, knowledge, and road 

testing at age 75) with similar controls 

in States that do not have age-based 

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

States that had age-based testing, there 

was a 7 percent reduction in involvement in injurious crashes, but an 

increase in at-fault single-vehicle crash 

rates.180 The authors concluded that 

routine road testing was not warranted. 

An examination of the effects of shorter 

licensure renewal periods for older 

adults along with an analysis of the 

crashes before and after discontinuation 

of road tests for those under 75 in Illinois 

was performed. Comparing changes in 

1989 from before to after new policies 

were enacted, no effects were observed 

on crashes, fatal crashes, crash rates, or 

licensure rates of older drivers. Although 

there are no data to support an improvement in public safety when 

road testing the general older adult 

population during license renewal, 

mandatory road testing requirements 

along with vision testing have been 

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

and State license renewal policies to driving 

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

180. Lange, J. E., & McKnight, A. J. (1996). Agebased road test policy evaluation. Transport Res 

Rec. 1550:81–87. 

69 
 

 

 

 

noted to decrease license renewal safety benefits for mandatory assessment 

rates.181 programs.185 Similarly, a comparison of 

Swedish and Finnish licensing practices 

A recent U.S. study raises further doubt did not demonstrate an advantage for 

about the efficacy of intensive screen­ age-related license renewal requireing during the license renewal process. ments. Finland requires regular mediVision tests were not found to reduce cal evaluations starting at age 70 for 

crash risk, while an in-person renewal license renewals, whereas Sweden has 

requirement reduced fatalities for driv­ no age-related requirements. The Finners 85 and older by 16.3 percent.182 This ish program not only did not have a 

may result from license renewal staff reduction in crash rates but was actually 

requesting that older adults be evaluat­ associated with higher pedestrian fataled, with subsequent revocation of their ity rates.186 

license or some older drivers deciding 

to give up their licenses rather than go 

through the renewal process. Specific State information 

Information on each specific State was 

These testing procedures and regulations obtained from each State’s driver licensdo impose significant costs on States, ing agency and reflects the most current 

and at times inconvenience and costs information at the time of publication. 

to individual drivers. If licenses are Please note that this information is 

revoked, older adults face the problems subject to change. Contact your specific 

of restricted mobility and loss of out-of- States’ statutes for up-to-date changes 

home activities, which may decrease in the laws or requirements. This is 

social connectedness. In addition, the especially important when it comes to 

impact on family members and caregiv­ creating a clinic policy or deciding on 

ers, such as time away from work, is an individualized approach to reporting. 

not insignificant. This burden must Legal counsel is recommended to advise 

be carefully weighed against the actual your decision-making in this area. 

“added value” or benefits of improved 

public safety.183 When information was not available 

from an individual State’s driver licensInternational experience ing agency, the following references were 

used and remain as useful resources for 

In Australia, different States have clinicians. The Insurance Institute for 

various requirements for older adults, Highway Safety and Insurance Informaranging from no license renewal tion Institute sites are usually updated 

requirements, to vision, road, and/or at frequent intervals and the Web site 

requirement for a medical evaluation will indicate the latest version. 

from a physician.184 One study found 

similar crash rates across populations 

based on the number of licenses issued, 

indicating there were no demonstrable 

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

Relationship between driver’s license renewal 

policies and fatal crashes involving drivers 70 

years and older. JAMA. 274:1026–1030. 

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

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

vehicle fatalities. JAMA. 291:2840–2846. 

183. Miller, T.R., & Levey, D.T. (2000). Cost-out­ 185. Langford, J., Fitzharris, M., Newstead, S., & Kocome analysis in injury prevention and control: ppel, S. (2004). Some consequences of different 

eighty-four recent estimates for the United older driver licensing procedures in Australia. 

States. Med Care. 2000;28(6):562–582. Accid Anal Prev. 36: 993–1001. 

184. Fildes, B., Pronk, N., Langford, J., Hull, M., 186. Hakamies-Blomqvist, L., Johansson, K., &LunFrith, W., & Anderson, R. (2000). Model dberg, C. (1996). Medical screening of older 

license re-assessment procedure for older and drivers as a traffic safety measure: a comparative 

disabled drivers (Report # AP-176/00). Finnish-Swedish evaluation study. J Am Geriatr 

Canberra, Australia: Ausroads. Soc. 446:650–653. 

70 chapter 8—State Licensing and Reporting Laws 
 

Alabama 

Name of State & DMV Alabama Department of Public Safety 334-242-4239 

contact information PO Box 1471 

Montgomery, AL 36102-1471 

www.dps.state.al.us 

Licensing Requirements 

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

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

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

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

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

20/40 

20/40 

20/40 

20/60 in best eye with or without 

corrective lenses. Class D only. 

Yes-for daylight driving only for 

2 years then will be reviewed. 

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

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

110° both eyes-Class D only 

Keystone View 

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

Restricted licenses Yes 

License Renewal Procedures 

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

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

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

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

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

4 years 

In-person 

Yes 

No 

No 

Age-based renewal procedures No special requirements for age. 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Physician reporting is encouraged. 

Immunity Yes 

Legal protection Yes 

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

completed by patient’s doctor. 

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

and signs the appropriate forms. 

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

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

Medical Advisory Board 

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

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

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

information 

71 
 

 

 

Alaska
 

Name of State & DMV Alaska Department of Motor Vehicles 907-269-5551 

contact information 3300 B Fairbanks Street 

Anchorage, AK 99503 

www.state.ak.us/dmv/ 

Licensing Requirements 

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

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

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

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

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

20/40 

20/40 

20/40 

20/100 needs report from eye 

specialist—license request determined by discretion 

Only under certain conditions specifically recommended by physician 

in regards to lighting conditions, 

number of miles to and from specific 

locations. Need letter stating “with 

the bioptic telescopes this patient 

can safely operate a motor vehicle 

without endangering the public under 

the following conditions:” 

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

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

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

Restricted licenses Yes 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 5 years
 

Renewal options and conditions.................................................. Mail in every other cycle
 

Vision testing required at time of renewal? .................................. Yes, at in-person renewal
 

Written test required?................................................................. No
 

Road test required?.................................................................... No
 

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

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting A licensee should self-report medical conditions that cause loss of consciousness to the DMV. 

Immunity No 

Legal protection N/A 

DMV follow-up All medical information submitted to DMV is reviewed by the Department of Public Safety personnel. 

Other reporting Requires retest/re-exam upon receipt of documented problem by law enforcement, other DMVs, and 

family members. 

Anonymity N/A 

Medical Advisory Board 

Role of the MAB	 Alaska does not have a Medical Advisory Board 

Medical Review contact 	 Referrals for reexamination can be sent to: 

information	 Department of Administration, Juneau Driver Licensing | Po Box 110221 | Juneau, Alaska 99811 

907-465-4361 | fax 907-465-5509 

72 
 

 

Arizona
 

Name of State & DMV Arizona Motor Vehicle Department 623-925-5795 phone 

contact information Medical Review Program 623-925-9323 fax 

Mail Drop 818Z 

PO Box 2100 

Phoenix, AZ 85001-2100 

www.dot.state.az.us/MVD/mvd.htm 

Licensing Requirements 

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

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

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

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

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

20/40 

20/40 

20/40 

20/60 in best eye restricted to 

daytime only 

No 

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

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

70°, 35° Nasal 

Keystone view 

Color vision Is there a color vision requirement?.............................................Commercial Drivers Licenses only 

Road test Depends on physician recommendation and provided information 

Restricted licenses Yes, daylight only 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 12 years
 

Renewal options and conditions.................................................. N/A
 

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

Written test required?................................................................. No
 

Road test required?.................................................................... If recommended
 

Age-based renewal procedures	 At age 65, reduction of cycle to 5 years. No renewal by mail after age 70 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Yes 

Immunity Yes 

Legal protection Reporting immunity is granted 

DMV follow-up Follows physician recommendation 

Other reporting Will accept information from courts, police, other DMVs, family members and other resources. 

Anonymity Yes 

Medical Advisory Board 

Role of the MAB	 Reports are reviewed by the Medical Review Program staff to determine of a license requires 

a re-examination of driving skills/written testing, or medical/psychological evaluation. 

Medical Review contact 	 Mail Drop 818Z 

information	 Medical Review Program 

PO Box 2100 

Phoenix, AZ 85001 

623-925-5795 

Fax 623-925 9323 

73 
 

 

Arkansas
 

Name of State & DMV Arkansas Driver Control 501-682-1631 

contact information Hearing Officer, Rm 1070 

1910 West 7th 

Little Rock, AR 72203 

www.state.ar.us/dfa/odd/motor_vehicle.html 

Licensing Requirements 

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

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

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

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

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

20/40 

20/50 

20/40 

20/40 in best eye for unrestricted; 

20/60 restricted 

Yes, under certain circumstances. 

20/50 through telescope, 20/50 

through carrier/must still have 

minimal field of vision 105° 

Visual fields Minimum field requirement.........................................................Both eyes 105° 

Color vision Is there a color vision requirement?.............................................OPTEC Screening Machine 

Road test Type of road test ........................................................................Standardized 

Restricted licenses Yes, daylight driving only at physicians’ recommendation— 

however must meet minimal visual requirements 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 years
 

Renewal options and conditions.................................................. In person, and by mail only 


if out of State 

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

Written test required?................................................................. No 

Road test required?.................................................................... No 

Age-based renewal procedures	 No 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting We do encourage unsafe driver’s to be reported to our office. 

Immunity No 

Legal protection No 

DMV follow-up Medical information is reviewed by the director of Driver Control. An appointment is scheduled within 2 

weeks of receipt. At that time, a medical form is given to the licensee for completion by a physician. If 

the medical exam is favorable, the road test is given. 

Other reporting	 Will accept information from courts, police, other DMVs, and family members. 

Anonymity	 N/A 

Medical Advisory Board 

Role of the MAB	 Arkansas has no Medical Advisory Board. 

Medical Review contact Unsafe drivers may be referred to Driver Control at the contact above. 

information 

74 
 

 

 

California
 

Name of State & DMV Licensing Policy Section 916-657-6550 

contact information California Department of Motor Vehicles 

2570 24th Street 

Sacramento, CA 95818 

www.dmv.ca.gov/ 

Licensing Requirements 

Visual acuity Each eye with/without correction................................................. One eye 20/70 if other is 20/40. This 

is a screening standard, if failure then 

referral to vision specialist, possible 

road test. Not an absolute standard. 

Both eyes with/without correction ............................................... 20/40. Also a screening standard 

If one eye blind—other with/without correction............................ 20/40 (with road test given unless 

stable, long-standing condition 

Absolute visual acuity minimum .................................................. Better than 20/200, best corrected, in 

at least one eye. Cannot use bioptic 

telescope to meet standard. 

Are bioptic telescopes allowed? .................................................. Yes, daylight driving only. 

Visual fields Minimum field requirement.........................................................75 degrees for a person wearing a 

bioptic telescopic lens. No minimum 

field exists for any other drivers 

Color vision requirement	 No 

Type of road test	 The Driving Performance Evaluation (DPE) is administered for original licensing and for some experienced impaired drivers (e.g., drivers with vision problems). For other experienced drivers (e.g., drivers 

with cognitive deficits), the Supplemental Driving Performance Evaluation (SDPE) is administered. 

Restricted licenses	 Yes, varied restrictions—most commonly to corrective lenses. 

License Renewal Procedures 

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

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

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

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

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

Age-based renewal procedures No mail renewal at 70+ 

5 years 

In person or, if qualify, Internet or mail 

renewal for no more than 2 license 

terms in sequence. 

Yes, at in person, not mail, renewal 

At in-person renewal, unless driver 

has had 2 and would be eligible for a 

3rd sequential mail renewal, if there 

were such. These drivers don’t take a 

written test. 

Not generally, unless evidence of 

highly likely impairment for driving. 

Reporting Procedures 

Mandatory medical reporting	 Yes, physicians are required to report all patients diagnosed with “disorders characterized by lapses of 

consciousness”. Law specifies that this definition includes Alzheimer’s “and those related disorders that 

are severe enough to be likely to impair a person’s ability to operate a motor vehicle” 

Physician/medical reporting	 No, though they are authorized to report, given their good faith judgment that it’s in the public interest. 

Immunity	 Yes, if condition is required to be reported. (A physician who has failed to report such a patient may be 

held liable for damages.) A physician has immunity from reporting a condition, even if it is not required, 

if in good faith, the physician believes it will serve the public interest. 

Legal protection	 See above. 

75 
California (continued)
 

DMV follow-up	 The medical information obtained from physician is reviewed by DMV hearing officers within Driver 

Safety Branch. Driver will be reexamined; at conclusion of process DMV may take no action, impose 

restrictions, limit license term, order periodic reexaminations, suspend or revoke the driver’s license. 

Other reporting	 Basically anyone—DMV will accept information from driver him or herself, courts, police, other DMVs, 

family members and other resources. 

Anonymity	 If so requested, name will not be divulged (unless court order mandates disclosure) 

Medical Advisory Board 

Role of the MAB Gathers specialists for panels on special driving related topics (e.g., vision). Panels make policy recommendations to DMV for dealing with groups of drivers having a particular type of impairment. No recommendations are made regarding individuals as such. 

Medical Review contact information MAB no longer meets as a group. For further information contact: 

Licensing Policy Section 

California Dept. of Motor Vehicles 

2570 24th Street 

Sacramento, CA 95818 

916-657-6550 

76 
 

 

 

Colorado
 

Name of State & DMV Colorado Division of Motor Vehicles 303-205-5646 

contact information Driver’s License Administration 

1881 Pierce Street, Room 136 

Lakewood, CO 80214 

www.colorado.gov/revenue/dmv 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40*
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. No absolute minimum acuity. Will 


license any individual that physician/ 

optometrist feels is not a danger. 

Are bioptic telescopes allowed? .................................................. Yes, however we are going to revisit 

the issue in the near future. 

Visual fields Minimum field requirement......................................................... Yes, we now test for minimum 

horizontal fields. 

Color vision requirement	 No 

Restricted licenses	 Yes: based on the results of the vision screening test and/or doctor’s recommendations. 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 5 years
 

Renewal options and conditions.................................................. If eligible, mail in every other cycle
 

Vision testing required at time of renewal? .................................. Yes, unless mail-in renewal
 

Written test required?................................................................. Only if point accumulation results in 


suspension 

Road test required?.................................................................... No, unless condition has developed 

since last renewal that warrants road 

test. 

Age-based renewal procedures	 All licenses are valid for 5 years. However, license holders 61 and older cannot renew by mail. 

Reporting Procedures 

Mandatory medical reporting	 No 

Physician/medical reporting	 Drivers should self-report medical conditions that may cause a lapse of consciousness, seizures, etc. 

Physicians are encouraged but not required to report patients who have a medical condition that may 

affect their ability to safely operate a motor vehicle. 

Immunity	 Yes—no civil or criminal action may be brought against a physician or optometrist, licensed to practice 

in Colorado, for providing a written medical or optometric opinion. 

Legal protection	 No 

DMV follow-up	 Driver notified in writing of referral. Driver undergoes re-examination. One circumstance for retest: 

incident report from law enforcement. Medical clearance may be required from a physician. 

Restrictions may be added to license. 

Other reporting	 Will accept information from courts, police, other DMVs and family members. 

Anonymity	 Not confidential 

Medical Advisory Board 

Role of the MAB Colorado does not currently retain a medical advisory board. 

Medical Review contact information Questions about medical review can be referred to 303-205-5788 

* Unless the driver is blind in one eye, testing each eye is not typically conducted. 

77 
 

 

 

Connecticut
 

Name of State & DMV Connecticut DMV Medical Review Division 860-263-5223 

contact information 60 State Street Fax: 860-263-5774 

Wethersfield, CT 06161-2510 

http://dmvct.org/ 

Licensing Requirements 

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

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

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

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

20/40 

20/40 

20/40 

20/70 better eye restricted; some 

circumstances allow for license at 

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

20/200 or better 

No 

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

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

100° monocular; 140° binocular 

OPTEC 1000 

Color vision Is there a color vision requirement?.............................................No (only for commercial drivers) 

Road test A general on the road skills test with Motor Vehicle instructor or licensing agent. Test for “graduated 

license’ conducted by off-site staff who makes and appt. with applicant at residence and conducts test 

in State-owned, dual control vehicle. Applicant with specific needs is trained/tested by a Handicapped 

Driver Training Unit certified driving instructor. 

Restricted licenses Graduated license considerations include applicant’s health problem/condition, accident record and 

driving history. Restrictions include: daylight only, corrective lenses, no highway driving, automatic 

transmission only, required external mirrors, special controls or equipment, use of hearing aid. 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 6 years
 

Renewal options and conditions..................................................	 In-person at DMV full-service branch, 

mobile units scheduled locations, 

satellite offices, license renewal 

centers, authorized AAA offices. 

Vision testing required at time of renewal? .................................. Yes, at age 65.
 

Written test required?................................................................. No
 

Road test required?.................................................................... Only for new applicants or for 


applicants whose license has 

expired for two or more years. 

Age-based renewal procedures Yes, age 65+ may renew for 2 years; age 65+ may renew by mail upon written application showing 

hardship which shall include but not limited to proximity of operator’s residence to DMV renewal facility. 

Reporting Procedures 

Mandatory medical reporting	 No 

Physician/medical reporting	 Sec 14-46 states that “physicians may report to the DMV, in writing the name, age, and address of any 

person diagnosed by him to have any chronic health problem which in the physicians judgment will 

significantly affect the person’s ability to safely operate a motor vehicle.” 

Immunity	 No civil action my be brought against the commissioner, the department or any of its employees, the 

board or any if its members or any physician for providing any reports, records, examinations, opinions 

or recommendations. Any person acting in good faith, shall be immune from liability. 

Legal protection	 Only the laws regarding immunity apply. 

DMV follow-up	 Driver notified in writing of referral to MAB. If MAB requires additional information for review in order to 

make a recommendation, driver is requested to file the additional medical information requested; entire 

file is referred back to MAB and driver is notified of such referral. 

78 
Connecticut (continued)
 

Other reporting	 State regulations, require “reliable information’ to be on file for DMV to initiate a medical review case. 

This includes a written, signed report from person in medical/law enforcement profession., or a third 

party report on the DMV affidavit which requires signing in the presence of a notary public. 

Anonymity	 All information on file in a medical review case is classified as “confidential” but is subject to release to 

the person at their representative, upon written authorization from the person to release the data. 

Medical Advisory Board 

Role of the MAB MAB must be comprised of 8 specialties: general medicine or surgery, internal medicine, cardiovascular, 

medicine, neurology, or neurological surgery, ophthalmology, orthopedics, psychiatry or optometrist. 

Advise commissioner on health standards relating to safe operation of motor vehicles; recommend 

procedures and guidelines for licensing individuals with impaired health; assist in developing 

medically acceptable standardized report forms; recommend training course for motor vehicle 

examiners on medical aspects of operator licensure; undertake any programs/activities commissioner 

may request relating to medical aspects of motor vehicle operator licensure; make recommendations 

and offer advice on individual health problem cases referred and establish guidelines for dealing with 

such individual cases. 

Medical Review contact 

information 

Department of Motor Vehicles 

Medical Review Division 

60 State Street 

Wethersfield, CT 06161-2510 

79 
 

 

Delaware
 

Name of State & DMV 	 Delaware Department of Safety 302-744-2507 

contact information	 Division of Motor Vehicles 

Medical Records 

PO Box 698 

Dover, DE 19903 

www.dmv.de.gov 

Licensing Requirements 

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

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

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

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

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

20/40 

20/40 

20/40 

20/50 restricted license, beyond 

20/50 driving privileges denied 

Yes, on a case by case basis: 

daytime only 

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

Color vision Is there a color vision requirement?.............................................None 

Restricted licenses Yes, daytime only 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 5 years
 

Renewal options and conditions.................................................. In person
 

Vision testing required at time of renewal? .................................. Yes, must pass vision screening
 

Written test required?................................................................. No
 

Road test required?.................................................................... No
 

Age-based renewal procedures	 No 

Reporting Procedures 

Mandatory medical reporting	 Yes. Failure to do so is punishable by a fine of $5 to $50. Physicians should report patients subject to 

“losses of consciousness due to disease of the central nervous system.” 

Physician/medical reporting	 Yes 

Immunity	 Yes 

Legal protection	 Unknown 

DMV follow-up	 Driver notified in writing of referral; license suspended and further examination necessary. 

Other reporting	 DMV will accept information from courts, other DMVs, police, and family members. 

Anonymity	 Yes. DMV protects the identity of the reporter. 

Medical Advisory Board 

Role of the MAB If the DMV receives conflicting or questionable medical reports, they are sent to the MAB for a determination as to whether or not a person is medically safe to operate a motor vehicle. 

Medical Review contact information Medical Records Section - Driver Improvement Unit 

PO Box 698 

Dover, DE 19903-0698 

Phone: 302-744-2507 

Fax: 302-739-5667 

80 
 

 

District of Columbia
 

Name of State & DMV District of Columbia Department of Motor Vehicles 202-727-6244 

contact information Medical Review Office 

301 C Street NW., Room 1033 

Washington, DC 20001 

http://dmv.washingtondc.gov/ 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/70
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/40 acuity; 20/70 in better eye 


requires 140 E visual field for 

restricted license. 

Are bioptic telescopes allowed? .................................................. No 

Visual fields Minimum field requirement......................................................... 130° both eyes (may be approved by 

director at 110°) 

Visual field testing device ........................................................... Confrontation or perimetry (Binocular) 

Color vision requirement New drivers 

Type of road test	 Road test is required for new drivers. Senior citizens may be required to take the read test on an 

observational basis. Also, some physical disabilities may require re-testing. 

Restricted licenses	 Yes: acuity not less than 20/70 and daytime, if field of vision is 140° 

License Renewal Procedures 

Standard Length of license validation......................................................... 5 years 

Renewal options and conditions.................................................. IDC drivers with clean driver record 

and no medical requirements can 

now renew driver licenses on-line 

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

Written test required?................................................................. Yes, however drivers are allowed a 

6 months grace period 

Road test required?.................................................................... No 

Age-based renewal procedures	 At age 70, the licensee must have the physician complete the certification on the drivers license 

application form. 

Reporting Procedures 

Physician/medical reporting	 If patient has a medical condition that may impair your ability to safely operate a motor vehicle, even 

temporarily, you must provide a Medical and/or Eye Report* from your physician. Some of these conditions include: Alzheimer’s disease: Requires a Medical Report* and the completion of the knowledge 

and road skills tests; Seizure Disorder/Loss of Consciousness: Requires a Medical Report* DC regulation 

states you must be seizure-free for at least twelvemonths prior to obtaining a driver’s license. If you are 

currently licensed and experience a seizure or loss of consciousness, you must report the incident to 

DMV within 30 days. Unless your physician indicates the seizure was due to a change in medication, 

or strictly nocturnal, DMV will suspend your driving privilege for twelve months from the date of the 

last episode; Insulin-dependent Diabetes: Requires a Medical and Eye Report; Vision impairment (i.e., 

glaucoma, cataracts, eye disease, and monocular vision): Requires an Eye Report* 

Immunity	 No 

Legal protection	 No 

81 
 

 

District of Columbia (continued) 

DMV follow-up DMV will use the medical information provided by your physician to determine if a driver’s license may 

be issued or issued with restrictions. We may also issue a driver’s license for a shorter duration based 

on your physician’s information. Also, if your doctor recommends follow-up Medical and/or Eye Reports,* 

we will track this information to ensure compliance. If we do not receive the follow-up reports within the 

timeframe specified by your physician, your license will be subject to suspension. 

Other reporting A Medical Report* is also required when a law enforcement officer suspects a driver may have a medical condition that led to a traffic citation or accident. If DMV receives a detailed, written statement from 

a family member, law enforcement officer, or physician related to the unsafe driving of a resident, we 

will also require the resident to complete a Medical Report.* Driving tests may also be required in any of 

these situations, depending on the circumstances. 

Anonymity Yes, reporters are allowed to remain anonymous 

Medical Advisory Board 

Role of the MAB DC-DMV does not currently have a Medical Advisory Board. 

Medical Review contact information Referrals can be made to the contact above. 

* Available at www.dmv.washingtondc.gov/info/forms/medical_eye_pdf.shtm 

82 
 

 

 

Florida
 

Name of State & DMV Florida Division of Drivers License 850-488-8982 phone 

contact information Medical Review 850-921-6147 fax 

Neil Kirkman Building, Room A227-MS 86 

Tallahassee, FL 32399-0500 

www.hsmv.state.fl.us/ddl/dlfaq_new.html 

Licensing Requirements 

Visual acuity Each eye without correction........................................................ 20/40: 20/50 or worse referred to eye
 

specialist for possible improvement
 

Both eyes without correction....................................................... 20/40: 20/50 or worse referred to eye
 

specialist for possible improvement
 

Each eye with correction............................................................. 20/70, other eye better than 20/200
 

Both eyes with correction ........................................................... 20/70, unless one eye 20/200
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/70
 

Are bioptic telescopes allowed? .................................................. No
 

Visual fields Minimum field requirement......................................................... 130° horizontal 

Visual field testing device ........................................................... None, Goldman by eye specialist if 

indicated 

Color vision requirement No 

Type of road test	 Standard Road Test 

Restricted licenses	 Yes: Corrective lenses, outside rearview mirror, business &/or employment purposes only, daylight 

driving, automatic transmission, power steering, directional signals, grim on steering wheel, hearing 

aid, seat cushion, hand control or pedal ext, left foot accelerator, probation interlock device, medical 

alert bracelet, educational purposes, graduated license restrictions, other restrictions. 

License Renewal Procedures 

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

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

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

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

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

Age-based renewal procedures None 

4–6 years, depending on driving 

history 

In-person, every 3rd cycle 

At in-person renewal only 

Depending on driving history and/or 

DL supervisor requires on the basis 

of observation of physical or mental 

impairments 

Only if DL supervisor requires on the 

basis of observation of physical or 

mental impairments 

Reporting Procedures 

Mandatory medical reporting	 No 

Physician/medical reporting	 “Any physician, person or agency having knowledge of a licensed driver or applicant’s mental or physical disability to drive may report the person to the Department of Highway Safety and Motor Vehicles.” 

Forms are available on DHSMV Web site, as well as at local driver license offices. Physicians are 

“authorized” by law and encouraged to report—DDL Medical Section provides other forms as situation 

requires. 

Immunity	 The law provides that no report shall be used as evidence in any civil or criminal trial or in any court 

proceeding. 

Legal protection	 Florida law “authorizes” the physician to report unsafe drivers. 

DMV follow-up	 Investigation: Sanction actions if needed, Driver notified in writing. 

Other reporting	 Law authorizes any person, physician or agency. 

Anonymity	 Yes 

83 
Florida (continued)
 

Medical Advisory Board 

Role of the MAB To advise the Department on medical criteria and vision standards and to make recommendations on 

mental and physical qualifications of individual drivers. 

Medical Review contact information MAB Chairperson 

DHSMV/DDL/Driver Improvement Medical Section 

2900 Apalachee Parkway 

Tallahassee, FL 32399-0570 

Telephone: 850-488-8982 

Fax 850-921-6147 

84 
 

 

Georgia
 

Name of State & DMV Georgia Department of Public Safety 678-413-8500 or 678-413-8600 

contact information Attn: Medical Unit 

PO Box 1456 

Atlanta, GA 30371 

Outside Atlanta metro 

866-754-3687 

www.dds.ga.gov/drivers/index.aspx 

Licensing Requirements 

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

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

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

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

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

Visual fields 

Color vision requirement 

Type of road test 

Restricted licenses 

Minimum field requirement......................................................... 

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

None 

N/A 

Yes 

20/60 

20/60 

20/60 

20/60 in either eye with or without 

corrective lenses. 

Yes, permitted for best acuity as low 

as 20/200, with restrictions. 20/60 

through telescope; 20/60 through 

carrier 

140° each eye; 140° both eyes 

Juno Vision machine 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 years
 

Renewal options and conditions.................................................. In person
 

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

Written test required?................................................................. Not required for renewals
 

Road test required?.................................................................... Not required for renewals
 

Age-based renewal procedures	 None 

Reporting Procedures 

Mandatory medical reporting Yes. Physicians should report patients with a diagnosed “conditions hazardous to driving” 

Physician/medical reporting Yes, physicians may report a person who has a handicap which would render the individual incapable 

of safely operating a motor vehicle 

Immunity No 

Legal protection No 

DMV follow-up Medical evaluation and retest 

Other reporting Will take information from anyone with knowledge that the driver may be medically or mentally unsafe. 

Anonymity No 

Medical Advisory Board 

Role of the MAB	 The Medical Advisory Board advises agency personnel on individual medical reports and 

assists the agency in the decision making process. 

Medical Review contact information	 Department of Motor Vehicle Safety 

C/O Medical Unit 

PO Box 80447 

Conyers, GA, 30013 

85 
 

 

Hawaii
 

Name of State & DMV Honolulu Division of Motor Vehicles & Licensing 808-532-7730 

contact information Drivers License Branch 

1199 Dillingham Boulevard, Bay A-101 

Honolulu, HI 96817 

www.co.honolulu.hi.us/mvl.index.htm 

Licensing Requirements 

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

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

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

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

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

20/40 

20/40 

20/40 

20/40 for better eye 

Not allowed to meet visual field 

requirements, however permitted to 

use while driving 

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

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

70° one eye 

Eye testing machine or eye specialist 

certification 

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

Road test N/A 

Restricted licenses Yes 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 2, 4 or 6 years
 

Renewal options and conditions.................................................. In person, or by mail
 

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

Written test required?................................................................. No
 

Road test required?.................................................................... Only if necessary
 

Age-based renewal procedures	 After age 72, must renew every 2 years. Age 15 to 17 every 4 years, age 18 to 71 every 6 years 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting No 

Immunity No 

Legal protection No 

DMV follow-up Driver notified in writing of referral. 

Other reporting Will accept information from courts, police, other DMVs, and family members. 

Anonymity N/A 

Medical Advisory Board 

Role of the MAB	 Action based on recommendation of majority. 

Medical Review contact 	 General Information: Department of Transportation 808-692-7656 

information	 Case Specific, County of Issue: 

Honolulu 808-532-7730 

Hawaii: 808-961-2222 

Kauai: 808-241-6550 

Maui: 808-270-7363 

86 
 

 

Idaho
 

Name of State & DMV Idaho Transportation Department 208-334-8735 

contact information Division of Motor Vehicles, Driver Services 

PO Box 7129 

Boise, ID 83707 

http://itd.idaho.gov/dmv/online_services.htm 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40 in better eye for unrestricted 


Absolute visual acuity minimum .................................................. license; 20/50-20/60 requires annual 


testing; 20/70 denied license 

Are bioptic telescopes allowed? .................................................. Yes, if acuity is 20/40 through lens, 

20/60 through carrier 

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

Color vision requirement	 None 

Type of road test	 Annual road test may be required to coincide with vision or medical re-testing requirements 

Restricted licenses	 Available 

License Renewal Procedures 

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

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

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

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

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

Age-based renewal procedures After age 69, no renewal by mail. 

DL expires 5 days after age 18 and 

age 21. 4-year renewal age 21 and 

older. 8-year renewal for age 21 to 62. 

Mail in every other cycle, if 4 year DL, 

not CDL’s 

Yes 

No 

Only if requested by examiner, law 

Enforcement agency, family member 

or DMV. An annual road test may be 

required to coincide with vision or 

medical re-testing requirements. 

Reporting Procedures 

Physician/medical reporting Yes (not specified) 

Immunity None 

Legal protection N/A 

DMV follow-up License suspended upon referral. 

Other reporting Will accept information from family members, other DMVs, and law enforcement officers. 

Anonymity Not anonymous or confidential 

Medical Advisory Board 

Medical Desk Technician The medical information submitted is initially reviewed by employees within the Driver Support Division 

who work specifically with medical cases. 

Role of the MAB Idaho does not have an MAB. 

Medical Review contact information MVR/Medical Unit Supervisor can be reached at 208-334-8716 

87 
 

Illinois
 

Name of State & DMV Illinois Office of the Secretary of State 217-785-0963 

contact information Driver Services Department–Downstate 

2701 S. Dirksen Parkway 

Springfield, IL 62723 

Driver Services Department–Metro 312-814-2975 

17 N. State Street, Suite 1100 

Chicago, IL 60602 

www.sos.state.il.us/departments/drivers/drivers.html 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................... 20/40
 

Both eyes with/without correction ................................. 20/40
 

If one eye blind—other with/without correction.............. 20/40
 

Absolute visual acuity minimum .................................... 20/40 in better eye unrestricted; 20/70 in 


better eye daylight only restrictions, 

Are bioptic telescopes allowed? .................................... Yes, may have 20/100 in better eye and 20/40 

through bioptic telescope. 

Visual fields	 Minimum field requirement............................................ 105° one eye, 140° both eyes
 

Visual field testing device .............................................. Stereo optical testing machine
 

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

Road test	 Type of road test...........................................................On-road driving test
 

Restricted licenses	 Yes: daytime, two outside mirrors 

License Renewal Procedures 

Standard	 Length of license validation........................................... 4 years
 

Renewal options and conditions.................................... Mail in every other cycle for drivers with clean 


records and no medical report 

Vision testing required at time of renewal? .................... At in-person renewal only 

Written test required?................................................... Every 8 years unless clean driving record 

Road test required?...................................................... Only for applicants age 75+ 

Age-based renewal procedures	 Age 81–86 every 2 years, at age 87 reduce renewal to 1 year. Age 75+ no renewal by mail, vision test 

required, and on-road driving test required. 

Reporting Procedures 

Mandatory medical reporting Are physicians required/encouraged to report “unsafe” 

drivers? 

Are physicians required to report patients with certain 

medical conditions? 

Physician/medical reporting Are physicians exempt from liability for civil damages 

caused by the patient if they report the patient to the 

DMV beforehand? 

Immunity Does the State offer the physician legal protection for 

breaking the patient’s confidentiality? 

Legal protection How does the DMV follow up? 

Physicians are encouraged to inform patients 

of their responsibility to notify the Secretary 

of State of any medical conditions that may 

cause a loss of consciousness or affect safe 

operation of a motor vehicle within 10 days of 

becoming aware of the condition. 

No 

Yes 

N/A. Illinois is not a mandatory reporting State. 

Driver notified in writing of referral. Driver 

required to submit a favorable medical report. 

Determination of further action based on 

various scenarios. 

88 
Illinois (continued)
 

DMV follow-up Aside from physicians, who else can report? Will accept information from courts, foreign 

State DMVs, law enforcement, member of 

the IL Medical Advisory Board, NDR, PDPS, 

SOS management employee, FMCSA, driver 

rehabilitation specialist, or self-admission. 

Other reporting Does the DMV protect the identity of the reporter? Yes 

Anonymity Does the DMV protect the identity of the reporter? Yes 

Medical Advisory Board 

Role of the MAB	 Review the medical report and make a determination as to the status of the driving privileges of the 

driver. Decision of the MAB implemented by the Secretary of State. 

Medical Review contact 	 Supervisor, Medical Review Unit 

information	 Office of the Secretary of State 

Driver Services Department 

2701 South Dirksen Parkway 

Springfield, IL 62723 

217-785-3002 

89 
 

Indiana
 

Name of State & DMV Indiana Bureau of Motor Vehicles 317-233-6000 

contact information Medical Section 

Indiana Government Center North 

100 N Senate Avenue. Room N402 

Indianapolis, IN 46204 

www.mybmv.IN.gov 

Licensing Requirements 

Visual acuity Each eye with/without correction................................................. 20/40 minimum each eye without 

restrictions. 20/50 each eye with 

correction = glasses/contacts restriction required unless vision referral 

presented with approval from Medical 

Advisory Board specifying that corrective lenses will not improve acuity. 

Both eyes with/without correction ............................................... Indiana tests each eye individually 

If one eye blind—other with/without correction............................ One eye 20/40 other eye 20/50 

through blind without correction = 

outside rearview mirrors restriction. 

One eye 20/40 other eye 20/50 

through blind with correction = 

glasses/contacts, outside rearview 

mirrors restriction. 

One eye 20/50 other eye 20/70 

through blind with correction = 

glasses/contacts, outside rearview 

mirrors and daylight driving only 

restrictions. 

Absolute visual acuity minimum .................................................. The absolute minimum visual acuity 

obtained by a customer service representative in order to issue a license 

is 20/70 in each eye with correction 

= glasses/contacts, outside rearview 

mirrors and daylight driving only 

restrictions for licensing. The BMV will 

license an individual with less acuity 

upon the recommendation of the 

Medical Advisory Board. 

Are bioptic telescopes allowed? .................................................. Yes, for acuity as low as 20/200 

if 20/40 can be achieved with 

telescope = restrictions apply 

Visual fields Minimum field requirement.........................................................N/A for standard license renewal, 

70° one eye, 120° both eyes 

(when required) 

Color vision Is there a color vision requirement?.............................................N/A for standard renewal
 

Road test Type of road test........................................................................Standardized road tests are 

administered by State examiners 

Special/courtesy drives tests 

(extended) are administered 

by a State senior examiner 

Restricted licenses A variety of restrictions are available—most common restriction is for corrective lenses 

* Testing (visual, written or skills) to obtain a 4-year commercial driver license is more stringent per Federal guidelines than for renewal 

of a standard operator license as stated here. 

90 
 

 

 

 

Indiana (continued)
 

License Renewal Procedures 

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

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

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

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

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

Standard length of license validation 

Operator License 

June 7th 2007–Dec. 31st 2007: 

5 years 

Jan. 1st 2008–Dec. 31st 2008: 

4 years 

Jan. 1st 2009: 6 years 

In person 

Yes (acuity) 

Yes, if new to State, if 6 or more 

points appear on the driving record, 

if expired more than 2 years or 

recommended by the Medical 

Advisory Board. 

Yes, if new from out of country, if out 

of State license is expired more than 

1 year, if Indiana license is expired 

more than 3 years or in the event the 

bureau receives evidence of driving 

impairment 

Age-based renewal procedures	 Licenses issued to individuals under the age of 18 expire at midnight on the individuals’ 21st birthday. 

Age 75–84, renewal cycle is reduced to 3 years 

Age 84 +, renewal cycle is reduced to 2 years. 

Reporting Procedures 

Mandatory medical reporting	 None 

Physician/medical reporting	 Drivers should self-report medical conditions that may cause lapse of consciousness, seizure, etc. 

Physicians are encouraged but not required to report to the bureau a patient who may have a medical 

condition that would adversely affect their ability to operate a motor vehicle safely. 

Immunity	 A physician licensed to practice medicine under IC 25-22.5, an optometrist licensed to practice 

optometry under IC 25-24, or an advanced practice nurse licensed under IC 25-23 who has personally 

examined the patient not more than thirty (30) days before making a report concerning the patient’s 

fitness to operate a motor vehicle is not civilly or criminally liable for a report made in good faith to the:

 (1) bureau;

 (2) commission; or

 (3) driver licensing medical advisory board; 

concerning the fitness of a patient of the physician, optometrist, or advanced practice nurse to operate 

a motor vehicle in a manner that does not jeopardize the safety of individuals or property. 

Legal protection	 Applicable immunity law only. 

DMV follow-up	 Written notification. 

Other reporting	 Will accept information from courts, law enforcement, family members and other reliable sources 

Anonymity	 The BMV protects the identity of the reporter, unless information is required by a court of law 

Medical Advisory Board 

Role of the MAB	 MAB advises the Bureau of Motor Vehicles on medical issues regarding individual drivers. Actions are 

based on the recommendation of the majority and/or specialist. 

Medical Review contact information	 Referrals can be faxed to 317-233-3138. Questions should be directed to 317-232-0901 

91 
 

 

 

Iowa
 

Name of State & DMV Iowa Department of Motor Vehicles 515-237-3201 

contact information IA DOT, Park Fair Mall 

100 Euclid Avenue, PO Box 9204 

Des Moines, IA 50306-9204 

www.dot.state.ia.us/mvd/ 

Licensing Requirements 

Visual acuity Each eye with/without correction................................................. 20/40 

Both eyes with/without correction ............................................... 20/40 

If one eye blind—other with/without correction............................ 20/40 

Absolute visual acuity minimum .................................................. 20/50 daylight driving only, 20/70 

in better eye restricted license for 

daylight only up to 35 mph; 20/100 

recommendation from vision specialist, if worse—recommendation from 

MAB; absolute minimum 20/200 

Are bioptic telescopes allowed? .................................................. No 

Visual fields Minimum field requirement.........................................................140° both eyes. With outside mirrors 

70°T + 45° N one eye, 115° both 

eyes. If less than 95° both eyes and 

60°T+35°N one eye need MAB 

recommendation 

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

Road test	 Type of road test........................................................................Non-fixed Course, general traffic
 

Restricted licenses	 Yes 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 2 or 4 years
 

Renewal options and conditions.................................................. In-person, extensions available if out 


of State for 6 months. 

Vision testing required at time of renewal? .................................. No
 

Written test required?................................................................. No
 

Road test required?.................................................................... Yes, If physical or mental condition 


present Age-based renewal procedures	 At age 70, renewal every 2 years. 

Reporting Procedures 

Mandatory medical reporting	 No 

Physician/medical reporting	 A physician may report to the department of motor vehicles “the identity of a person who has been diagnosed as having a physical or mental condition which would render the person physically or mentally 

incompetent to operate a motor vehicle in a safe manner. 

Immunity	 Yes 

Legal protection	 Yes—321.186 A physician or optometrist making a report shall be immune from any liability, civil or 

criminal, which might otherwise be incurred or imposed as a result of the report 

DMV follow-up	 Driver notified in writing of referral. License suspended upon referral. 

Other reporting	 Will accept information from courts, other DMVs, police and family members. 

Anonymity	 Not confidential 

Medical Advisory Board 

Role of the MAB To review medical/vision reports as requested and advise of their recommendation to a person’s capability to drive safely. 

Medical Review contact Iowa Department of Transportation Des Moines, IA 50306-9204 

information Office of Driver Services Phone 800-532-1121 

92 PO Box 9204 
 

 

 

 

Kansas
 

Name of State & DMV 	 Kansas Division of Motor Vehicles, Driver Control 

contact information	 Docking State Office Building 

915 SW Harrison Street 1st Floor 

Topeka, Kansas 66625 

www.ksrevenue.org/dmvdrlic.htm 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/40 better eye unrestricted, 20/60 


better eye with doctor report, worse 

than 20/60 must demonstrate ability 

to operate a vehicle and safe driving 

record for 3 years. 

Are bioptic telescopes allowed? .................................................. Yes, with eye doctor’s report.
 

Visual fields Minimum field requirement......................................................... Worse than 110° with both eyes and 

55° monocular 

Color vision requirement	 None 

Type of road test	 Non-fixed course 

Restricted licenses	 Up to 4 restrictions can be added, at doctors/examiners discretion. These can include: corrective 

lenses, daylight only, no interstate driving, outside business area, within city limits, mileage restriction 

in increments of 5 mi. up to 30, outside mirror, mechanical aid, automatic transmission, prosthetic aid, 

licensed driver in front seat. 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 6 years
 

Renewal options and conditions.................................................. In person
 

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

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

Road test required?.................................................................... Yes, by examiner challenge or for visual 


acuity, or at medical doctor request. 

Age-based renewal procedures	 At age 65, renewal every 4 years. There is no age-based road test. 

Reporting Procedures 

Mandatory medical reporting	 No, statutes specify that physicians may not be required to volunteer information to the division or to the 

medical advisory board concerning the mental or physical condition of any patient 

Physician/medical reporting	 N/A 

Immunity	 Yes, people reporting in good faith are statutorily immunized from civil actions for damages caused by 

such reporting. 

Legal protection	 Patient has to sign a form to show it is ok for M.D. or O.D. to release information to DMV. 

DMV follow-up	 Driver is notified in writing of referral. 

Other reporting	 Will accept information from courts, other DMVs, police and family members, concerned citizens. 

Letters must be signed. 

Anonymity	 Yes. Letters of concern are confidential. 

Medical Advisory Board 

Role of the MAB To help Director of Vehicles and Driver Review interpret conflicting information or action based on 

recommendation of specialists. Determine eligibility of hardest or borderline cases. 

Medical Review contact information Kansas Driver Review, Medical Advisory Board 

915 SW Harrison Room 162 | Topeka, KS 66626 

785-296-3601 93 
 

Kentucky
 

Name of State & DMV Kentucky Division of Driver Licensing 502-564-0280 

contact information 200 Mero Street 

Frankfort, KY 40622 

www.kytc.state.ky.us/drlic 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/60
 

Both eyes with/without correction ............................................... 20/60
 

If one eye blind—other with/without correction............................ 20/60
 

Absolute visual acuity minimum .................................................. 20/60 with corrective lenses
 

Are bioptic telescopes allowed? .................................................. Yes, with distance acuity of 20/60 


or better using a bioptic telescopic 

device. KRS 186.578(1)c. 

Visual fields Minimum field requirement.........................................................	 Binocular horizontal field of vision of 

at least 35 degrees to the left and 

right side of fixation and a binocular 

vertical field of vision of at least 25 

degrees above and below fixation. 

Visual field testing device ........................................................... N/A
 

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

Road test	 Medical Advisory Board may recommend further examination or investigative testing. 

Restricted licenses	 Available 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 years
 

Renewal options and conditions.................................................. In person
 

Vision testing required at time of renewal? .................................. No
 

Written test required?................................................................. No
 

Road test required?.................................................................... No
 

Age-based renewal procedures	 None 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting No 

Immunity Yes 

Legal protection None 

DMV follow-up Driver notified in writing of referral to medical advisory board. 

Other reporting Will accept information from courts, other DMVs, family members and police. 

Anonymity None 

Medical Advisory Board 

Role of the MAB	 The medical advisory board identifies drivers with physical or mental impairments that impede their 

ability to safely operate a motor vehicle. 

Medical Review contact Questions regarding medical review can be directed to 502-564-0280 ext. 2174. 

information FAQs for medical review can be found at http://transportation.ky.gov/DrLic/mrb/MRB.htm 

94 
 

 

 

Louisiana
 

Name of State & DMV Louisiana Office of Motor Vehicles 225-925-3929 

contact information Drivers License Suspension Unit 

PO Box 64886 

Baton Rouge, LA 70896 

www.expresslane.org 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/40 in better eye unrestricted,
 

20/50-20/70 better eye with restrictions, 20/70-20/100 better eye with 

possible restricted license. Less than 

20/100 for better eye refer to MAB 

Are bioptic telescopes allowed? .................................................. No
 

Visual fields	 Minimum field requirement.........................................................No
 

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

Restricted licenses	 Yes, daytime only, weather restrictions, radius limitation, no interstate driving 

License Renewal Procedures 

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

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

4 years 

In person or mail in every other cycle, 

Internet, interactive voice response, 

unless license expired 6 months or 

more. 

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

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

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

Yes 

Yes, if expired one year or more 

Yes, if expired 2 years or more 

Age-based renewal procedures No renewal by mail for drivers over the age of 70 

Reporting Procedures 

Mandatory medical reporting No, there is no statutory provision requiring physicians to report patients 

Physician/medical reporting N/A 

Immunity Yes, a physician who provides such information has statutory immunity from civil or criminal liability 

for damages arising out of an accident. 

Legal protection Louisiana has statutory protection for good faith reporting of unsafe drivers. 

DMV follow-up Driver is notified in writing of referral. 

Other reporting DMV employee or agent in performance of duties, law enforcement officer, health care provider, 

or family member 

Anonymity An order from a court of competent jurisdiction required before identity of reporter can be released. 

Medical Advisory Board 

Role of the MAB	 The medical advisory board identifies drivers with physical or mental impairments that impede their 

ability to safely operate a motor vehicle. 

Medical Review contact Questions regarding medical review can be directed to 502-564-0280 ext. 2174. 

information FAQs for medical review can be found at http://transportation.ky.gov/DrLic/mrb/MRB.htm 

95 
Maine
 

Name of State & DMV Maine Bureau of Motor Vehicles 209-624-9000 

contact information Attn: Medical Unit 

29 State House Station 

Augusta, ME 04333-0029 

www.state.me.us/sos/bmv 

Licensing Requirements 

Visual acuity Both eyes with/without correction ............................................... 

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

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

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

20/40 

20/40 

20/70 with restrictions 

No 

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

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

110° both eyes-Class D only 

Keystone View 

Color vision requirement None 

Type of road test Assesses general driving skills 

Restricted licenses Yes: daytime only, radius from home, special equipment 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 6 years
 

Vision testing required at time of renewal? .................................. At age 40, 52, 65 and every 4 years 


thereafter 

Written test required?................................................................. No 

Road test required?.................................................................... No 

Age-based renewal procedures	 At age 65, renew every 4 years. 

Reporting Procedures 

Mandatory medical reporting Yes 

Physician/medical reporting Yes 

Immunity Yes 

Legal protection Yes 

DMV follow-up Requires a medical evaluation form to be completed by a physician at periodic intervals 

Other reporting Will accept information from courts, other DMVs, police, family members and other resources 

Anonymity Yes, but identity may be revealed at an administrative hearing if requested. 

Medical Advisory Board 

Role of the MAB The Medical Advisory Board reviews the medical information submitted whenever a person contests a 

Division action. Reports received or made by the Board are confidential and may not be disclosed unless 

the individual gives written permission 

Medical Review contact information The Medical Review Coordinator can be reached at 207-624-9101 

96 
 

Maryland
 

Name of State & DMV Maryland Motor Vehicle Administration 301-729-4550 or 

contact information 6601 Ritchie Highway, NE 800-950-1682 

Glen Burnie, MD 21062 

www.marylandmva.com 

Licensing Requirements 

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

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

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

If one eye blind—other with correction........................................ 

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

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

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

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

Color vision requirement 

Type of road test 

Restricted licenses 

Only for commercial drivers 

N/A 

Yes: daytime only, outside mirrors for low vision drivers 

20/40 

20/40 

20/40 

20/40 

20/70 in better eye for restricted; 

20/70-20/100 requires special 

permission from MAB. 

Yes: daytime only, outside mirrors 

20/70 through telescope. 20/100 

through carrier lens. 

Continuous field of vision at least 

140E in each eye unrestricted; 70° 

(+/- 35°)/110° 

Stereo Optical Optec 1000 

vision screener 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 5 year
 

Renewal options and conditions.................................................. In-person
 

Vision testing required at time of renewal? .................................. Yes (binocular, acuity, peripheral)
 

Written test required?................................................................. No
 

Road test required?.................................................................... No
 

Age-based renewal procedures	 Are there any age-based license renewal procedures? 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Maryland law provides for the discretionary reporting to the Motor Vehicle Administration of people who 

have “disorders characterized by lapses of consciousness” 

Immunity Yes, a civil or criminal action may not be brought against any person who makes a report to the Medical 

Advisory Board and who does not violate any confidential or privileged relationship conferred by law. 

Legal protection Action may not be brought against any person who makes a report to the Medical Advisory Board and 

does not violate any confidential or privileged relationship conferred by law. 

DMV follow-up Driver is notified in writing of referral. License is suspended and further examination is required. 

Other reporting Will accept information from court, other DMVs, police, family members and other resources. 

Anonymity Yes, if requested 

Medical Advisory Board 

Role of the MAB	 The MAB advises the Motor Vehicle Administration regarding medical review for fitness to drive through 

its Division of Driver Wellness and Safety. 

Medical Review contact information	 Manager, Driver Wellness & Safety Division, Maryland Motor Vehicle Administration 

6601 Ritchie Highway, NE | Glen Burnie, MD 21062 

410-424-3644; Fax: 410-768-7627 

97 
 

 

 

Massachusetts
 

Name of State & DMV Massachusetts Medical Affairs 617-351-9222 

contact information PO Box 199100 

Boston, MA 02119 

www.state.ma.us/rmv/index.htm 

Licensing Requirements 

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

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

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

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

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

Visual fields 

Color vision requirement 

Type of road test 

Restricted licenses 

Minimum field requirement......................................................... 

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

Yes—distinguish red, green and amber 

N/A 

Yes: daytime only 

20/40
 

20/40
 

N/A
 

20/40 better eye unrestricted; 20/50­

2070 in better eye results in daylight 


only restriction.
 

Yes. As long as 1) The peripheral 


vision is at least 120; 2) Vision is 


corrected to 20/40 through the bioptic and 20/100 through the carrier 


lens. Also, must have at least 20/100 


in the other eye. The bioptic must 


meet certain requirements: it must 


be monocular, fixed focus, no greater 


than 3X magnification, and must be 


an “integral part of the lens”
 

120° 


Optec 1000 Vision Testing Machine
 

License Renewal Procedures 

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

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

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

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

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

Age-based renewal procedures None 

5 Years 

In person, or via Internet. 

Yes 

No; however DMV reviews on 

case-by-case basis and if indicated 

will administer test. 

No; however DMV reviews on 

case-by-case basis and if indicated 

will administer test. 

Reporting Procedures 

Mandatory medical reporting	 No, MA is a self-reporting State, meaning it is the responsibility of the driver to report to the RMV any 

medical condition that may impair driving ability. 

Physician/medical reporting	 Yes, physicians are encouraged to report unfit drivers to the RMV. 

Immunity	 No, the law does not provide any protection from liability, nor does it promise confidentiality due to 

“Public Records” law which states simply that a driver is entitled to any information upon receipt of 

written approval. 

Legal protection	 No, see “Immunity” 

98 
 

 

Massachusetts (continued)
 

DMV follow-up If report comes from family or member of public it must be in writing and signed. If report is accepted, 

then driver contacted by mail and asked to obtain medical clearance to certify that he/she is safe to 

drive. If DMV does not receive a response within 30 days a second request is mailed. If still no response, a license revoked. 

If report is from law enforcement or physician, it is considered “immediate threat.” Driver is contacted 

by mail and requested to voluntarily surrender license or submit medical clearance within 10 days. 

If no response, license revoked. 

Other reporting Will accept information from court, other DMVs, police, family members and other resources. 

Anonymity No, see “Immunity” 

Medical Advisory Board 

Role of the MAB The purpose is to provide guidance to the Registry when a medical issue has been raised regarding the 

ability of applicants for learner’s permits and licenses to operate a motor vehicle and for those whose 

privileges to operate a motor vehicle has been (or should be) restricted, suspended or revoked. One of 

our goals in consulting with the MAB on matters requiring medical expertise is to bring consistency to 

these decision making processes. 

Medical Review contact Registry of Motor Vehicles 

information Director of Medical Affairs 

PO Box 55889 

Boston, MA 02205-5889 

Attn: Director of Medical Affairs 

Fax: 617-351-9223 

99 
 

 

 

Michigan
 

Name of State & DMV Michigan Department of State 517-335-7051 phone 

contact information Driver Assessment and Appeal Unit 517-335-2189 fax 

PO Box 30196 

Lansing, MI 48909-7696 

www.michigan.gov/sos 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40 to and including 20/50
 

If one eye blind—other with/without correction............................ 20/50
 

Absolute visual acuity minimum .................................................. Minimum of 20/70 in better eye 


with no progressive abnormalities 

of the eye, daylight only restriction; 

Minimum of 20/60 in better eye if 

progressive abnormalities or disease 

of the eye, daylight only restriction. 

Are bioptic telescopes allowed? .................................................. Yes, will require a road test for all 

first-time users. 

Visual fields Minimum field requirement......................................................... 110°-140° both eyes; less than 110° 

to/including 90° additional conditions and requirements; less than 90 

degrees, no driving allowed. 

Visual field testing device ........................................................... Optic 1000 DMV Vision Tester
 

Color vision requirement	 No 

Type of road test	 Standardized course and requirements with various locations throughout the State 

Restricted licenses	 Yes. Restrictions are based on review of medical input and reexamination testing. Examples include 

radius driving, daylight only driving, no expressway driving. 

License Renewal Procedures 

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

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

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

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

Age-based renewal procedures 

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

No 

4 years 

Mail in every other cycle, if free of 

convictions 

Yes 

No. A written test is not required 

at the time of renewal. It may be 

required at driver assessment reexaminations and to obtain an 

original license. 

Yes, if license expired more than 

4 years. 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Physicians are encouraged to report unsafe drivers to the Department of State for evaluation. 

Immunity No 

Legal protection No 

DMV follow-up The driver is notified in writing of the request for evaluation. The Department may require the driver to 

submit updated medical information and to appear for reexamination and testing. The testing includes a 

vision screening, written exam, and on-road driving evaluation. 

Other reporting	 The Department accepts requests for driver evaluation from family, police, public officials and any other 

concerned persons who have knowledge of a driver’s inability to drive safely or health concerns that 

may affect his/her driving ability. 

100 
Michigan (continued)
 

Anonymity	 The Department of State cannot accept anonymous requests for driver evaluation. The requestor must 

include his/her name, address, daytime phone number and signature. The Department would protect 

the identity of the author of the request for driver evaluation to the extent allowed by law. 

Medical Advisory Board 

Role of the MAB	 Current medical reviews are based on recommendation of specialist. The Department of State is in the 

process of reestablishing a Medical Advisory Board. The Department intends for the MAB to review 

current Department medical review processes and establish updated guidelines for the medical review 

of Michigan drivers. 

Medical Review contact Driver Assessment and Appeal Division can be reached at 517-335-7051. 

information 

101 
 

Minnesota
 

Name of State & DMV Minnesota Medical Unit 651-296-2021 

contact information 445 Minnesota Street, Suite 170 

Town Square Building 

St. Paul, MN 55101-5170 

www.dps.state.mn.us/dvs/index.html 

Licensing Requirements 

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

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

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

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

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

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

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

Color vision requirement No 

Type of road test 20/80, special test with driver exam supervisor 

Restricted licenses Yes: daytime, area restriction, speed, no freeway 

20/40 

20/40 

20/40 

20/70 in better eye with speed 

limitations, 20/80 referred to a 

driver evaluation unit; 20/100 denied 

license 

No 

105° unrestricted 

Yes, at renewal 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 years
 

Renewal options and conditions.................................................. In person
 

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

Written test required?................................................................. Only if driver license expired more 


than 1 year 

Road test required?.................................................................... If driver license is expired more than 

5 years 

Age-based renewal procedures	 None 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Physician reporting is encouraged 

Immunity Yes 

Legal protection Not addressed in driver licensing laws 

DMV follow-up Driver is notified in writing of referral. License is suspended upon referral and further examination is 

conducted. 

Other reporting	 Will accept information from court, other DMVs, police, family members and other resources. 

Anonymity	 Yes, unless court subpoenas record 

Medical Advisory Board 

Role of the MAB	 Action is based on recommendation of majority. 

Medical Review contact 	 Minnesota Department of Public Safety 

information	 Medical Unit 

445 Minnesota Street, Suite 170 

St. Paul, MN 55101-5170 

651-296-2021 

102 
 

Mississippi
 

Name of State & DMV Mississippi Driver Improvement 601-987-1231 

contact information PO Box 958 

Jackson, MS 39205 

www.dps.state.ms.us 

Licensing Requirements 

Visual acuity Each eye with/without correction................................................. 20/40 

Both eyes with/without correction ............................................... 20/40 

Absolute visual acuity minimum .................................................. 20/70 daytime 

Are bioptic telescopes allowed? .................................................. Yes, 20/70 with telescope 

Visual fields Minimum field requirement......................................................... 140° unrestricted; one eye T 70°; N 

35° with 2 outside mirrors 

Color vision requirement No 

Type of road test 

Restricted licenses Yes 

License Renewal Procedures 

Standard Length of license validation......................................................... 4 years
 

Renewal options and conditions.................................................. In person
 

Vision testing required at time of renewal? .................................. No
 

Written test required?................................................................. No
 

Road test required?.................................................................... No (an exception can be made if 


examiner feels testing is warranted) 

Age-based renewal procedures Those 71 and older are not allowed to do on-line renewal. 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting 

Immunity No 

Legal protection 

DMV follow-up Patient is called into DMV office for road and vision test when they receive a report from any source. 

Other reporting Will accept information from court, other DMVs, police and family members. 

Anonymity Yes, granted for all reporters. 

Medical Advisory Board 

Role of the MAB In situations where the DMV is unsure, cases are reviewed by an external medical panel convened by 

the State medical board. 

Medical Review contact The medical board can be reached at 601-853-6733 

information Questions about referrals to the DMV should go to 601-987-1231 

103 
 

 

 

 

Missouri
 

Name of State & DMV Missouri Drivers License Bureau 573-751-2730 

contact information Attn: Medical Review 

PO Box 200 

Jefferson City, MO 65105 

http://dor.mo.gov/mvdl/drivers/ 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/50
 

Absolute visual acuity minimum .................................................. 20/160 for restricted
 

Are bioptic telescopes allowed? .................................................. Not for meeting vision requirements 


but can be used for skills tests and 

while driving 

Visual fields Minimum field requirement......................................................... 55° or better in both eyes; 85° in one 

eye with restrictions 

Visual field testing device ........................................................... Objective/Quantitative 

Color vision requirement No 

Restricted licenses	 Yes. As long as they meet the vision requirements, we have restrictions for equipment, speed, 

radius, (location of driving) time of day and/or length of time driving. Virtually any restriction a doctor 

or examiner recommends. 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 6 years
 

Renewal options and conditions.................................................. In person, or renewal by mail if out 


of State. 

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

Written test required?................................................................. Only if license is expired for more 

than 6 months (184 days) or if an 

individual is cited and after the review 

process a written test could be 

required. 

Road test required?.................................................................... See written test requirement above.
 

Age-based renewal procedures	 At age 70, reduction in renewal cycle to 3 years. Also, any school bus driver 70 or older must renew 

their School Bus Permit annually. Below 70, renewal is every 3 years. 

Reporting Procedures 

Mandatory medical reporting	 Not mandatory but encouraged for any condition that could impair or limit a person’s driving ability. 

A form is available (form 1528, Physician’s Statement) but not required. Forms are available at the 

Department of Revenue, P.O. Box 200 Jefferson City, Mo 65105-0200. Attention Medical Review. 

Physician/medical reporting	 Medical professionals will not be prevented from making a report because of their physician-patient 

relationships 302.291. 

Immunity	 Yes, an individual is immune from civil liability when they have made a report in good faith. 

Legal protection	 See Physician Reporting Laws above. 

DMV follow-up	 Depending on the information received, we may ask for additional information, add restrictions, require a 

written exam, skills test, vision exam, physical exam or deny the privilege. 

Other reporting Will accept information from court, DMV clerks, peace officers, social workers and family members 

within three degrees of consanguinity. 

Anonymity Yes 

104 
Missouri (continued)
 

Medical Advisory Board 

Role of the MAB	 The Medical Advisory Board evaluates each case on an individual basis. The medical information 

is reviewed by staff personnel of the Driver’s License Bureau. The MAB relies on the person’s 

physician’s opinion on whether the applicant or licensee can drive safely. Action is based on 

recommendation of majority. 

Medical Review contact information	 Attention Medical Review 

Department of Revenue 

P.O. Box 200 

Jefferson City, Mo 65105-0200 

573-751-2730 

Fax: 573-522-8174 

http://dor.mo.gov/mvdl/drivers/faq/doctor.htm 

105 
 

 

 

 

Montana
 

Name of State & DMV Montana Motor Vehicles Division 406-444-4536 

contact information Medical Unit 

PO Box 201430 

Helena, MT 59620-1430 

www.doj.mt.gov/driving/default.asp 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/70 in better eye with restrictions 


on daylight and speed; 20/100 in 

better eye, with possible restricted 

license. 

Are bioptic telescopes allowed? .................................................. Yes, 20/100 through carrier lens
 

Visual fields	 Minimum field requirement......................................................... Only for commercial drivers 


Visual field testing device ........................................................... Optic 1000
 

Color vision requirement	 Commercial only 

Type of road test	 Figure-8, 3 left and 3 right turns, 2 stop signs, through intersection and parallel parking. 

Restricted licenses	 Yes 

License Renewal Procedures 

Standard Length of license validation......................................................... 8 years; if renewing by mail a 4 year 

license is issued—next renewal 

requires a personal appearance by 

the applicant. Commercial licenses 

are now only good for 5 years. 

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

Written test required?................................................................. Discretion of examiner if safe 

operation of the motor vehicle is in 

question. 

Road test required?.................................................................... Same as written requirement 

Age-based renewal procedures	 For ages 68 to 74, renewal cycle reduced to 1–6 years. At age 75, renewal cycle is reduced to 4 years. 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Physicians are encouraged to report 

Immunity Yes, There is a statute giving the physician immunity from liability for reporting in good faith any patient 

whom the physician diagnoses as having a condition that will significantly impair the patient’s ability to 

safely operate a motor vehicle. No action may be brought against a physician for not making such a report. 

Other reporting Will accept information from court, other DMVs, police, family members, and other resources. 

Anonymity State is required to tell person who reported them, if asked. 

Medical Advisory Board 

Role of the MAB	 Montana does not have a Medical Advisory Board 

Medical Review contact information	 Supervisor 

Records and Control Bureau 

303 North Roberts 

Helena, Montana 59620 

106 
 

 

Nebraska
 

Name of State & DMV Nebraska Department of Motor Vehicles 402-471-3861 

contact information Driver License Examining Division 

PO Box 94726 

Lincoln, NE 68509 

www.dmv.state.ne.us 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/70, the other eye not blind; 


17 restrictions are used, depending 

on vision in each eye 

Are bioptic telescopes allowed? .................................................. Yes, 20/70 minimum through 

telescope 

Visual fields	 Minimum field requirement......................................................... Less than 100° denied, 140° both eyes
 

Visual field testing device ........................................................... Vision Machine
 

Color vision requirement	 Commercial only 

Type of road test	 On the road test that includes requirements such as emergency stop, right turns, left turns, etc. 

Restricted licenses	 Yes, Nebraska offers restricted licenses. 

License Renewal Procedures 

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

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

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

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

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

Age-based renewal procedures No. Nebraska does not have age-based renewal regulations. 

5 years 

Must apply in person before a driver 

license employee. Individuals who reside out-of-State during their renewal 

time may renew via mail. 

Yes 

Only if license is expired over 1 year 

or license is suspended, revoked or 

cancelled. 

Only if license is expired over 1 year 

or license is suspended, revoked or 

cancelled. 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Yes, encouraged but not required. 

Immunity No 

Legal protection No 

DMV Follow-up Drivers are notified by certified mail that they must appear for retesting. Drivers are also required to bring 

in a vision and medical statement that has been completed by their physicians within the last 90 days. 

Other reporting Will accept information from law enforcement and other concerned parties. 

Anonymity Yes, unless the driver appeals the denial or cancellation of their license to District Court. 

107 
Nebraska (continued)
 

Medical Advisory Board 

Role of the MAB	 To provide advice to the Department concerning the physical a mental ability of an applicant or holder of 

an operator’s license to operate a motor vehicle. 

Medical Review contact information	 Driver’s License Administrator 

Nebraska Department of Motor Vehicles 

P.O. Box 94789, 

301 Centennial Mall South 

Lincoln, NE 68509 

108 
 

 

 

Nevada
 

Name of State & DMV Nevada Department of Motor Vehicles 775-684-4717 

contact information Management Services and Programs Division 

555 Write Way 

Carson City, NV 89711 

www.dmvnv.com 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/50, other eye no worse than 


20/60 daylight driving only. 

Are bioptic telescopes allowed? .................................................. Yes, 20/40 through telescope, 20/120 

through carrier, 130 E visual field. 

Visual fields Minimum field requirement.........................................................Binocular 140° unrestricted 

Binocular 110°-140° restricted 

Color vision requirement	 None 

Type of road test	 Yes, if the vision specialist’s report does not meet the 20/40 standard but within the minimum (restricted) acuity levels for licensing. 

Restricted licenses	 Yes; daytime only 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 years
 

Renewal options and conditions.................................................. Mail-in or Internet every other cycle.
 

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

Written test required?................................................................. Only if license classification 


has changed 

Road test required?.................................................................... Only if license classification 

has changed 

Age-based renewal procedures	 Vision test and medical report required to renew by mail at age 70. 

Reporting Procedures 

Mandatory medical reporting	 Yes. Physicians are required to report patients diagnosed with epilepsy or any seizure disorder or lapse 

of consciousness 

Physician/medical reporting	 Yes 

Immunity	 Yes 

Legal protection	 Yes 

DMV follow-up	 Letters and suspensions 

Other reporting	 Court, other DMVs, police and family members. 

Anonymity	 Yes 

Medical Advisory Board 

Role of the MAB	 Advisory role to DMV. Developing medical and health standards. Advisory role regarding medical reports 

submitted to determine the mental or physical condition of the applicant. The department has the 

authority to have a Medical Advisory Board due to Nevada Administrative Code 483.380. However, due 

to the cost, Nevada has been unable to have such an advisory board in place. 

Medical Review contact information	 Questions about medical review can be directed to 775-684-4717. 

109 
 

New Hampshire
 

Name of State & DMV New Hampshire Department of Motor Vehicles 603-271-2371 

contact information Directors Office 

10 Hazen Drive 

Concord, NH 03305 

www.state.nh.us/dmv 

Licensing Requirements 

Visual acuity Vision in both eyes ..................................................................... 

Vision in one eye........................................................................ 

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

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

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

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

Color vision requirement No 

Type of road test Yes, on road practical 

Restricted licenses Yes, daytime only 

20/40 

20/30 

20/70, restricted to daytime only 

Yes 

No 

Snellen Eye chart or Stereo Optical 

Viewer 

License Renewal Procedures 

Standard 

Age-based renewal procedures 

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

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

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

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

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

No special requirements for age. 

4 years 

In-person 

Yes 

No 

No 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Physicians are encouraged to report 

Immunity N/A 

Legal protection No, as reporting is not a requirement 

DMV follow-up Full re-examination and in some cases an administrative hearing 

Other reporting Will accept information from court, other DMVs, police, and family members. 

Anonymity Not confidential 

Medical Advisory Board 

Role of the MAB None 

Medical Review contact Department of Safety 

information Division of Motor Vehicles 

Driver Licensing 

23 Hazen Drive 

Concord NH 03305 

603-271-2371 

110 
 

New Jersey
 

Name of State & DMV New Jersey Division of Motor Vehicles 609-292-4035 

contact information Medical Division 

PO Box 173 

Trenton, NJ 08666 

www.njmvc.gov 

Licensing Requirements 

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

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

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

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

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

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

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

Color vision requirement	 Yes—new drivers (not cause for denial) 

Type of road test	 Standardized 

Restricted licenses	 Yes 

20/50 

20/50 

20/50 

20/50 

Yes, 20/50 through telescope 

No 

N/A 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 years
 

Renewal options and conditions.................................................. In-person digitized photos were 


implemented in 2003. 

Vision testing required at time of renewal? .................................. Only if recommended. 

Written test required?................................................................. If recommended by examiner 

Road test required?.................................................................... If recommended by examiner 

Age-based renewal procedures	 No 

Reporting Procedures 

Mandatory medical reporting Yes. Only for cases of recurrent loss of consciousness 

Physician/medical reporting Physicians are required to report patients who experience convulsive, seizures, recurrent periods of 

unconsciousness, impairment or loss or loss of motor coordination. 

Immunity	 Yes 

Legal protection	 No 

DMV follow-up	 A medical review is generated. Results of the medical review may result in suspension of license; the 

driver may request an appeal. 

Other reporting	 Will accept information from police, family, other agencies, courts, and other concerned persons. MVC 

will not generate a letter based on an anonymous letter. 

Anonymity	 No 

Medical Advisory Board 

Role of the MAB New Jersey has forms for each type of medical condition that may be cause for concern. Form is completed by driver’s physician. In problem cases, then passed on to the Medical Advisory Board. MAB is a 

multidisciplinary group of physicians who then make licensing recommendations based on information. 

Medical Review contact 

information 

New Jersey Division of Motor Vehicles 

609-292-7500 ext. 5032 

Medical Division 

PO Box 173 

Trenton, NJ 08666 

111 
 

 

 

New Mexico
 

Name of State & DMV New Mexico Motor Vehicles Division 505-827-2296 

contact information Driver Services, Attn: Medical 

PO Box 1028 

Santa Fe, NM 87504-1028 

www.state.nm.us/ 

Licensing Requirements 

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

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

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

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

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

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

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

Color vision requirement	 No 

Type of road test 

Restricted licenses	 Yes 

20/40 

20/40 

20/40 

20/80 better eye with restrictions 

No 

120°E, 30° in nasal field of one eye 

Normal Ophthalmic Procedures 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 or 8 years
 

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

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

Written test required?................................................................. May be required
 

Road test required?.................................................................... May be required
 

Age-based renewal procedures	 Drivers may not apply for 8-year renewal, if they turn 75 during the last 4 years of the 8-year period. 

Becomes 1-year renewal after age 75. 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Yes 

Immunity Yes 

Legal protection No 

DMV follow-up By notice, drivers are informed that their licenses will be cancelled in 30 days unless they provide a 

medical report clearing them to drive. If they do not provide reports, their licenses are cancelled. 

Other reporting	 Will accept information from court, other DMVs, police, and family members. 

Anonymity	 Not confidential 

Medical Advisory Board 

Role of the MAB	 Periodic medical updates required by drivers with certain medical conditions including epilepsy, 

diabetes, and certain heart conditions. The DMV learns of an individual’s condition through questions 

asked on the application 

Medical Review contact information	 New Mexico MVD Driver Services Bureau can be reached at 505-827-2296. 

112 
 

 

 

 

New York
 

Name of State & DMV New York Department of Motor Vehicles 518-474-0841 

contact information Attn: Driver Improvement Bureau 

6 Empire State Plaza 

Albany, NY 12228 

www.nydmv.state.ny.us 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. For applicants with visual acuity less 


than 20/40 but not less than 20/70, 

can complete form MV-80L and 

submit for licensing consideration. 

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

Visual fields Minimum field requirement......................................................... 20/40-20/70 best corrected requires 

140 E horizontal visual fields; 20/80­

20/1000 best corrected requires 

minimum 140 E horizontal visual field 

plus 20/40 through bioptic telescope 

lens 

Visual field testing device ........................................................... Eye chart
 

Color vision requirement	 No 

Type of road test	 Standard road test, includes basic maneuvers needed for everyday driving. 

Restricted licenses	 Yes: daytime only, radius from home, annual vision update 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 8 years
 

Renewal options and conditions.................................................. Mail or in person
 

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

Written test required?................................................................. No
 

Road test required?.................................................................... No
 

Age-based renewal procedures	 No 

Reporting Procedures 

Mandatory medical reporting	 No 

Physician/medical reporting	 No 

Immunity	 No 

Legal protection	 N/A 

DMV follow-up	 If a physician reports a condition that can affect the driving skills of a patient, the DMV can suspend the 

driver license. The DMV suspends the driver license until a physician provides a certification that the 

condition has been treated or controlled and does not affect driving skills If the DMV receives a report 

from a source who is not a physician the DMV decides each case separately. 

Other reporting	 Will accept information from court, other DMVs, police, family members and other resources. 

Letters must be signed. 

Anonymity	 If a person in a professional or official position (i.e., physician), the DMV does disclose the name of the 

person who sent the report however if the reporter does not fall under this category, under the Freedom 

of Information Law, the identity is protected. 

113 
New York (continued)
 

Medical Advisory Board 

Role of the MAB	 The medical advisory board advises the commissioner on medical criteria and vision standards for the 

licensing of drivers. 

Medical Review contact information	 Referrals for reexamination must be made in writing to: 

New York State 

Department of Motor Vehicles 

Medical Review Unit Room 220 

6 Empire State Plaza 

Albany, NY 12228-0220 

Information about the forms and procedures can be found at 

www.nydmv.state.ny.us/license.htm#drivermed 

114 
 

 

 

North Carolina
 

Name of State & DMV North Carolina Division of Motor Vehicles 919-861-3809 

contact information Driver License Medical Division 

1100 New Bern Ave. 

Raleigh, NC 27697 

www.dmv.dot.state.nc.us 

Licensing Requirements 

Visual acuity Each eye without correction........................................................ 

Both eyes without correction....................................................... 

Each eye with correction............................................................. 

Both eyes with correction ........................................................... 

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

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

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

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

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

Color vision requirement No 

Type of road test Standardized road test, certain tasks must be completed to pass. 

Restricted licenses Yes: daytime, speed restrictions, no interstate driving. 

20/40 

20/40 

20/50 

20/50 

20/30 or better 

20/100; 20/70 if one eye blind 

No. However, there is a medical 

appeal process if requested. 

60° in one eye (30° on each side 

Keystone; Stereo Optic 1000 

License Renewal Procedures 

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

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

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

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

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

5 years 

In person 

Yes 

Yes 

No 

Age-based renewal procedures 60+ are not required to parallel park on road test. 

Reporting Procedures 

Mandatory medical reporting No
 

Physician/medical reporting Physicians are encouraged to report unsafe drivers.
 

Immunity Yes, North Carolina statutes protect the physician who reports an unsafe driver.
 

Legal protection No
 

DMV follow-up Driver is notified in writing of referral.
 

Other reporting Will accept information from court, other DMVs, police, family members, and other resources, as long as 


they are signed. 

Anonymity No, however must request records in writing. 

Medical Advisory Board 

Role of the MAB	 Action is based on majority and/or opinion of specialist. Medical physicians review all medical 

information that is submitted to the DMV. If more information is necessary, can issue a request. 

Board decides what action should be taken. This action can be appealed. 

Medical Review contact information	 Medical Review Unit 

3112 Mail Service Center 

Raleigh, NC 27697 

Fax 919-733-9569 

115 
 

North Dakota
 

Name of State & DMV 	 North Dakota Department of Transportation 701-328-2601 

contact information	 Drivers License and Traffic Safety Division 

Attn: Chief Examiner 

608 East Boulevard Avenue 

Bismarck, ND 58505 

www.dot.nd.gov/ 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/80 better eye if 20/100 in other 


eye 

Are bioptic telescopes allowed? .................................................. Yes: 20/130 in carrier, 20/40 in 

telescope, full peripheral field 

Visual fields	 Minimum field requirement......................................................... Both eyes 105°
 

Visual field testing device ........................................................... OPTEC 1000 Vision Tester
 

Color vision requirement	 No 

Type of road test	 N/A 

Restricted licenses	 Yes: daytime, pending a sight-related road test, area and distance restriction 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 years
 

Renewal options and conditions.................................................. N/A
 

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

Written test required?................................................................. No
 

Road test required?.................................................................... No
 

Age-based renewal procedures	 No 

Reporting Procedures 

Mandatory medical reporting No, physicians may report. Submit letter to the Drivers License and Traffic Safety Division 

Physician/medical reporting There is a law giving physicians permission to report to the ND Department of Transportation in writing, 

the name, date of birth, and address of every patient over the age of 14 whom they have reasonable 

cause to believe is incapable, due to physical or mental reason, of safely operating a motor vehicle 

Immunity Yes, physicians who in good faith make a report or give an opinion or recommendation or participate in 

any proceeding pursuant to this law, are immune from liability. 

Legal protection ND Century Code addresses medical advice provided by physicians. 

DMV follow-up Vision and/or medical reports 

Other reporting Will accept information from court, other DMVs, police and family members. 

Anonymity No 

Medical Advisory Board 

Role of the MAB	 Action based on recommendation of majority and/or specialist. MAB is used when drafting 

Administrative rules. 

Medical Review contact information	 Drivers License and Traffic Safety Division staff can be reached at 701-328-2070 

116 
 

 

Ohio
 

Name of State & DMV Ohio Driver License Information Unit 614-752-7500 

contact information Ohio Bureau of Motor Vehicles, Attn: Medical Unit 

PO Box 16784 

Columbus, OH 43216-6784 

www.bmv.ohio.gov 

Licensing Requirements 

Visual acuity Each eye with/without correction................................................. 20/200 or better 

Both eyes with/without correction ............................................... 20/40 or Better: Unrestricted Driving 

20/50 – 20/70: Daylight Driving Only 

Worse than 20/70: No Driving Privileges 

If one eye blind—other with/without correction............................ Primary eye no worse than 20/200 

Deficient eye: Worse than 20/300 

Both eyes with/without correction when one eye is blind............... 20/30 or Better: Unrestricted Driving 

20/40 – 20/60: Daylight Driving Only 

Worse than 20/60: No Driving Privileges 

Absolute visual acuity minimum .................................................. 20/70 through telescope, 20/200 

through carrier lens. 

Are bioptic telescopes allowed? .................................................. Yes: 20/70 through telescope, 

20/200 through carrier lens. 

Visual fields Minimum field requirement......................................................... Each eye must have 70° temporal 

reading 

Visual field testing device ........................................................... Keystone Vision II 

Color vision requirement Yes 

Type of road test	 Standardized course 

Restricted licenses	 Right or left outside mirror restrictions for persons who are unable to obtain the required minimum 

Temporal field requirement of 70 degrees in each eye but has a visual field of 70∞ Temporal and 45∞ 

nasal readings (mirror required on the side that does not have 70 ∞ Temporal). Persons with certain 

medical or physical conditions may be required to furnish periodic medical statements or take periodic 

drivers license examinations. 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 years 


Renewal options and conditions.................................................. In person or renewal by mail only if 


out of State. 

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

Written test required?................................................................. No 

Road test required?.................................................................... No 

Age-based renewal procedures	 No 

Reporting Procedures 

Mandatory medical reporting No
 

Physician/medical reporting No, however we will accept and take action on information submitted by a physician on an unsafe driver.
 

The doctor must agree to be our source of information and allow us to divulge this information to the driver. 

Immunity	 No 

Legal protection	 No 

DMV follow-up	 Letter is sent requiring driver to submit a medical statement and/or take a driver license examination. 

Driver is given 30 days to comply. 

Other reporting	 Will accept information regarding unsafe drivers from courts, law enforcement agencies, hospitals, 

rehabilitation facilities, family and friends. The person or facility making the report must agree to be our 

source of information and allow us to divulge this information to the driver. 

Anonymity	 Not confidential 

117 
Ohio (continued)
 

Medical Advisory Board 

Role of the MAB	 No medical advisory board. Ohio has a medical consultant to contact for assistance with difficult cases 

or policy-making assistance. 

Medical Review contact information	 Information on making referrals can be obtained through the contacts above. 

118 
 

 

Oklahoma
 

Name of State & DMV Oklahoma Driver Improvement Division Department 405-425-2059 

contact information of Public Safety 

Attn: Medical 

PO Box 11415 

Oklahoma City, OK 73136 

www.dps.state.ok.us/dls/ 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/60
 

Both eyes with/without correction ............................................... 20/60
 

If one eye blind—other with/without correction............................ 20/50
 

Absolute visual acuity minimum .................................................. 20/100 for better eye with 


restrictions 

Are bioptic telescopes allowed? .................................................. Not permitted. Laws will not allow 

for consideration of licensing or 

restrictions. 

Visual fields Minimum field requirement......................................................... Both eyes, 70° in the horizontal 

meridian. 

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

Color vision requirement No 

Type of road test	 Non-fixed course 

Restricted licenses	 Yes, physician recommendations such as daylight driving only, speed limitations, or local driving only 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 years
 

Renewal options and conditions.................................................. In-person
 

Vision testing required at time of renewal? .................................. No
 

Written test required?................................................................. No
 

Road test required?.................................................................... No
 

Age-based renewal procedures	 No 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Yes, any physician participating in good faith and without malicious intent in making a report of an 

unsafe driver shall have immunity from civil liability that might otherwise be incurred. 

Immunity	 Yes 

Legal protection	 By statute the physician has full immunity. 

DMV follow-up	 Driver is notified in writing of referral, required to appear for an interview at the Department. Requires a 

current medical evaluation from qualified practitioner as determined a full review examination. 

Other reporting	 Will accept information from any verifiable source with direct knowledge of the medical condition that 

would render the driver unsafe. 

Anonymity	 No 

Medical Advisory Board 

Role of the MAB	 Action is based on the recommendation of the majority and/or specialist. 

Medical Review contact information	 Department of Public Safety 

Executive Medical Secretary 

PO Box 11415 

Oklahoma City, OK 73136 

119 
 

 

 

 

Oregon
 

Name of State & DMV Oregon Department of Motor Vehicles 503-945-5000 

contact information Attn: Driver Programs Section, Medical Program Coordinator 

1905 Lana Avenue NE 

Salem, OR 97314 

www.oregon.gov/ODOT/DMV/ATRISK/index.shtml 

Licensing Requirements 

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

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

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

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

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

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

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

Color vision requirement 

Type of road test 

Restricted licenses 

No 

Standardized course 

Yes. Daytime driving only for vision between 20/40 and 20/70 

20/40 

20/40 

20/40 

20/70 better eye with restrictions 

Bioptic-telescopic lenses are not 

permitted to meet acuity standards; 

however, may be used while driving. 

Must pass vision test with carrier 

lens only. 

110° in horizontal (one or both eyes 

Both Keystone Driver Vision Screening System & OPTEC Vision Screening 

Instruments are used. 

License Renewal Procedures 

Standard 

Age-based renewal procedures 

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

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

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

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

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

After age 50, vision screening every 8 years. 

8 years 

In person renewal. A “valid without 

photograph” license may be issued if 

the person is temporarily out of State 

at the time of license renewal. 

After age 50 

No 

No 

Reporting Procedures 

Mandatory medical reporting	 Oregon’s mandatory medical reporting system is not based solely on diagnosis or medical condition. 

Physicians and health care providers meeting the definition of “primary care provider” are required to 

report persons presenting functional and/or cognitive impairments that are severe and cannot be corrected/controlled by surgery, medication, therapy or driving device or technique. 

Physician/medical reporting	 ORS 807.710 addresses mandatory reporting by physicians and other health care providers. 

Oregon also has a voluntary reporting system that can be utilized by physicians and other medical 

providers. This reporting system is not required by law. 

Immunity	 Under the mandatory reporting system, the law provides the primary care provider with immunity from 

civil liability. 

Legal protection	 By Oregon law, a report filed under the mandatory reporting system is confidential and may not be 

admitted as evidence in any civil or criminal action. 

120 
 

Oregon (continued)
 

DMV follow-up	 In most cases, drivers reported under the mandatory system have their driving privileges immediately 

suspended. A driver may request the opportunity to demonstrate ability to safely operate a motor vehicle 

via knowledge and drive tests. For cognitive impairments (and for specific functional impairments), 

medical file and driving record is sent to the State Health Office for determination of whether or not it is 

safe at this point in time. 

The majority of reports received under the voluntary reporting system will not result in an immediate 

suspension action. Instead, these drivers will be given 30–60 days to pass DMV tests and/or submit 

medical information before a suspension action is taken. 

Other reporting	 Under the voluntary system, DMV will accept information from court, other DMVs, law enforcement, 

physicians, family members and other sources. 

Anonymity	 Under the mandatory system, only the medical information being reported is confidential. Under the 

voluntary system, DMV will make every attempt to hold the reporter’s name confidential if requested. 

Medical Advisory Board 

Role of the MAB Oregon does not have a Medical Advisory Board. DMV’s Medical Determination Officer reviews medical 

cases and makes determination on an individual’s medical condition and ability to drive. Cases can be 

referred to the Health Department for advice. 

Medical Review contact information DMV-Driver Programs Section 

503-945-5295 

Attn: Medical Program Coordinator 

1905 Lana Avenue NE 

Salem, OR 97314 

121 
 

Pennsylvania
 

Name of State & DMV Pennsylvania Department of Transportation 717-787-9662 

contact information Attn: Medical Unit 

PO Box 68682 

Harrisburg, PA 17106 

www.dmv.state.pa.us/centers/olderDriverCenter.shtml 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/40 in better eye unrestricted, up 


to 20/100 combined vision restricted 

Are bioptic telescopes allowed? .................................................. Not permitted to meet acuity standards; however, are permitted for 

driving. Must pass vision test with 

carrier lens only: 20/100. 

Visual fields Minimum field requirement......................................................... 120° both eyes 

Visual field testing device ........................................................... PENNDOT does not regulate the kind 

of testing devise used to measure this 

Color vision requirement	 No 

Type of road test	 Standardized road test, same as those used for the first-time permit application drivers. 

Restricted licenses	 Yes: daytime driving only, area restrictions, dual mirrors, class restriction—all vision related 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 4 years
 

Renewal options and conditions.................................................. Internet, mail, in-person
 

Vision testing required at time of renewal? .................................. No
 

Written test required?................................................................. No
 

Road test required?.................................................................... No
 

Age-based renewal procedures	 Drivers 65+ renew every 2 years instead of 4; all drivers 45+ requested to submit physical and vision 

exam prior to renewing (random mailing of 1,650 per month) 

Reporting Procedures 

Mandatory medical reporting	 Any person qualified to make a medical diagnosis is required to report any patient they feel exhibits 

unsafe driving behaviors. 

Physician/medical reporting	 Required, “All physicians and other persons authorized to diagnose or treat disorders and disabilities 

defined by the Medical Advisory Board shall report to PENNDOT in writing the full name, DOB, and address of every person 15 years of age and older, diagnosed as having any specified disorder or disability 

within 10 days.” 

Immunity	 Yes—see 1518 (f)—“No civil or criminal action may be brought against any person or agency for 

providing the information required under this system.” 

Legal protection	 Yes 

DMV follow-up	 PENNDOT then sends out appropriate correspondence to drivers asking them to have necessary forms 

completed and/or test performed. 

Other reporting	 Will accept information from court, other DMVs, police, emergency personnel, and family members/ 

neighbors/caregivers, so long as reports are signed with a way to confirm reporter facts. 

Anonymity	 Yes 

122 
Pennsylvania (continued)
 

Medical Advisory Board 

Role of the MAB The board advises PENNDOT and reviews regulations proposed by PENNDOT concerning physical and 

mental criteria including vision standards relating to the licensing of drivers. It meets, typically, once 

every 2 years or as needed. 

Medical Review contact information Bureau of Driver Licensing 

Driver Qualifications Section 

PO Box 68682 

Harrisburg, PA 17106-8682 

717-787-9662 

123 
 

 

Rhode Island
 

Name of State & DMV Rhode Island Department of Motor Vehicles 401-588-3020 

contact information Division of Motor Vehicles Services 

286 Main Street 

Pawtucket, RI 02860 

www.dmv.state.ri.us/ 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/40 better eye.
 

Are bioptic telescopes allowed? .................................................. Not mentioned in the regulations
 

Visual fields Minimum field requirement.........................................................115° in horizontal meridian, for one 

eye 40° nasally 

Color vision requirement	 No 

Type of road test 

Restricted licenses	 No 

License Renewal Procedures 

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

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

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

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

5 years 

If license has been expired three 

years or more, it cannot be renewed 

Yes 

No, only if license has been expired 3 

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

years or more 

No, only if license has been expired 3 

years or more 

Age-based renewal procedures Age 75, renewal cycle reduced to 2 years. 

Reporting Procedures 

Mandatory medical reporting	 No 

Physician/medical reporting	 Yes, Any physician who diagnoses a physical or mental condition which in the physician’s judgment 

will significantly impair the person’s ability to safely operate a motor vehicle may voluntarily report the 

person’s name and other information relevant to the condition to the Medical Advisory Board within the 

Registry of Motor Vehicles. 

Immunity	 Yes, Any physician reporting in good faith and exercising due care shall have immunity from any liability, 

civil or criminal, that otherwise might result by reason of his actions pursuant to the section. No cause 

of action may be brought against any physician for not making a report pursuant to this section. 

Legal protection 

DMV follow-up	 Driver is notified in writing of referral. 

Other reporting	 Will accept information from court, other DMVs, police, and family members. 

Anonymity 

Medical Advisory Board 

Role of the MAB Action is based on the recommendation of the majority.
 

Medical Review contact information Information related to medical review can be obtained by calling 401-588-3020
 

124 
 

 

South Carolina
 

Name of State & DMV Department of Motor Vehicles 803-896-5000 

contact information PO Box 1498 

Blythewood, SC 29016 

www.scdmvonline.org 

Licensing Requirements 

Visual acuity Each eye without correction........................................................ 

Both eyes without correction....................................................... 

Each eye with correction............................................................. 

Both eyes with correction ........................................................... 

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

If one eye blind—other with correction........................................ 

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

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

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

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

Color vision requirement No 

Type of road test Not specified. 

Restricted licenses Yes: corrective lens, outside mirrors, daylight driving only 

20/40
 

20/40
 

20/40
 

20/40
 

20/40
 

20/40—must have outside mirror
 

20/40 better eye unrestricted, 20/70 


in better eye if worse eye is 20/200 


or better; if not then 20/40.
 

Not permitted to meet acuity standard 


(must meet acuity standard through 


carrier lens); however, permitted to 


use while driving.
 

No
 

Not specified.
 

License Renewal Procedures 

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

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

5 years 

Renewal by mail if no violations in 

past 2 years, no suspension, revocations or cancellations. 

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

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

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

Only if 5+ points on record 

Only if 5+ points on record 

Only if there appears to be a need. 

Age-based renewal procedures No 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting No 

Immunity No 

Legal protection N/A 

DMV follow-up License is suspended upon referral and further examination is conducted. 

Other reporting Will accept information from court, other DMVs, and police. 

Anonymity N/A 

Medical Advisory Board 

Role of the MAB	 The Medical Advisory Board determines the mental of physical fitness of license applicants through a 

medical evaluation process, and makes recommendations to the department’s director or designee on 

the handling of impaired drivers. 

Medical Review contact information	 South Carolina Driver Improvement Office 

PO Box 1498 

Columbia, SC 29216 

803-896-9925 

125 
 

South Dakota
 

Name of State & DMV South Dakota Driver Licensing 800-952-3696 or 

contact information 118 West Capitol Avenue 605-773-6883 

Pierre, SD 57501 

www.state.sd.us/dps/dl 

Licensing Requirements 

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

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/60 both eyes with/without 


correction 

Are bioptic telescopes allowed? .................................................. Yes (skill test required) 

Visual fields Minimum field requirement.........................................................No 

Color vision requirement	 No 

Type of road test	 Standardized course 

Restricted licenses	 Yes: daylight only, outside rearview mirrors; corrective lenses, 50 mile radius from home, no driving 

outside of town 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 5 years
 

Renewal options and conditions.................................................. In person; renewal by mail for military 


and military dependents only. 

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

Written test required?................................................................. No (unless expired more than 30 days) 

Road test required?.................................................................... No 

Age-based renewal procedures	 No 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Yes, physicians may report unsafe drivers if they so choose. The form to be used is a request 

re-evaluation form. It can be found on our Web site or by calling our office. 

Immunity	 No 

DMV follow-up	 An appointment is scheduled and the driver is notified to appear for an interview, written and road test 

may be included. 

Other reporting	 Will accept information from court, other DMVs, police, family members, and other resources. 

Anonymity	 No 

Medical Advisory Board 

Role of the MAB	 Medical information is reviewed by Department of Public Safety personnel. Upon having good cause 

to believe that a licensed operator is not qualified to be licensed, may upon written notice of at least 5 

days to the licensee, require him or her to submit to an examination or interview. The department shall 

take action as may be appropriate and may withdraw/cancel the license of such person or permit him or 

her to retain such license, or may issue a license subject to restrictions. 

Medical Review contact information	 Information on making referrals can be obtained through the contacts above. 

126 
 

 

Tennessee
 

Name of State & DMV Tennessee Department of Safety 615-741-3954 

contact information Driver License Division 

1150 Foster Avenue 

Nashville, TN 37249-1000 

http://state.tn.us/safety/driverservices.shtml 

Licensing Requirements 

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

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

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

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

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

Visual fields 

Color vision requirement 

Type of road test 

Restricted licenses 

Minimum field requirement......................................................... 

Visual field testing device ........................................................... 

Yes, commercial only 

Standardized, certain requirements in course. 

Yes: with area limitations 

20/40 

20/40 

20/40 

20/40 better eye with/without 

correction, minimum 20/60 

each/both eye with restrictions 

Yes, for 20/200 better eye, 20/60 

through scope; visual field 150° or 

larger, telescope no greater than 4X 

For professional drivers only 

Stereo Optic 

License Renewal Procedures 

Standard Length of license validation......................................................... 5 years
 

Renewal options and conditions.................................................. Mail in every other cycle, by mail,
 

in person and by Internet
 

Vision testing required at time of renewal? .................................. No
 

Written test required?................................................................. No (except in case of 


hazardous material ) 

Road test required?.................................................................... No 

Age-based renewal procedures No 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting No 

Immunity Yes 

Legal protection No 

DMV follow-up Driver is notified in writing of referral. 

Other reporting Will accept information from court, other DMVs, police, family members, and other resources. 

Anonymity No 

Medical Advisory Board 

Role of the MAB	 Paid physicians make recommendations upon review of medical report. Action is based upon recommendation of the majority. 

Medical Review contact information	 Driver Improvement Office can be reached at 615-251-5193 

http://state.tn.us/safety/forms/medical.pdf 

127 
 

 

 

 

Texas
 

Name of State & DMV Texas Department of Public Safety 512-424-2600 

contact information Driver License Division 

PO Box 4087 

Austin, TX 78773-0001 

www.txdps.state.tx.us/ 

Licensing Requirements 

Visual acuity	 Each/both eyes without correction............................................... 20/40
 

Each/both eyes with correction ................................................... 20/50
 

If one eye blind—other without correction ................................... 20/50 with eye specialist statement
 

If one eye blind—other with correction........................................ 20/50 with eye specialist statement
 

Absolute visual acuity minimum .................................................. 20/40 in better eye for unrestricted 


license; 20/70 in better eye with 

restrictions. 

Are bioptic telescopes allowed? .................................................. Yes, provided that the client has 

acuity of 20/40 through the telescope 

and passes road test. 

Visual fields	 Minimum field requirement.........................................................None
 

Color vision requirement	 There is a requirement for all new drivers (not specified) 

Type of road test	 Standardized Course 

Restricted licenses	 Yes, restrictions applied per medical advisory direction (daytime only, speed limit <45 mph; 

no expressway driving) Restrictions are based on medical advice and may include daytime driving 

only where the speed limit <45 mph and no expressway driving. 

License Renewal Procedures 

Standard Length of license validation......................................................... 6 years 

Renewal options and conditions.................................................. In person; every second renewal 

period may be eligible for alternate 

renewal by Internet, telephone, or mail. 

Vision testing required at time of renewal? .................................. At in-person renewal 

Written test required?................................................................. May be required based upon 

evaluation of medical, physical, 

or mental impairments. 

Road test required?.................................................................... May be required based upon 

evaluation of medical, physical, 

or mental impairments. 

Age-based renewal procedures	 No. Effective 9/1/2007, drivers 79 or older must renew in person; renewal is required every 2 years for 

drivers 85 or older. 

Reporting Procedures 

Physician/medical reporting	 Any physician licensed to practice medicine in Texas may inform the Department of Public Safety. 

This release of information is an exception to the patient-physician privilege. There is no special 

reporting form; a letter from the physician will suffice. 

Immunity	 Yes 

DMV follow-up	 The driver is notified in writing of the referral and required to provide medical information from his/her 

personal physician. 

Legal Protection	 Yes 

Other reporting	 Will accept information from court, other DMVs, police, family members, and other resources. 

Anonymity	 Not anonymous or confidential. However, an attempt is made to protect the identity of the reporter. If 

the client requests an administrative hearing to contest enforcement action, the identity of the reporter 

may be revealed at that time. 

128 
 

Texas (continued)
 

Medical Advisory Board 

Role of the MAB The MAB advises the Department of Public Safety on medical issues regarding individual drivers. 

The Department bases its actions on the recommendation of the physician who reviews the case. 

Medical Review contact information Texas Department of Public Safety 

Medical Advisory Board 

PO Box 4087 

Austin, TX 78773 

512-424-7120 

129 
 

 

Utah
 

Name of State & DMV Utah Department of Public Safet 801-965-4437 

contact information Driver License Division 

PO Box 144501 

Salt Lake City, UT 84114-4501 

www.driverlicense.utah.gov 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/100 in better eye with restrictions.
 

Are bioptic telescopes allowed? .................................................. No
 

Visual fields Minimum field requirement......................................................... 120° horizontal, 20° vertical, 90° 

with restrictions 

Visual field testing device ........................................................... Stereo Optical (DMV2000) 

Color vision requirement	 No 

Type of road test	 In applicant’s own car, with examiner. Certain driving tasks required to complete. 

Restricted licenses	 Yes: daytime only, speed limit <45 mph, radius limit. 

License Renewal Procedures 

Standard Length of license validation......................................................... 

Renewal options and conditions .................................................. 

Vision testing required at time of renewal? .................................. 

Age-based renewal procedures 

Written test required?................................................................. 

Road test required?.................................................................... 

No 

5 years 

Mail in every other cycle if no suspensions, revocations, convictions, 

and not more that 4 violations. 

Yes, for age 65+. All drivers are 

required to take the vision test when 

renewing in person. The age-based 

vision-testing requirement pertaining 

to those 65 and over applies only to 

the renewal by mail program. 

No 

No, unless examiner feels the applicant’s ability to drive is in question 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Yes 

Immunity Yes, any physician or other person who becomes aware of a physical, mental or emotional impairment which appears to present an imminent threat to driving safety and reports this information to the 

Department of Public Safety, through its agents, in good faith shall have immunity from any damages 

claimed as a result of so doing. 

Legal protection No 

DMV follow-up Driver is notified in writing of referral. License is suspended upon referral 

Other reporting Will accept information from court, other DMVs, police, family members, and other resources. 

Anonymity Not confidential 

130 
Utah (continued)
 

Medical Advisory Board 

Role of the MAB	 A Driver License Medical Advisory Board was created to advise the Director of the Driver License 

Division and to recommend written guidelines and standards for determining the physical, mental, 

and emotional capabilities appropriate to various types of driving in an effort to minimize the conflict 

between the individual’s desire to drive and the community’s desire for safety. 

Medical Review contact information	 Program Coordinator, Utah Driver License Division 

PO Box 144501 

Salt Lake City, Utah 84114-4501 

Phone: 801/965-3819 

Fax: 801/965-4084 

http://publicsafety.utah.gov/dld/med_standards.html 

131 
 

 

Vermont
 

Name of State & DMV Vermont Department of Motor Vehicles 802-828-2000 

contact information 120 State Street 

Montpelier, VT 05603 

www.dmv.state.vt.us/dmvhp.htm 

Licensing Requirements 

Visual acuity Each eye with/without correction................................................. 

Both eyes with/without correction ............................................... 

If one eye blind—other with/without correction............................ 

Absolute visual acuity minimum .................................................. 

Are bioptic telescopes allowed? .................................................. 

Visual fields Minimum field requirement......................................................... 

Visual field testing device ........................................................... 

Color vision requirement No 

Type of road test Standard 

Restricted licenses Yes, for glasses or contact lenses 

20/40 

20/40 

20/40 

20/40 in better eye. 

Yes, and must pass road test, daytime 

only under 10,000 lbs. 

Each eye 60° External binocular, 60° 

external and 60° nasal monocular 

Yes 

License Renewal Procedures 

Standard	 Length of license validation......................................................... 2 to 4 years
 

Renewal options and conditions.................................................. Mail and in person
 

Vision testing required at time of renewal? .................................. No
 

Written test required?................................................................. No
 

Road test required?.................................................................... No
 

Age-based renewal procedures	 No 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Doctors may only provide information to the DMV with the permission of the patient 

Immunity No 

Legal protection No 

DMV follow-up Driver is notified of referral by mail. 

Other reporting Will accept information from court, other DMVs, police, concerned citizens, or family members, provided 

the complaint is signed. 

Anonymity Only up until a hearing is requested. 

Medical Advisory Board 

Role of the MAB	 Vermont no longer has a Medical Advisory Board. 

132 
 

 

 

Virginia
 

Name of State & DMV Virginia Department of Motor Vehicles 804-367-0531 or 804-367-6203 

contact information Attn: Medical Review Center 

PO Box 27412 

Richmond, VA 23269-0001 

www.dmv.state.va.us/ 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/40 better eye, 20/70 daylight only,
 

20/200 better eye with restrictions. 

Are bioptic telescopes allowed? .................................................. Yes, with 20/200 through carrier, 

20/70 through telescope—test 

required. 

Visual fields Minimum field requirement......................................................... 100° monocular and binocular; 

70° monocular and binocular— 

daylight only. 40 ° or better temporal 

and 30° or better nasal—vision in 

one eye only. 

Visual field testing device ........................................................... Stereo Optical/Titmus 10mm W 

@333 mm. Color vision requirement	 No 

Type of road test	 Behind-the-wheel test is administered with the DMV examiner instructing and evaluating the person on 

specific driving maneuvers. 

Restricted licenses	 Yes. A person can obtain a restricted license with a variety of restrictions if authorized by Virginia 

law and granted by DMV (based on performance on road test, for medical reasons, or for violation 

of probation) or by the court (based on conviction). The restrictions range from corrective lenses, 

hand controls, and 5-mile radius of residence, to daylight driving only, ignition interlock device, 

and to and from work/school. 

License Renewal Procedures 

Standard Length of license validation......................................................... 

Renewal options and conditions .................................................. 

Age-based renewal procedures 

Vision testing required at time of renewal? .................................. 

Written test required?................................................................. 

Road test required?.................................................................... 

No 

5 years 

Customers may use alternative 

method of renewing driver’s license 

applications every other cycle unless 

suspended or revoked, 2+ violations, 

DMV medical review indicator on 

license, failed vision test. Alternative 

methods include mail-in, Internet, 

touch-tone telephone, fax, and 

ExtraTeller. 

Yes 

Only if 2+ violations in 5 years 

No 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Physicians are not required to report unsafe drivers. However, for physicians who do report unsafe 

drivers, laws have been enacted to prohibit release of the physician’s name as the source of the report. 

Immunity No 

Legal protection 

DMV follow-up 

133 
Virginia (continued)
 

Other reporting	 DMV relies upon information from courts, other DMVs, law enforcement officers, physicians and other 

medical professionals, relatives and concerned citizens to help identify drivers who may be impaired. 

Anonymity	 Virginia law provides confidentiality, only for relatives and physicians. 

Medical Advisory Board 

Role of the MAB	 The board enables the Department of Motor Vehicles (DMV) to comply with its responsibilities of 

monitoring drivers throughout the State who may have physical or mental problems. The board assists 

the commissioner through the development of medical and health standards for use in the issuance of 

driver’s licenses. The board helps the department avoid the issuance of licenses to persons suffering 

from any physical or mental disability or disease that will prevent their exercising reasonable and ordinary control over a motor vehicle while driving it on the highways. They review the more complex cases 

and cases referred for administrative hearings and provide recommendations for medical review action. 

Medical Review contact information	 Questions about medical review can be directed to 804-497-7188 

www.dmv.state.va.us/webdoc/citizen/medical/index.asp 

134 
 

 

 

 

 

Washington
 

Name of State & DMV Washington Department of Licensing 360-902-3900 

contact information Driver Services 

PO Box 9030 

Olympia, WA 98507-9030 

www.dol.wa.gov/ 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40
 

Both eyes with/without correction ............................................... 20/40
 

If one eye blind—other with/without correction............................ 20/40
 

Absolute visual acuity minimum .................................................. 20/40 in better eye; 20/70 in better 


eye with restriction. Person must 

have vision better than 20/200. 

20/50 or worse with both eyes person 

must take standard drive test. 

Are bioptic telescopes allowed? .................................................. Yes: training and test required. Training 

is not required but encouraged. 

Visual fields Minimum field requirement......................................................... 110° in horizontal meridian for 

binocular and monocular. 

Visual field testing device ........................................................... OPTEC 1000; Keystone Telebinocular; 

Keystone DVSII 

Color vision requirement	 Yes, for new and professional drivers. 

Type of road test	 Standardized scoring using approved test routes at each licensing office. 

Restricted licenses	 Yes, depending on circumstances. Corrective lenses to meet minimum acuity; daytime driving only 

based on eye care practitioner’s report, or after failed night time driving test; also if needed to compensate for visual or physical impairment-equipment restrictions, route, distance, or geographic area limits 

depending on outcome of testing driver’s ability. We no longer give night drives or have route, distance, 

or geographic area limits. We do still have equipment restrictions. 

License Renewal Procedures 

Standard Length of license validation......................................................... 

Renewal options and conditions .................................................. 

Vision testing required at time of renewal? .................................. 

Written test required?................................................................. 

Road test required?.................................................................... 

Age-based renewal procedures None 

5 years
 

In-State renewal—in person only. Out 


of State, can renew by mail once.
 

Yes, both eyes together only. Full eye 


test anytime we issue a new license.
 

Waived unless warranted by vision,
 

health or medical screening.
 

Waived unless warranted by vision,
 

health or medical screening.
 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting No 

Immunity No 

Legal protection No 

DMV follow-up Letter to the driver with information detailing due process and action following any failure to respond. 

Other reporting Will accept information from court, other DMVs, police, family members, and other competent 

sources. If in doubt, the reporting party may be required to establish firsthand knowledge and 

standing for making a report. 

135 
Washington (continued)
 

Anonymity Not confidential 

Medical Advisory Board 

Role of the MAB Washington does not have an MAB. 

Medical Review contact information Information on referrals can be found at www.dol.wa.gov/driverslicense/reportunsafe.html 

or by writing to 

Driver Records 

Department of Licensing 

PO Box 9030 

Olympia, WA 98507-9030 

136 
 

 

West Virginia
 

Name of State & DMV West Virginia Department of Transportation 800-642-9066 or 304-558-3900 

contact information Division of Motor Vehicles 

Building 3, Room 1240 

1800 Kanawha Boulevard East 

Charleston, WV 25317 

www.wvdmv.gov 

Licensing Requirements 

Visual acuity Both eyes with/without correction ............................................... 

If one eye blind—other with/without correction............................ 

Absolute visual acuity minimum .................................................. 

Are bioptic telescopes allowed? .................................................. 

Visual fields Minimum field requirement......................................................... 

Visual field testing device ........................................................... 

Color vision requirement No 

Type of road test Standard Road Skills Exam 

Restricted licenses None 

20/40 

20/40 

20/60 better eye; if less then optometrist or ophthalmologist must declare 

ability to be safe. 

No 

None 

No 

License Renewal Procedures 

Standard Length of license validation......................................................... 

Renewal options and conditions .................................................. 

Vision testing required at time of renewal? .................................. 

Written test required?................................................................. 

Road test required?.................................................................... 

5 years 

5 years, no examinations required 

No 

No 

No 

Age-based renewal procedures None 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting Physicians are encouraged to report and may do so. 

Immunity No 

Legal protection No 

DMV follow-up A medical report is sent to the driver, to be completed by his/her physician. Failure to comply—the drivers license is revoked. 

Anonymity Not confidential 

Medical Advisory Board 

Role of the MAB To review medical cases and advise the Division on the condition of the driver and how their condition 

might affect their ability to drive. If the MAB comes to the conclusion that the driver is unsafe they make 

a recommendation to the Commissioner of Motor Vehicles and it is the Commissioner that has the final 

say as to revoke the driver. 

Medical Review contact information Questions about medical review can go to 304-558-0238 

137 
 

 

 

Wisconsin
 

Name of State & DMV Wisconsin Driver Services, Medical Division 608-266-2327 

contact information Medical Review Section 

PO Box 7918 

Madison, WI 53707 

www.dot.wisconsin.gov/drivers/index.htm 

Licensing Requirements 

Visual acuity	 Each eye with/without correction................................................. 20/40 to 20/100 in better eye
 

Both eyes with/without correction ............................................... Not acceptable
 

If one eye blind—other with/without correction............................ 20/40 to 20/100 in better eye
 

Absolute visual acuity minimum .................................................. 20/100 in better eye with or without 


correction 

Are bioptic telescopes allowed? .................................................. Not to meet vision standards but can 

use to drive 

Visual fields	 Minimum field requirement......................................................... 20° better eye for regular license
 

Visual field testing device ........................................................... Stereo optical machines
 

Color vision requirement	 Yes 

Type of road test	 Knowledge and sign test, prior to road test. Limited area test is non-fixed, otherwise standardized. 

Restricted licenses	 Yes, restrictions can be recommended by physician, vision specialist or determined by road test (daytime driving only, mileage radius, road posted and/or freeway restriction). 

License Renewal Procedures 

Standard Length of license validation......................................................... 8 years 

Renewal options and conditions.................................................. In person 

Vision testing required at time of renewal? .................................. By mail if person is out of State 

Written test required?................................................................. Yes 

Determined by DOT, vision specialist, 

or physician. 

Road test required?.................................................................... Determined by DOT, vision specialist, 

or physician 

Age-based renewal procedures	 None 

Reporting Procedures 

Mandatory medical reporting None 

Physician/medical reporting Physicians are not required but encouraged to report. They can report by submitting form MV3141 

Driver Condition or Behavior Report or by letter on stationary letterhead. 

Immunity	 Yes 

Legal protection	 Yes 

DMV follow-up	 Driver is notified in writing requirements and depending on requirements given 15, 30, or 60 days to 

comply. If do not comply within the time period given, driver’s license is cancelled. They are notified in 

writing of cancellation 

Other reporting	 Will accept information from court, other DMVs, police, family members, and other resources. 

Anonymity	 WI has open records law; however, individuals can submit acceptable pledge of confidentiality form 

MV3454 

138 
 

 

Wisconsin (continued)
 

Medical Advisory Board 

Role of the MAB	 Action is taken based on recommendation of the majority, the individuals driver record, medical information provided from physician and, if appropriate, driving examination results. Wisconsin has 2 types of 

Medical Review Boards: 

1. By-mail board: paper file is mailed to 3 physicians (specialists, i.e., neurologists, endocrinologists) for 

recommendation, based on medical condition. 

2. In-person board: interview with 3 physicians (psychiatrist, neurologist, and internal medicine). 

The final step in the review process is judicial review which goes through a court process. 

Medical Review contact information	 Information about the medical review program can be obtained through the following: 

E-mail: dre.dmv@dot.state.wi.us 

Phone: 608-266-2327 

FAX: 608-267-0518 

www.dot.wisconsin.gov/drivers/drivers/aging/impaired.htm 

139 
 

 

Wyoming
 

Name of State & DMV Wyoming Dept. of Transportation 307-777-4871 

contact information Driver Services Program 

5300 Bishop Blvd 

Cheyenne, WY 82009-3340 

http://dot.state.wy.us 

Licensing Requirements: Must meet minimum of 20/100 with both eyes, with or without correction. 

Visual acuity	 Each eye with/without correction................................................. None
 

Both eyes with/without correction ............................................... Minimum of 20/100 


If one eye blind—other with/without correction............................ Minimum of 20/100 with both eyes
 

Absolute visual acuity minimum .................................................. 20/100 


Are bioptic telescopes allowed? .................................................. Yes, but the person must meet the 


minimum visual acuity & visual field 

levels with the lenses–generally 

restricted to “no interstate driving”, as 

well as restrictions to speed and area. 

Visual fields	 Minimum field requirement......................................................... 120° 


Visual field testing device ........................................................... Keystone Machine
 

Color vision requirement	 N/A 

Type of road test	 Driving skills test with an examiner. 

Restricted licenses	 B = glasses required, F = left & right outside rearview mirrors required 

G = Daylight driving only, I = limited other (such as distance, speed, etc.) 

License Renewal Procedures 

Standard Length of license validation......................................................... 

Renewal options and conditions .................................................. 

4 years 

Vision screening required for each 

renewal. 

Vision testing required at time of renewal? .................................. 

Written test required?................................................................. 

Road test required?.................................................................... 

Yes 

No 

No—dependent upon vision specialist recommendation and/or decrease 

in visual acuity level (i.e., 20/50 or 

worse visual acuity) 

Age-based renewal procedures Are there any age-based license renewal procedures? No 

Reporting Procedures 

Mandatory medical reporting No 

Physician/medical reporting No 

Immunity No 

Legal protection No 

DMV follow-up Re-examinations are performed upon request from family, medical specialists, law enforcement agencies, and examiner observation. 

Other reporting	 Law enforcement, family member, medical specialist, vision specialist, etc. 

Anonymity	 N/A 

Medical Advisory Board 

Role of the MAB	 Wyoming does not have a Medical Advisory Board. 

Medical Review contact information	 Requests for review must be made in writing to: 

Driver Services - Medical Review 

5300 Bishop Blvd. 

Cheyenne, WY 82009 

140 
 

Resources 


Coley, M. J., Coughlin, J. F. (2001, 

Summer). State Driving Regulations. 

Adapted from National Academy on an 

Aging Society. The Public Policy and 

Aging Report, Volume 11, Number 4. 

Washington, DC: The Gerontological 

Society of America. 

Epilepsy Foundation. Driver information 

by State. www.epilepsyfoundation.org/living 

/wellness/transportation/drivinglaws.cfm. 

Accessed November 21, 2007. 

Insurance Institute for Highway Safety. 

(2007). U.S. driver licensing procedures 

for older drivers. www.iihs.org/laws/ 

olderdrivers.aspx. Accessed November 

31, 2007. 

Insurance Information Institute. (2007). 

Older Drivers. New York. www.iii.org/ 

media/hottopics/insurance/olderdrivers/?p 

rinterfriendly=yes. Accessed November 

21, 2007. 

NHTSA. (2003). Older Drivers: State 

Reporting Practices. DOT HS 809 301, 

2003. Washington, DC: National 

Highway Traffic and Safety Administration www.nhtsa.dot.gov/people/injury/ 

olddrive/FamilynFriends/state.htm. 

Accessed November 21, 2007. 

Staplin, L. (2003). Model Driver 

Screening and Evaluation Program: 

Guidelines for Motor Vehicle Administrators. Washington, DC: National Highway Traffic and Safety 

Administration www.nhtsa.com/people/ 

injury/olddrive/modeldriver/guidelines. 

htm#Table%20of%20Contents. 

Accessed November 22, 2007. 

chapter 8—State Licensing and Reporting Laws 141 

chapter 9 

Medical Conditions and 

Medications That May 

Affect Driving 

chapter 9 

Medical Conditions and 


Medications That May 


Affect Driving
 

This chapter contains a reference table 

of medical conditions and medications 

that may affect driving skills, with 

consensus recommendations for each. 

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, these 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 evidencedbased literature indicating a correlation 

with driving impairment. The interested clinician is referred to two recent 

reviews that comprehensively covered 

many of these conditions.187 188 In addition, several other countries have published guidelines, including Canada,189 

187. Charlton, J., Koppel, S., O’Hare, M., et al. 

(2004). Influence of Chronic Illness on Crash 

Involvement of Motor Vehicle Drivers. Monash 

University. Accident Research Centre. Report 

#213. Supported by Swedish National Road 

Administration. Melbourna, Australia: Monash 

University. 

188. Dobbs, B. M. (2002). Medical Conditions and 

Driving: Current Knowledge, Final Report Association for the Advancement of Automotive 

Medicine. NHTSA Publication DOT HS 809 

690. Washington, DC: National Highway Traffic Safety Administration. www.nhtsa.dot.gov/ 

people/injury/research/Medical_Condition_Driving/ 

pages/TRD.html. 

189. Canadian Medical Association. Determining 

Medical Fitness to Drive: A Guide for Physicians, 

6th ed. Ottawa; 2000. 

Australia,190 the United Kingdom,191 

and New Zealand.192 

Although the corresponding recommendations are based on scientific 

evidence whenever possible, please note 

that use of these recommendations has 

not yet been proven to reduce crash 

risk,193 except for a few medical conditions (e.g., treating obstructive sleep 

apnea, performing cataract surgery, 

and discontinuing a benzodiazepine). 

As such, these recommendations are 

provided to physicians as a tool to guide 

the decision-making process. They are 

not intended to substitute for the physician’s clinical judgment. 

How to use this chapter 

Physicians may consult this chapter if 

they have questions on specific medical 

conditions and their effect on driving. 

If a patient presents with a particular 

medical condition and/or related functional deficits (e.g., deficits in vision, 

190. Austroads. Assessing Fitness to Drive for 

Commercial and Private Vehicle Drivers. 

Medical Standards for Licensing and Clinical 

Management Guidelines. A Resource for Health 

Professionals in Australia; 2003. 

191. Driver Medical Group DVLA Swansea for 

Medical Practitioners. At a Glance Guide to the 

Current Medical Standards of Fitness to Drive. 

(2003). Swansea, UK. 

192. Land Transport Safety Authority. (2002). 

Medical Aspect of Fitness to Drive. Wellington, 

New Zealand. 

193. Although scientific evidence links certain 

medical conditions and levels of functional impairment with crash risk, more research is needed 

to establish that driving restrictions based on 

these medical conditions and levels of functional 

impairment significantly reduce crash risk. 

cognition, or motor function) that may 

affect his/her driving safety, the physician may base interventions for driving 

safety on this chapter’s guidelines. We 

make the following recommendations: 

• Treat the underlying medical condition to correct functional deficits and 

prevent further functional decline. 

• If the functional deficit is due to an 

offending agent (e.g., medication 

with impairing side effects), remove 

the offending agent or reduce the 

dose, if possible. 

• Advise the patient about the risks to 

his/her driving safety, and recommend 

driving restrictions or driving cessation as needed. 

• For acute or episodic illnesses (e.g., 

seizure disorder and/or diabetics with 

hypoglycemia), clinical judgment and 

subspecialist input is recommended, 

in addition to following specific State 

statutes. 

If further evaluation is required or the 

functional deficits are not medically 

correctable, refer the patient to a driver 

rehabilitation specialist for a driving evaluation (including an on-road 

assessment) for a chronic condition 

whenever possible. The driver rehabilitation specialist may prescribe adaptive 

techniques and devices to compensate 

for these deficits, and train the patient 

in their use. (See Chapter 5 for a further 

discussion of driver rehabilitation 

services.) 

Physicians should advise patients 

against driving if they report symptoms 

145 
that are irreversible and incompatible Medical conditions and mediwith safe driving (e.g., visual changes, 

syncope or pre-syncope, vertigo, severe cations that may affect driving 

pain, etc.). If despite extensive medical work-up these symptoms continue, Table of contents 

such patients should be strongly urged Contents .......................................Page 

to seek alternate forms of transportation, including taxis, rides from family Section 1 .......................................146 

and friends, and medical transportation Vision and Hearing Loss 

services. 

Section 2 .......................................151 

In the inpatient and emergency depart- Cardiovascular Diseases 

ment, driving should be routinely addressed prior to the patient’s discharge Section 3 .......................................155 

whenever appropriate, especially when Cerebrovascular Diseases 

prescribing new sedating medications. 

Even for the patient whose symptom Section 4 .......................................157 

or treatment clearly precludes driv- Neurologic Diseases 

ing, it should not be assumed that the 

patient is aware that he/she should not Section 5 .......................................163 

drive. The physician should counsel the Psychiatric Disorders 

patient regarding driving, and discuss a 

future plan (e.g., resumption of driving Section 6 .......................................165 

upon resolution of symptoms, driver Metabolic Disorders 

rehabilitation upon stabilization of 

symptoms, and so forth.). Section 7 .......................................167 

Musculoskeletal Disabilities 

Keep in mind that an individual’s driving purposes (e.g., responsible for taking Section 8 .......................................171 

grandchildren to day care) and/or need Peripheral Vascular Diseases 

to drive for a vocation (e.g., salesperson 

who has increased exposure or miles Section 9 .......................................172 

driven per year) may influence the Renal Disease 

extent of the interventions or advice in 

regard to an evaluation. For example, Section 10 .....................................173 

more restriction or a performance-based Respiratory Diseases 

road test may be more aggressively pursued for a patient who frequently drives Section 11 .....................................175 

long distances over unfamiliar roads Effects of Anesthesia and Surgery 

in comparison to a patient who drives 

short, familiar routes. Section 12 .....................................177 

Miscellaneous Conditions 

Section 13 .....................................178 

Medications 

Section 1: 


Vision and hearing loss
 

Vision is the primary sense employed 

in driving when compared to hearing 

and proprioception, and is responsible 

for 95 percent of driving-related sensory 

inputs.194 Age- and disease-related 

changes of the eye and brain may affect 

visual acuity, visual fields, night vision, 

contrast sensitivity, and other aspects 

of vision. External obstruction of view 

(e.g., blepharoptosis) should not be 

overlooked, as it may significantly limit 

visual fields. The literature that is available on eye disease suggests that driving 

impairment is likely mediated by impairment in contrast sensitivity,

195 visual 

fields,196 or visual processing speed. 

Whenever possible, vision deficits 

should be managed and corrected. 

Recent data suggest that intervention 

with current treatments for common 

eye diseases such as age-related macular 

degeneration,197 glaucoma,198 and cataracts199 have the potential to improve 

or stabilize the condition, and in some 

cases these interventions have been 

noted to reduce crash risk.200 Patients 

with persistent vision deficits may 

reduce their impact on driving safety by 

restricting travel to low-risk areas and 

conditions, such as familiar surround194. Shinar, D., & Schieber, F. (1991). Visual 

requirements for safety and mobility of older 

drivers. Hum Factors. 33(5):507–519. 

195. Mabtyjari, M., & Tuppurainen, K. (1999). Cataract in traffic. Graefes Arch Clin Exp Ophthalmal. 

237:278–282. 

196. Szlyk, J. P., Mahler, C. L., Seiple, W., et al. 

(2005). Driving performance of glaucoma 

patients correlates with peripheral visual field 

loss. J Glaucoma. 14:145–150. 

197. Smith, B.T., Joseph, D.P., & Grand, 

M.G.(2007). Treatment of neovascular agerelated macular degeneration: past, present, 

and future directions. Curr Opin Ophthalmol. 

18:240–244. 

198. Leske, M.C., Hejl, A., Hussein, M., et al. 

(2003). Factors for glaucoma progression and 

the effect of treatment: the Early Manifest 

Glaucoma Trial. Arch Ophthamol. 121:48–56. 

199. Van Den Berg, T., Van Rijn, L.J., Rene, M., 

Michael, R., Heine, C., et al. (2007). Straylight 

effects with aging and lens extraction. Am J 

Ophthalmol. 144(3):358–363. 

200. Owsley, C., McGwin, G. Jr., Sloane, M., et al. 

(2002). Impact of cataract surgery on motor 

vehicle crash involvement by older adults. 

JAMA. 288:841–849. 

146 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

ings, low speed areas, non-rush hour 

traffic, daytime, and good weather conditions. This has been noted for certain 

eye diseases, especially glaucoma.201 

201. Adler, G., Bauer, M. J., Rottunda, S., et al. 

(2005). Driving habits and patterns in older 

men with glaucoma. Social Work Health Care. 

40(3):75–87. 

Sensory Deprivation 

1. Visual acuity 

a. Cataracts 

b. Retinopathy 

(diabetic or hypertensive) 

c. Keratoconus 

d. Macular degeneration 

e. Nystagmus 

f. Telescopic lens 

2. Visual 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 

Section 1: Sensory deprivation 

Visual acuity 

Cataracts 

Please note that the recommendations stated below are subject to your particular 

State’s licensing requirements. (See Chapter 8 for a State-by-State reference list of 

licensing requirements.) Many States require far visual acuity of 20/40 for licensure; 

however, recent studies indicate that there may be no basis for this requirement. 

State driver licensing agencies are urged to base their visual acuity requirements 

on the most current data, as appropriate. However, referral to an ophthalmologist 

is recommended since common causes for visual impairment (cataracts, macular 

degeneration, glaucoma) can improve and/or stabilize with treatment. 

Visual acuity may be measured with both eyes open or with the best eye open, as 

the patient prefers. The patient should wear any corrective lenses usually worn for 

driving. 

Patients with decreased far visual acuity may lessen its impact on driving safety 

by restricting driving to low-risk areas and conditions (e.g., familiar surroundings, 

non-rush hour traffic, low speed areas, daytime, and good weather conditions). 

For best-corrected far visual acuity less than 20/70, the physician should recommend an on-road assessment performed by a driver rehabilitation specialist (where 

it is permitted and available) to evaluate the patient’s performance in the actual 

driving task. 

For best-corrected far visual acuity less than 20/100, the physician should recommend that the patient not drive unless safe driving ability can be demonstrated in 

an on-road assessment, where permitted and available. (See also Telescopic lens in 

this section.) 

No restrictions if standards for visual acuity and visual fields are met, either with or 

without cataract removal. 

Patients who require increased illumination or who experience difficulty with glare 

recovery should avoid driving at night and under low-light conditions, such as 

adverse weather conditions. 

Diabetic or hypertensive retinopathy No restrictions if standards for visual acuity and visual fields are met. 


It is recommended that diabetic patients have annual eye examinations.
 

chapter 9—Medical Conditions and Medications That May Affect Driving 147 
Keratoconus Patients with severe keratoconus correctable with hard contact lenses should drive 

only when the lenses are in place. If lenses cannot be tolerated, patients with severe 

keratoconus should not drive even if they meet standards for visual acuity, as their 

acuity dramatically declines outside their foveal vision, rendering their peripheral 

vision useless. 

Macular degeneration No restrictions if standards for visual acuity and visual fields are met. 

Patients who experience difficulty with glare recovery should avoid driving at 

night. Patients with the neovascular “wet” form of the disease may require frequent 

assessment due to the rapid progression of the disease. 

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.202 The specialist who prescribes a 

telescopic lens should ensure that the patient is properly trained in its use. 

It has not been established whether telescopes enhance the safety of low-vision 

drivers. As stated in the American Academy of Ophthalmology’s Policy Statement, 

Vision Requirements for Driving (approved by Board of Trustees, October 2001): 

“More than half the States allow drivers to use bioptic telescopes mounted on 

glasses, through which they spot 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.” 

Please note that the statement above is subject to your particular State’s licensing 

requirements. A road test should be administered only in those States that permit 

the use of bioptic telescopes in driving. 

Visual field While it is acknowledged that an adequate visual field is important for safe driving, 

there is no conclusive evidence to define what is meant by “adequate” nor 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.203 

(See Chapter 8 for a State-by-State reference list of visual field requirements.) 

If the primary care physician has any reason to suspect a visual field defect (e.g., 

through patient report, medical history, or confrontation testing), he/she should 

refer the patient to an ophthalmologist or optometrist for further evaluation. The 

primary care physician and specialist should be aware of their particular State’s 

visual field requirements, if any, and adhere to them. 

202. Peli, E., & Peli, D. (2002). Driving With Confidence: A Practical Guide to Driving with Low Vision. 

Singapore: World Scientific Publishing Co. Pte. Ltd.; p.100–101. 

203. Peli, E., & Peli, D. (2002). Driving With Confidence: A Practical Guide to Driving with Low Vision. Singapore: World Scientific Publishing Co. Pte. Ltd.; p.20–22. 

148 chapter 9—Medical Conditions and Medications That May Affect Driving 
Visual field (continued) For binocular visual field at or near the State minimum requirement or of questionable adequacy (as deemed by clinical judgment), a driver evaluation (including 

on-road assessment) performed by a driver rehabilitation specialist is strongly recommended. Through driving rehabilitation, the patient may learn how to compensate for decreased visual fields, although not hemi-neglect. In addition, the driver 

rehabilitation specialist may prescribe enlarged side and rear view mirrors as needed 

and train the patient in their use. 

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 

Monocular vision 

The physician may choose to refer the patient to a driver rehabilitation specialist for assessment and rehabilitation. With or without rehabilitation, the patient 

should drive only if he/she demonstrates safe driving ability in an on-road assessment performed by a driver rehabilitation specialist. 

Please note that the recommendations stated above are subject to your particular 

State’s licensing restrictions, if any, for hemianopia and quadrantanopia. 

Patients with acquired monocularity may need time to adjust to the lack of depth 

perception and reduction in total visual field. This period of adjustment varies 

among individuals, but it is reasonable to recommend temporary driving cessation 

for several weeks. 

Following this period, there are no restrictions if standards for visual acuity and 

visual fields are met. Upon resumption of driving, patients should be advised to 

assess their comfort level by driving in familiar, traffic-free areas before advancing 

to heavy traffic. Again, use of larger mirrors and evaluation and training by a driver 

rehabilitation specialist is encouraged. 

Ptosis or lid redundancy, blepharospasm	 Individuals with fixed ptosis or lid redundancy may drive without restrictions 

if their eyelids do not obscure the visual axis of either eye, and they are able to 

meet standards for visual acuity and visual 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. 

Patients 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. 

chapter 9—Medical Conditions and Medications That May Affect Driving 149 
contrast sensitivity Contrast sensitivity is a measure of an individual’s ability to perceive visual stimuli 

that differ in contrast and spatial frequency. Contrast sensitivity tends to decline 

with age; accordingly, deficits in contrast sensitivity are much greater in older individuals compared to their younger counterparts.204 

Among older drivers, binocular measures of contrast sensitivity have been found 

to be a valid predictor of crash risk in patients with cataracts.205 However, there are 

presently no standardized cut-off points for contrast sensitivity and safe driving, 

and it is not routinely measured in eye examinations. 

defective color vision No restrictions if standards for visual acuity and visual fields are met. 

Deficits in color vision are common (especially in the male population) and 

usually mild. 

There appears to be no correlation between defective color vision and crash 

rates.206 Only 19 States require prospective drivers to undergo color vision screening, and most of these States require screening for commercial drivers only.207 

Despite reported difficulties with color vision discrimination while driving (difficulty distinguishing the 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.208With the standardization of traffic 

signal positions, color blind individuals are able to interpret traffic signals correctly 

because they can identify the traffic signal by its position. Physicians may wish to 

advise patients that the order of signals in the less commonly used horizontal placement is (from left to right) red, yellow, green. 

poor night vision If the patient reports poor visibility at night, the physician should recommend 

optometric and/or ophthalmologic evaluation. If the evaluation does not reveal a 

treatable cause for poor night vision, the physician should recommend that the patient not drive at night or under other low-light conditions, such as during storms 

or at dusk. 

diplopia Patients with double vision in the central aspect of vision (20 degrees above and 

below, left and right of fixation) should not drive. Patients 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 three-month adjustment period, after which 

specialists can determine if adequate adjustment has occurred.209 

204. Dobbs, B. M. (2002, February). Medical Conditions and Driving: Current Knowledge, p. 15. DTNH22­

94-G-05297. Submitted to the Association for the Advancement of Automotive Medicine under 

contract with the Washington, DC: National Highway Traffic Safety Administration. 

205. Owsley, C., Stalvey, B. T., Wells, J., et al. (2001). Visual risk factors for crash involvement in older drivers 

with cataract. Arch Opthalmol. 119: 881–887. 

206. Policy Statement. American Association of Ophthalmology, 2006. www.aao.org/about/policy/upload/ 

AAODrivingPolicyWebcopy.pdf. Accessed December 12, 2007. 

207. Peli, E., & Peli, D. (2002). Driving With Confidence: A Practical Guide to Driving with Low Vision. 

Singapore: World Scientific Publishing Co. Pte. Ltd.; p.25. 

208. Dobbs, B. M. (2002, February). Medical Conditions and Driving: Current Knowledge. DTNH22­

94-G-05297. Submitted to the Association for the Advancement of Automotive Medicine under 

contract with NHTSA, p. 15. Washington, DC: National Highway Traffic Safety Administration. 

209. Canadian Ophthalmological Society. Vision Standards for Driving in Canada, 2000. http://eyesite.ca/ 

english/program-and-services/policy-Statements-guidelines/drivingstd.html. Accessed December 12, 2007. 

150 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.210 

210. Dobbs, B. M. (2002, February). Medical Conditions and Driving: Current Knowledge. DTNH22­

94-G-05297. Submitted to the Association for the Advancement of Automotive Medicine under 

contract with NHTSA, p. 37-38. Washington, DC: National Highway Traffic Safety Administration. 

Section 2: 

Cardiovascular diseases 

1.	­Unstable coronary syndrome 

(unstable angina or myocardial 

infarction) 

2.	 Cardiac conditions that may cause a 

sudden, unpredictable loss of 

consciousness 

a. Atrial flutter/fibrillation with 

bradycardia or rapid ventricular 

response 

b. Paroxysmal supraventricular 

tachycardia (PSVT), including 

Wolf-Parkinson-White (WPW) 

syndrome 

c.	 Prolonged, nonsustained 

ventricular tachycardia (VT) 

d. Sustained ventricular 


tachycardia
 

e.	 Cardiac arrest 

f.	 High grade atrio-ventricular 

(AV) block 

g.	­Sick sinus syndrome/sinus 

bradycardia/sinus exit block/ 

sinus arrest 

3.	 Cardiac disease resulting from structural or functional abnormalities 

a.	 Congestive heart failure (CHF) 

with low output syndrome 

b. Hypertrophic obstructive 


cardiomyopathy
 

c.	 Valvular disease 

(especially aortic stenosis) 

4.	 Time-limited restrictions: cardiac 

procedures 

a.	 Percutaneous transluminal coronary angioplasty (PTCA) 

b. Pacemaker insertion or revision 

c.	 Cardiac surgery involving 


median sternotomy
 

d. Coronary artery bypass graft 

(CABG) 

e.	 Valve repair or replacement 

f.	 Heart transplant 

5.	 Internal cardioverter defibrillator 

(ICD) 

Although the data are still unclear 

in regard to a definitive relationship 

between crash risk and cardiovascular diseases, a recent study did note a 

modest increase in total crash risk and 

at-fault risk for older adults with cardiac 

disease.211 For the patient with known 

cardiac disease, the physician should 

strongly and repeatedly caution him/ 

her to seek help immediately upon 

experiencing any symptoms—including 

prolonged chest discomfort, acute shortness of breath, syncope, pre-syncope, 

palpitations, lightheadedness—that may 

indicate an unstable cardiac situation. 

Under no circumstances should the 

patient drive to seek help. 

While hypertension is not included 

in this section, physicians should 

always be alert to any potential impairment in driving skills resulting from 

hypertensive end-organ damage or 

antihypertensive medications. 

211. McGwin, G., Sims, R. V., Pulley, L., & 

Roseman, J. M. (2000). Relations among 

chronic medical conditions, medications, 

and automobile crashes in the elderly: a 

population-based case-control study. 

Am J Epidemiol. 152,424–431. 

chapter 9—Medical Conditions and Medications That May Affect Driving 151 
 

Section 2: Cardiovascular diseases 

unstable coronary syndrome 

(unstable angina or myocardial 

infarction) 

Patients should not drive if they experience symptoms at rest or at the wheel. 

Patients may resume driving when they have been stable and asymptomatic for 

one to four weeks, as determined by the cardiologist, following treatment of the 

underlying coronary disease. Driving may usually resume within one week after 

successful revascularization by percutaneous transluminal coronary angioplasty 

(PTCA) and by four weeks after coronary artery bypass grafting (CABG).212 

(See also recommendations for CABG below [4.c in this section].) 

cardiac conditions that may cause 

a sudden, unpredictable loss of 

consciousness 

A main consideration in determining medical fitness to drive for patients with 

cardiac conditions is the risk of pre-syncope or syncope due to a brady- or tachyarrhythmia.213 For the patient with a known arrhythmia, the physician should 

identify and treat the underlying cause of arrhythmia, if possible, and recommend 

temporary driving cessation until control of symptoms has been achieved. 

Atrial flutter/fibrillation with bradycardia No further restrictions once control of heart rate and symptoms have been 

or rapid ventricular response achieved. 

Paroxysmal supraventricular tachycardia 

(PSVT), including Wolf-Parkinson-White 

(WPW) syndrome 

No restrictions if the patient is asymptomatic during documented episodes. 

Patients with a history of symptomatic tachycardia may resume driving after they 

have been asymptomatic for six months on antiarrhythmic therapy. 

Patients who undergo radio frequency ablation may resume driving after six months 

if there is no recurrence of symptoms, or sooner if no pre-excitation or arrhythmias 

are induced at repeat electrophysiologic testing. 

Prolonged, nonsustained ventricular 

tachycardia (VT) 

No restrictions if the patient is asymptomatic during documented episodes. 

Patients with symptomatic VT may resume driving after three months if they are 

on antiarrhythmic therapy (with or without an ICD) guided by invasive electrophysiologic (EP) testing, and VT is noninducible at repeat EP testing. They may 

resume driving after six months without arrhythmia events if they are on empiric 

antiarrhythmic therapy (with or without an ICD), or have an ICD alone without 

additional antiarrythmic therapy.214 

Sustained ventricular tachycardia (VT) Patients may resume driving after three months if they are on antiarrhythmic 

therapy (with or without an ICD) guided by invasive electrophysiologic (EP) 

testing, and VT is noninducible at repeat EP testing. 

Patients may resume driving after six months without arrhythmia events if they are 

on empiric antiarrythmic therapy (with or without an ICD), or have an ICD alone 

without additional antiarrythmic therapy.215 

212. Petch, M. C. (1998). European Society of Cardiology Task Force Report: Driving and Heart Disease. 

Eur Heart J. 19(8):1165–1177. 

213. Binns, H., & Camm, J. (2002). Driving and arrhythmias. Br Med J. 324:927–928. 

214. Epstein, A. I., Miles, W. M., Benditt, D. G., et al. (1996). Personal and public safety issues related to 

arrhythmias that may affect consciousness: implications for regulation and physician recommendations. 

Circulation. 94:1147–1166. 

215. Ibid. 

152 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

 

Sustained ventricular tachycardia (VT) When long-distance or sustained high-speed travel is anticipated, patients should 

(Continued) be encouraged to have an adult companion perform the driving. Patients should 

avoid the use of cruise-control.216 

Cardiac arrest Please refer to the recommendations for sustained ventricular tachycardia. 

If the patient experiences a seizure, please refer to the recommendations for seizure 

disorder in Section 4, Neurological Diseases. 

If clinically significant cognitive changes persist following the patient’s physical recovery, cognitive testing is recommended before the patient is permitted to resume 

driving. In addition, on-road testing performed by a driver rehabilitation specialist 

may be useful in assessing the patient’s fitness to drive. 

High grade atrio-ventricular (AV) block	 For symptomatic block managed with pacemaker implantation, please see 

pacemaker recommendations in this section. 

For symptomatic block corrected without a pacemaker (e.g., by withdrawal of medications that caused the block), the patient may resume driving after he/she has been 

asymptomatic for four weeks and EKG documentation shows resolution of the block. 

Sick sinus syndrome/sinus bradycardia/ 

sinus exit block/ sinus arrest 

No restrictions if patient is asymptomatic. Regular medical follow-up is recommended to monitor progression. 

For symptomatic disease managed with pacemaker implantation, please see 

pacemaker recommendations in this section. 

Physicians should be alert to possible cognitive deficits due to chronic cerebral 

ischemia. Physicians may refer patients with clinically significant cognitive 

changes to a driver rehabilitation specialist for a driver evaluation (including 

on-road assessment) to evaluate the patient’s driving safety. 

cardiac disease resulting from 

structural or functional abnormalities 

A main consideration in determining medical fitness to drive for patients with 

abnormalities of cardiac structure or function is the risk of pre-syncope or syncope 

due to low cardiac output, and of cognitive deficits due to chronic cerebral ischemia. 

Patients who experience pre-syncope, syncope, extreme fatigue, or dyspnea at rest 

or at the wheel should cease driving. 

Cognitive testing is recommended for those patients with a history of cognitive 

impairment that may impair the patient’s driving ability. Physicians may refer 

patients with clinically significant cognitive changes to a driver rehabilitation 

specialist for a driver evaluation (including on-road assessment) to evaluate the 

patient’s driving safety. 

216. Ibid. 

chapter 9—Medical Conditions and Medications That May Affect Driving 153 
 

Congestive heart failure (CHF) 

with low output syndrome 

Patients should not drive if they experience symptoms at rest or while operating a 

motor vehicle. 

Physicians should reassess patients for driving fitness every six months to two years 

as needed, depending on clinical course and control of symptoms. Patients with 

functional class III CHF (marked limitation of activity but no symptoms at rest, 

working capacity 2 to 4 METS) should be reassessed at least every six months. 

Hypertrophic obstructive cardiomyopathy Patients who experience syncope or pre-syncope should not drive until they have 

been successfully treated. 

Valvular disease (especially aortic stenosis) Patients who experience syncope or pre-syncope or unstable angina should not 

drive until the underlying disease is corrected. 

time-limited restrictions: 

cardiac procedures 

Driving restrictions for the following cardiac procedures are based on the patient’s 

recovery from the procedure itself and from the underlying disease for which the 

procedure was performed. 

Percutaneous transluminal coronary 

angioplasty (PTCA) 

The patient may resume driving 48 hours to one week after successful PTCA and/ 

or stenting procedures, depending on the patient’s baseline condition and course of 

recovery from the procedure and underlying coronary disease.217, 218 

Pacemaker insertion or revision 

Cardiac surgery involving median 

sternotomy 

The patient may resume driving one week after pacemaker implantation if: 

The patient no longer experiences pre-syncope or syncope 

a. EKG shows normal sensing and capture; and 

b. Pacemaker performs within manufacturer’s specifications.219 

Driving may usually resume four weeks following coronary artery bypass grafting 

(CABG) and/or valve replacement surgery, and within eight weeks following heart 

transplant, depending on resolution of cardiac symptoms and the patient’s course of 

recovery. In the absence of surgical or post-surgical complications, the main limitation to driving is the risk of sternal disruption following median sternotomy. 

If cognitive changes persist following the patient’s physical recovery, cognitive 

testing is recommended before the patient is permitted to resume driving. In addition, on-road testing performed by a driver rehabilitation specialist may be useful in 

assessing the patient’s fitness to drive. 

internal cardioverter defibrillator Please see the recommendations for nonsustained and sustained ventricular tachycardia (2.c and 2.d in this section). 

217. Petch, M. C. (1998) European Society of Cardiology Task Force Report: Driving and Heart Disease. 

Eur Heart J. 19(8):1165–1177. 

218. Consensus Conference, Canadian Cardiovascular Society: Assessment of the cardiac patient for fitness to 

drive. (1992). Can J Cardiol. 8:406–412. 

219. Ibid. 

154 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3: 

Cerebrovascular disorders 

1. Post intracranial surgery 

2. Stroke 

3. Transient ischemic attacks (TIA) 

4. Subarachnoid hemorrhage 

5. Vascular malformation 

6. Syncope 

Strokes and other insults to the cerebral 

vascular system may cause a wide variety 

of symptoms, including sensory 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 patient is affected 

uniquely, the physician must take into 

account the individual patient’s constellation of symptoms, severity of symptoms, 

course of recovery, and baseline function 

when making recommendations concerning driving. Studies have indicated 

that a significant number (>40%) of 

community dwelling stroke patients 

continue to drive a car.220 However, the 

majority of stroke patients (87 %) may 

not receive any type of formal driving 

220. Legh-Smith, J., Wade, D. T., & Langton 

Hewer, R. L. (1986). Driving after stroke. 

J R Soc Med. 79: 200–203. 

evaluation, but simply resume the 

operation of a motor vehicle.221 The 

larger the presence of a homonymous 

visual field defect, the more likely it is 

that the patient will lose his/her driver’s 

license. Unfortunately, many patients 

may not be aware of this deficit.222 

Driving should always be discussed 

prior to the patient’s discharge from 

the hospital or rehabilitation center. 

Patients with residual deficits who wish 

to resume driving should be referred to a 

driver rehabilitation specialist whenever 

possible. Although the time frame for 

this evaluation will depend on the 

severity and extent of the deficits, many 

evaluations for cognitive and motor 

defects will occur somewhere between 

three to six months. Upon stabilization 

of symptoms, the DRS assesses the 

patient for fitness-to-drive through 

clinical and on-road evaluations. After 

assessment, the DRS may recommend 

adaptive techniques or adaptive devices 

(e.g., wide rear view mirror, spinner 

knob for the steering wheel, left foot 

accelerator) and provide training for 

221. Fisk, G.D., Owsley, C., & Vonne Pulley, L. 

(1997). Driving after stroke: driving exposure, 

advice, and evaluations. Arch Phys Med Rehabil. 

78:1338–1345. 

222. Poole, D., Chaudry, F., & Jay, W. M. (2008). 

Stroke and driving. Topics Stroke Rehab. 

15:37–41. 

their proper use. Even patients with 

mild deficits should undergo driver 

evaluation prior to resuming driving, if 

possible. Research indicates that a poststroke determination of driving safety 

made on a medical basis alone may be 

inadequate.223 More recent studies note 

associations with impairment on road 

tests with measures of perception, visual 

selective attention, mental speed, working memory, executive function and 

complex visual-perception/attention 

information.224, 225, 226 

For the patient whose symptoms 

clearly preclude driving, it should 

not be assumed that the patient is 

aware that he/she should not drive. 

In such cases, the physician should 

counsel the patient on driving 

cessation. 

223. Wilson, T., Smith, T. (1983). Driving after 

stroke. Int Rehab Med. 5(4):170–177. 

224. Engrum, E.S., Lambert, E. W., & Scott, K. 

(1990). Criterion-related validity of the 

cognitive behavioral driver’s inventory: 

brain injured patients versus normal controls. 

Cogn Rehabil. 1990;8:20–26. 

225. Lundberg, C., Caneman G.,, Sven-Marten S.,, 

et al. (2003). Scand J Psychol. 44:23–30. 

226. Nouri F. M., & Lincoln N. B. (1993). Predicting 

driving performance after stroke. Br Med J. 

307;482–483. 

Section 3: Cerebrovascular diseases 

post intracranial surgery The patient should not drive until stabilization or resolution of disease and surgery 

symptoms. See also stroke recommendations below (Section 3.2). 

stroke Patients with acute, severe motor, sensory, or cognitive deficits should refrain from 

driving. Depending on the severity of residual symptoms and the degree of recovery, 

this restriction may be permanent or temporary. 

Upon the patient’s discharge from the hospital or rehabilitation center, the 

physician may recommend temporary driving cessation until further neurological 

recovery has occurred. Once neurological symptoms have stabilized, physicians 

should refer appropriate patients with residual sensory loss, cognitive impairment, 

visual field defects, and/or motor deficits to a driver rehabilitation specialist for 

driver assessment and rehabilitation. The specialist may prescribe vehicle adaptive 

devices and train the patient in their use. 

chapter 9—Medical Conditions and Medications That May Affect Driving 155 
 

 

stroke (continued) Patients with neglect or inattention should be counseled not to drive until 

symptoms have resolved and safe driving ability has been demonstrated through 

assessment by a driver rehabilitation specialist. 

All patients with moderate to severe residual hemiparesis should undergo driver 

assessment before resumption of driving. Even if symptoms improve to the extent 

that they are mild or completely resolved, patients should still undergo driver 

assessment, if available, as reaction time may continue to be affected and other 

comorbid conditions could further increase risk. 

Patients with aphasia who demonstrate safe driving ability may fail in their efforts 

to renew their license due to difficulties with the written examination. In these 

cases, the physician should urge the licensing authority to make reasonable accommodations for the patient’s language deficit. A driving rehabilitation specialist 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. 

Patients with residual cognitive deficits should be assessed and treated as described in 

section 4 on Dementia. Periodic re-evaluation of these patients is recommended, as 

some patients may recover sufficiently over time to permit safe driving. 

transient ischemic attacks (tia) Patients who have experienced a single TIA or recurrent TIAs should refrain from 

driving until they have undergone medical assessment and appropriate treatment. 

subarachnoid hemorrhage Patients should not drive until symptoms have stabilized or resolved. Driving may 

resume following medical assessment and, if deemed necessary by the physician, 

driver evaluation performed by a driver rehabilitation specialist (including on-road 

assessment). 

Vascular malformation Following the detection of a brain aneurysm or arterio-venous (AV) malformation, 

the patient should not drive until he/she has been assessed by a neurosurgeon. The 

patient may resume driving if the risk of a bleed is small; an embolization procedure 

has been successfully completed; and/or the patient is free of other medical contraindications to driving, such as uncontrolled seizures or significant perceptual or 

cognitive impairments. 

syncope Syncope usually results from various cardiovascular causes, and is recurrent in up to 

30 percent of cases. Cardiac arrhythmias are the most common cause of syncope.227 

(See Section 2 for causes of cardiac syncope.) 

Driving restrictions for neurally mediated syncope should be based on the severity 

of the presenting event and the anticipant likelihood of recurrence. No driving 

restrictions are necessary for infrequent syncope that occurs with warning and with 

clear precipitating causes. Patients with severe syncope may resume driving after 

adequate control of the arrhythmia has been documented and/or pacemaker followup criteria have been met (see 4 in Section 2).228 For patients who continue 

to experience unpredictable symptoms after treatment with medications and 

pacemaker insertion, driving cessation is recommended. 

227. Beers, M. H., & Berkow, R. (eds). (1999). The Merck Manual of Diagnosis and Therapy, 17thed. 

Whitehouse Station, NJ: Merck and Co., Inc. Section 6, Chapter 200. 

228. North American Society of Pacing and Electrophysiology/American Heart Association: Personal and 

Public Safety Issues Related to Arrhythmias That May Affect Consciousness: Implications for Regulation 

and Physician Recommendations (Part 3 of 4). September 1, 1996. 

156 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

 

 

 

Section 4: 

Neurologic diseases 

1.	 Brain tumor 

2.	 Closed head injury 

3.	 Dementia 

4.	 Migraine and other recurrent 

headache syndromes 

5.	 Movement disorders 

6.	 Multiple sclerosis 

7.	 Paraplegia and quadriplegia 

8.	­ Parkinson’s disease 

9.	 Peripheral neuropathy 

10. Seizure disorder 

a. Single unprovoked seizure 

b. Withdrawal or change of antiepileptic drug therapy 

11. Sleep disorders 

a. Narcolepsy 

b. Sleep apnea 

12. Stroke 

13. Tourette’s syndrome 

14. Vertigo 

Dementia deserves special emphasis 

in this section because it presents a 

significant challenge to driving safety. 

With progressive dementia, patients 

ultimately lose the ability to drive safely 

and lack insight. Therefore, dementia 

patients may be more likely than drivers 

with visual or motor deficits (who tend 

to self-restrict their driving to accommodate their declining abilities) to 

drive even when it is highly unsafe 

for them to be on the road. It becomes 

the responsibility of family members 

and other caregivers to protect the 

safety of these patients by enforcing 

driving cessation. 

Several recent reviews on this topic 

may be of interest to physicians.229, 230 

Fitness-to-drive studies in patients 

with dementia indicate that 90 percent 

may be able to pass a road test in the 

very mild stages of the disease (clinical 

dementia rating of 0.5), whereas 40 

percent may fail at a mild level of 

cognitive impairment (clinical 

229. Dobbs, B., Carr, D. B., & Morris, J. C. (2002). 

Management and assessment of the demented 

driver. Neurologist. 8:61–70. 

230. Brown, L. B., & Ott, B. R. (2004). Driving and 

dementia: a review of the literature. J Geriatr 

Psychiatry Neurol. 17:232–240. 

dementia rating of 1.0).231 Furthermore, 

most patients with Alzhiemer’s disease 

will eventually fail subsequent road tests 

when followed longitudinally, indicating 

that repeat testing at six to twelve months 

should be strongly considered.232 Some 

of these studies have led the American 

Academy of Neurology to conclude that 

patients with a mild level of dementia 

severity or greater should no longer 

operate an automobile.233 However, 

this recommendation has recently been 

challenged by a longitudinal study that 

found that some mildly demented drivers 

not only passed a performance-based 

road test, but also had an acceptable 

crash risk prospectively.234 Furthermore, 

recent studies indicate that physician 

evaluation in the office cannot replace 

the on-the-road assessment;235 however, 

tests of working memory and executive 

function are improving classification 

rates.236, 237 Finally, a dementia and 

driving curriculum modeled after this 

AMA guide has been shown to improve 

knowledge, attitudes, confidence, and 

behaviors for health professionals who 

deal with older adults with dementia.238 

231. Hunt L., Murphy C., Carr D., Duchek J., 

Buckles V., & Morris, J. (1997). The reliability 

of the Washington University Road Test. Arch 

Neurol. 54:707–712. 

232. Duchek, J. M., Carr DB., Hunt L., et al. (2003). 

Longitudinal driving performance in early stage 

dementia of the Alzheimer type. J Am Geriatr 

Soc. 51:1342–1347. 

233. Dubinsky, RM., Stein, AC., Lyons, K. (2000). 

Practice parameter: risk of driving and 

Alzheimer’s disease (an evidence-based review) 

–Report of the Quality Standards Subcommittee 

of the American Academy of Neurology. 

Neurology. 54, 2205–2211. 

234. Ott, BR., Heindel, WC., Papandonatos, GD., 

et al. (2008). Longitudinal study of drivers with 

Alzheimer’s disease. Neurology. 70:1171–1178. 

235. Ott, B. R., Anthony, D., Papandonatos, G. D., 

D’Abreu, A., Burock, J., Curtin, A., Wu, C. K., 

& Morris, J. C. (2005) Clinician assessment 

of the driving competence of patients with 

dementia. J Am Geriatr Soc. 53(5):829–833. 

236. Grace, J., Amick, M. M., D’Abreu, A., Festa, 

E. K., Heindel,W. C., & Ott, B. R. (2005). Neuropsychological deficits associated with driving 

performance in Parkinson’s and Alzheimer’s 

disease. J Int Neuropsychol Soc. 11(6):766–775. 

237. Brown, L. B., Stern, R. A., Cahn-Weiner, D. 

A., et al. (2005). Driving scenes test of the 

Neuropsychological Assessment Battery and onroad driving performance in aging and very mild 

dementia. Arch Clin Neuropsychol. 20:209–215 

238. Meuser, T. M., Carr, D. B., Berg-Weger, M., 

Niewoehner, P., & Morris, J. C. (2006). Driving 

and dementia in older adults: implementation 

and evaluation of a continuing education 

project. Gerontologist. 46:680–687. 

This is encouraging information that 

supports the feasibility and utility of 

using this guide. 

While it is optimal to initiate discussions of driving safety with the patient 

and family members before driving 

becomes unsafe, dementia may be undetected and undiagnosed until late in the 

course of the disease. Initially, family 

members and physicians may assume 

that the patient’s decline in cognitive 

function is a part of the “normal” aging 

process. Physicians may also hesitate 

to screen for and diagnose dementia 

because they feel that it is futile—in 

other words, that nothing can be done 

to improve the patient’s situation or 

slow disease progression. In addition, 

physicians may be concerned about the 

amount of time required to effectively 

diagnose dementia and educate patients 

and their families.239 However, some patients are able to achieve cognitive stability, at least for a period of time, with 

cholinesterace inhibitors or N-methyl 

d-aspartate (NMDA) receptor blockers. In addition, patients are now being 

diagnosed on the “cusp” of the disease 

in the very early stages. A diagnosis of 

dementia by itself should not preclude 

driving. 

Physician reluctance to screen for 

dementia is unfortunate because early 

diagnosis is the first step in promoting 

the driving safety of these patients. 

The second step is intervention, which 

includes medications to slow or stabilize 

the course of the disease, counseling to 

prepare the patient and family for eventual driving cessation, and serial assessment of the patient’s driving abilities. 

When assessment shows that driving 

may pose a significant safety risk to the 

patient, driving cessation is a necessary third step. With early planning, 

patients and their families can make a 

more seamless transition from driving to 

nondriving status. 

239. Valcour, V. G., Masaki, K. H., Curb, J. D., & 

Blanchette, P. L. (2000). The detection of 

dementia in the primary care setting. Arch 

Intern Med. 160:2964–2968. 

chapter 9—Medical Conditions and Medications That May Affect Driving 157 
 

 

 

 

 

 

Section 4: Neurologic diseases 

Brain tumor Driving recommendations should be based on the type of tumor; location; rate of 

growth; type of treatment; presence of seizures; and presence of cognitive or perceptual impairments. Due to the progressive nature of some tumors, the physician may 

need to evaluate the patient’s fitness to drive serially. 

See also the stroke recommendations in Section 3.2. 

If the patient experiences seizure(s), please see the seizure disorder recommendations 

below (4.10 in this section). 

closed head injury Patients should not drive until symptoms or signs have stabilized or resolved. 

For patients whose symptoms or signs resolve, driving may resume following 

medical assessment and, if deemed necessary by the physician, driver evaluation 

(including on-road assessment) performed by a driver rehabilitation specialist. 

Patients with residual neurological or cognitive deficits should be managed as 

described in Section 3. 

If the patient experiences seizure(s), please 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 10/20/01): 

• 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 states of their illness.240Therefore, the 

determining factor in withdrawing driving privileges should be the individual’s 

driving ability. When the individual poses a heightened risk to self or others, 

driving privileges must be withheld. 

• Physicians should consider the risks associated with driving for all of their 

patients with dementia, and they are encouraged to address the issue of driving 

safety with these patients and their families. When appropriate, patients should 

be included in decisions about current or future driving restrictions and cessation; otherwise, physicians and families must decide in the best interests of the 

patient whose decision-making capacity is impaired. 

• Physicians are recommended to perform a focused medical assessment that includes 

a history of any new impaired driving behaviors (e.g., new motor vehicle crashes) 

from a family member or caregiver and an evaluation of cognitive abilities, including memory, attention, judgment, and visuospatial abilities. Physicians should be 

aware that patients with a progressive dementia who are initially believed to be safe 

to drive will require serial assessment, and they should familiarize themselves with 

their State reporting laws and procedures for dementia (if any). (See Chapter 8 for 

a reference list of State reporting laws.) 

If concern exists that an individual with dementia has impaired driving ability, and 

the individual would like to continue driving, a formal assessment of driving 

skills should be administered. One type of assessment is an on-road driving assessment performed by a driver rehabilitation specialist. 

240. Carr, D. B., Duchek, J., & Morris, J. C. (2000). Characteristics of motor vehicle crashes with dementia of 

the Alzheimer type. J Am Geriatr Soc. 48(1):18–22. 

158 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

 

dementia (continued) • Physicians should encourage patients with progressive dementia to plan early 

for eventual cessation of driving privileges by developing alternative transportation options. The patient should be encouraged to coordinate these efforts 

with his/her family members and caregivers, and to seek assistance (as needed) 

from the local Area Agency on Aging. 

Migraine and other recurrent 

headache syndromes 

Patients with recurrent severe headaches should be cautioned against driving 

when experiencing neurologic manifestations (e.g., visual disturbances or 

dizziness); when distracted by pain; and while on any barbiturate, narcotic, 

or narcotic-like analgesic. (See Section 13 for further recommendations 

regarding narcotic analgesics.) Patients without a typical aura preceding the 

acute attack may be at higher risk. 

Movement disorders If the physician elicits complaints of interference with driving tasks or is 

(e.g., parkinsonism, dyskinesias) concerned that the patient’s symptoms compromise his/her driving safety, 

referral to a driver rehabilitation specialist for a driver evaluation (including 

on-road assessment) is recommended. 

Multiple sclerosis Driving recommendations should be based on the type of symptoms and level 

of symptom involvement. Physicians 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 driver evaluation (including on-road assessment) performed by a driver 

rehabilitation specialist may be useful in determining the patient’s safety to drive. 

Serial evaluations may be required as the patient’s symptoms evolve or progress. 

paraplegia and quadriplegia Referral to a driver rehabilitation specialist is necessary if the patient wishes to 

resume driving and/or requires a vehicle modified to accommodate him/her as a 

passenger. The specialist can recommend an appropriate vehicle and prescribe 

vehicle adaptive devices (such as low-resistance power steering and hand 

controls) and train the patient in their use. In addition, the specialist can assist 

the patient with access to the vehicle, including opening and closing car doors, 

transfer to the car seat, and independent wheelchair stowage, through vehicle 

adaptations and training. 

Driving should be restricted until the patient demonstrates safe driving ability in 

the adapted vehicle. 

parkinson’s disease Patients with advanced Parkinson’s disease may be at increased risk for motor 

vehicle crashes due to both motor and cognitive dysfunction.241 Physicians 

should base their driving recommendations on the level of both motor and 

cognitive symptom involvement, patient’s response to treatment, and presence 

and extent of any medication side effects. (See Section 13 for specific recommendations on antiparkinsonian medications.) Serial physical and cognitive 

evaluations are recommended every six to twelve months due to the progressive 

nature of the disease. 

241. Zesiewicz, T. A., Cimino, C. R., Malek, A. R., Gardner, N., Leaverton, P. L., Dunne, P. B., & Hauser, 

R. A. (2002). Driving safety in Parkinson’s disease. Neurology. 59:1787–1788. 

chapter 9—Medical Conditions and Medications That May Affect Driving 159 
parkinson’s disease (continued) If the physician is concerned that dementia and/or motor impairments may affect 

the patient’s driving skills, a driver evaluation (including on-road assessment) 

performed by a driver rehabilitation specialist may be useful in determining the 

patient’s fitness to drive. 

Lower extremity deficits in sensation and proprioception may be exceedingly 

dangerous for driving, as the driver may be unable to control the foot pedals. 

peripheral neuropathy If deficits in sensation and proprioception are identified, referral to a driver 

rehabilitation specialist is recommended. The specialist may prescribe vehicle 

adaptive devices (e.g., hand controls in place of the foot pedals) and train the 

patient in their use. 

seizure disorder The recommendations below (in this section only) are adapted from the Consensus 

Statements on Driver Licensing in Epilepsy, crafted and agreed upon by the American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of 

America in March 1992.242 Please note that these recommendations are subject to 

each particular State’s licensing requirements and reporting laws. 

A patient with seizure disorder should not drive until he/she has been seizurefree for three months. This recommendation appears consistent with recent data.243 

This three-month interval may be lengthened or shortened based on the following 

favorable and unfavorable 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 

242. American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America. 

(1994). Consensus Statements, Sample Statutory Provisions, and Model Regulations Regarding Driver 

Licensing and Epilepsy. Epilepsia. 35(3):696-705. 

243. Drazkowski, J. F., Fisher, R. S., Sirven, J. I., et al. (2003). Seizure-related motor vehicle crashes in Arizona 

before and after reducing the driving restriction from 12 to 3 months. Mayo Clin Proc. 78:819-825. 

160 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

seizure disorder (continued) Unfavorable modifiers: 

• Noncompliance with medication or medical visits and/or lack of credibility 

• Alcohol and/or drug abuse in the past three months 

• Increased number of seizures in the past year 

• Impaired driving record 

• Structural brain lesion 

• Noncorrectable brain functional or metabolic condition 

• Frequent seizures after seizure-free interval 

• Prior crashes due to seizures in the past five years 

• Single unprovoked seizure 

Single unprovoked seizure The patient should not drive until he/she has been seizure-free for three months. 

This time period may be shortened with physician approval. Predictors of recurrent 

seizures that may preclude shortening of this time period include: 

• The seizure was focal in origin 

• Focal or neurologic 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 

anti-epileptic drug therapy 

The patient should temporarily cease driving during the time of medication 

withdrawal or change due to the risk of recurrent seizure and potential medication 

side effects that may impair driving ability. 

If there is significant risk of recurrent seizure during medication withdrawal or 

change, the patient should cease driving during this time and for at least three 

months thereafter. 

If the patient experiences a seizure after medication withdrawal or change, he/she 

should not drive for one month after resuming a previously effective medication 

regimen. Alternatively, the patient should not drive for six months if he/she refuses 

to resume this medication regimen, but is seizure-free during this period. 

sleep disorders 

Narcolepsy The patient should cease driving upon diagnosis. The patient may resume driving 

upon treatment when he/she no longer suffers excessive daytime drowsiness or cataplexy. Physicians may consider using scoring tools such as the Epworth Sleepiness 

Scale to assess the patient’s level of daytime drowsiness.244 

Sleep apnea See Section 10. 

stroke See Section 3. 

244. Johns, M. W. (1991). A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. 

Sleep. 14:540–545. 

chapter 9—Medical Conditions and Medications That May Affect Driving 161 
tourette’s syndrome In evaluating the patient’s fitness to drive, the physician should consider any 

comorbid disorders (including attention deficit hyperactivity disorder, learning 

disabilities, and anxiety disorder) in addition to the patient’s motor tics. (For 

specific recommendations on these disorders, see Section 5, Psychiatric Disorders). 

If the physician is concerned that the patient’s symptoms compromise his/her 

driving safety, referral to a driver rehabilitation specialist for on-road assessment 

is recommended. 

Physicians should be aware that certain medications used in the treatment 

of Tourette’s syndrome have the potential to impair driving performance. 

(See Section 13 for more information on medication side effects.) 

Vertigo Vertigo and the medications commonly used to treat vertigo have a significant 

potential to impair driving skills. 

For acute vertigo, the patient should cease driving until symptoms have fully 

resolved. Under no circumstances should the patient drive to seek medical 

attention. 

Patients with a chronic vertiginous disorder are strongly recommended to 

undergo on-road assessment performed by a driver rehabilitation specialist 

prior to resuming driving. 

162 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

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 (ADD)/ 

Attention deficit hyperactivity 

disorder (ADHD) 

7. Tourette’s syndrome 

Patients 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 side 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 

(American Journal of Psychiatry. 1995. 

1S2(5):819; also at www.psych.org/ 

pract_of_psych/driving_pstate.cfm). 

Section 5: Psychiatric disorders 

affective disorders Physicians should advise the patient not to drive during the acute phase of illness. 

Physicians should also be aware that certain medications used in the treatment of 

affective disorders have the potential to impair driving performance. (See Section 

13 for more information on medication side effects.) 

Depression No restrictions if condition is mild and stable. The physician should always specifically ask about suicidal ideation and cognitive and motor symptoms. 

Patients should not drive if they are actively suicidal or experiencing significant mental or physical slowness, agitation psychosis, impaired attention, and/ 

or impaired concentration. Patients who seek care for these conditions should be 

counseled not to drive themselves to the clinic or hospital. 

Bipolar disorder No restrictions if condition is stable. 

Patients should not drive if they are actively suicidal, depressed as in 1.a (above) or 

in an acute phase of mania. Patients who seek care for these conditions should be 

counseled not to drive themselves to the clinic or hospital. 

anxiety disorders Patients should not drive during severe episodes of anxiety. Otherwise, there are no 

restrictions if the condition is stable. 

Physicians should also be aware that certain medications used in the treatment of 

anxiety disorders have the potential to impair driving performance. (See Section 

13 for more information on medication side effects.) 

chapter 9—Medical Conditions and Medications That May Affect Driving 163 
psychotic illness Physicians should advise the patient not to drive during the acute phase(s) of 

illness. Physicians should also be aware that medications used in the treatment of 

psychotic illness have the potential to impair driving performance. (See Section 13 

for more information on medication side effects.) 

Acute episodes Patients should not drive during acute episodes of psychosis. Patients who seek care 

for acute psychosis should be counseled not to drive themselves to the clinic or 

hospital. 

Chronic illness No restrictions if the condition is stable and there are no other factors 

(e.g., medication side effects) that can affect driving performance. 

personality disorders No restrictions unless the patient has a history of driving violations and his/her psychiatric review is unfavorable. This includes—but is not limited to—uncontrolled 

erratic, violent, aggressive or irresponsible behavior. 

Due to the high comorbidity of substance abuse with personality disorders, 

physicians are urged to be alert to substance abuse in these patients and counsel 

them accordingly (see recommendations for substance abuse below). 

substance abuse Driving while intoxicated is not only highly dangerous to the driver, passengers, 

and other road users, but it is also illegal. Drunk driving is the most common crime 

in the United States, and it is responsible for thousands of traffic deaths each year. 

Alcohol is not the only cause of intoxicated driving. Substances including, but not 

limited to, marijuana, cocaine, amphetamines (including amphetamine analogs), 

opiates, and benzodiazepines may also impair driving skills. 

Physicians should follow up all positive screens with appropriate interventions, including brief interventions or referral to support groups, counseling, and substance 

abuse treatment centers. Physicians 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. 

Physicians should also familiarize themselves with any State laws holding them 

responsible for detaining intoxicated patients who have driven to the hospital or 

clinic until they are legally unimpaired. 

attention deficit disorder/attention A recent review noted increased risk of driving behaviors and a positive effect 

deficit hyperactivity disorder of stimulant medications on driving performance.245 Physicians should educate 

their patients about the increased risk associated with the disease and the potential 

benefits of treatment. 

tourette’s syndrome See Section 4. 

245. 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):113–28. 

164 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

 

Section 6: Metabolic disorders 

1. Diabetes mellitus 

a. 	Insulin dependent diabetes 

mellitus (IDDM) 

b. 	Non-insulin dependent diabetes 

mellitus (NIDDM) 

2. Hypothyroidism 

3. Hyperthyroidism 

Individuals in the acute phase of a 

metabolic disorder (e.g., diabetes, 

Cushing’s disease, Addison’s disease, 

hyperfunction of the adrenal medulla, 

and thyroid disorders) may experience 

signs and symptoms that are incompatible with safe driving. Physicians should 

advise these individuals to refrain from 

driving (including driving to seek 

medical attention) until the symptoms 

have abated. There are data that suggest 

that older diabetic patients may be at 

increased risk for impaired driving, but 

the literature is not consistent in this 

area. Concern has been raised that the 

trend in the medical profession has 

been toward tighter control, which 

could result in hypoglycemia and 

possibly increased crash risk. 

Section 6: Metabolic disorders 

diabetes mellitus 

Insulin dependent diabetes mellitus 

(IDDM) 

No restrictions if the patient demonstrates satisfactory control of his/her 

diabetes, recognizes the warning symptoms of hypoglycemia, and meets 

required visual standards. 

The major concerns with insulin dependent diabetics are hypoglycemia unawareness. 

There are several studies that have noted that patients with type 1 IDDM had 

impaired driving performance during episodes of hypoglycemia and were unaware 

of their low blood sugars at the time of driving assessment.246, 247 

It is apparent from these studies that many drivers did not take appropriate action 

even when they recognized the symptoms of hypoglycemia. Diabetic patients who 

use insulin should be evaluated for hypoglycemia and should consider checking 

their blood sugar before driving or on prolonged trips. This is especially the case 

for individuals who have exhibited hypoglycemia unawareness (e.g., documented 

blood sugars below 60 mg/dL without symptoms). 

Patients should be counseled not to drive during acute hypoglycemic or hyperglycemic episodes. In addition, patients are advised to keep candy or glucose tablets 

within reach in their car at all times, in the event of a hypoglycemic attack. 

For peripheral neuropathy, see Section 4. 

Patients who experience recurrent hypoglycemic or hyperglycemic attacks should 

not drive until they have been free of significant hypoglycemic or hyperglycemic 

attacks for three months. 

Non-insulin dependent diabetes mellitus 	 Patients who are managed by lifestyle changes and/or oral medications have no 

(NIDDM)	 restrictions unless they develop relevant disabilities (e.g., diabetic retinopathy). 

If the physician prescribes an oral medication that has a significant potential to 

cause hypoglycemia, he/she should counsel the patient as above. Oral medications 

may also increase the likelihood of hypoglycemia, which should be managed as in 

1.a in this section. 

246. Weinger, I., Kinsley, B. T., Levy, C. J., et al. (1999). The perception of safe driving ability during 

hypoglycemia in patients with type I diabetes. Am J Med. 107:246–253. 

247. Cox, D. J., Gonder-Frederick, L. A., Kovatchev, B. P., et al. (2000). Progressive hypoglycemia’s impact on 

driving simulation performance: occurrence, awareness, and correction. Diabetes Care. 23:163–170. 

chapter 9—Medical Conditions and Medications That May Affect Driving 165 
hypothyroidism Patients who experience symptoms (e.g., cognitive impairment, drowsiness, and 

fatigue) that may compromise safe driving should be counseled not to drive until 

their hypothyroidism has been satisfactorily treated. If residual cognitive deficits 

are apparent despite treatment, a driver evaluation (including on-road assessment) 

performed by a driver rehabilitation specialist may be useful in determining the 

patient’s ability to drive safely. 

hyperthyroidism	 Patients who experience symptoms (e.g., anxiety, tachycardia, palpitations, etc.) 

should be counseled not to drive until their hyperthyroidism has been satisfactorily 

treated and symptoms have resolved. 

166 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 7:
 

Musculoskeletal disabilities
 

1. Arthritis 

2. Foot abnormalities 

3. Limitation of cervical movement 

4. Limitation of thoracic and 

lumbar spine 

5. Loss of extremities or loss of use 

of extremities 

6. Muscle disorders 

7. Orthopedic procedures/surgeries 

a. 	Amputation 

b. 	Anterior cruciate ligament 


(ACL) reconstruction
 

c. 	Limb fractures and treatment 

involving splints and casts 

d. 	Rotator cuff repair—open or 

arthroscopic 

e. 	Shoulder reconstruction 

f. 	Total hip replacement 

g. Total knee arthroplasty (TKA) 

The pain, decrease in motor strength, 

and compromised range of motion 

associated with musculoskeletal disabilities can affect an individual’s ability to 

drive. Physicians should encourage their 

patients with musculoskeletal disabilities 

to drive a vehicle with power steering 

and automatic transmission, if they do 

not already do so. Such vehicles require 

the least amount of motor ability for 

operation among all standard vehicles. 

If the physician is concerned that the 

patient’s musculoskeletal disabilities impair his/her driving performance, referral 

to a driver rehabilitation specialist for 

a driver evaluation (including on-road 

assessment) is also recommended. In 

addition to assessing the patient’s driving 

skills, the specialist can prescribe adaptive techniques and devices and train the 

patient in their use. 

Patients with musculoskeletal disorders, 

typically have problems with seat belt 

and ignition key use, adjusting mirrors 

and seats, in steering, in transferring in 

and out of the car, in driving in reverse, 

and in using the controls like the foot 

pedal.248 Driving impairment has been 

correlated with the inability to reach 

above the shoulder.249 Older adults with 

physical frailty or disabilities may be at 

increased risk for a crash,250, 251 and are 

more likely to be injured.252 Presence 

of foot abnormalities, walking less 

than one block a day, and impaired left 

knee flexion have been associated with 

adverse driving events.253 In one study, 

older crash-involved subjects were 

more likely to have difficulty walking 

one-quarter mile than controls; and the 

authors also noted an increased crash 

risk for drivers with a history of falls.254 

Diminished cervical range of motion 

and a slowed rapid pace walk have 

also been recently associated with an 

increased crash risk.255 

The use of nonsteroidal anti-inflammatory agents (NSAIDs) and a diagnosis of 

arthritis were associated with increased 

248. Jones, J. G., McCann, J., & Lassere, M. N. 

(1991). Driving and arthritis. Br J Rheumatol. 

1991;30:361-364. 

249. Hu, PS., Trumble, DA., Foley, DJ., et al. (1998). 

Crash risks of older drivers: a panel data analysis 

Accid Anal Prev. 30:569-581. 

250. Sims, R. V., McGwin, G., Allman, R. M., et al. 

(2000). Exploratory study of incident vehicle 

crashes among older drivers. J Gerontol Series A 

Bio Sci Med Sci. 55:M22-27. 

251. Marottoli, R. A., Wagner, D. R., Cooney, L. M., 

& Tinetti, M. E. (1994). Predictors of crashes 

and moving violations among elderly drivers. 

Ann Intern Med. 1994;121:842-846. 

252. Kent, R., Funk, J., &Crandall, J. (2003). How 

future trends in societal aging, air bag availability, seat belt use, and fleet composition will 

affect serious injury risk and occurrence in the 

United States. Traff Inj Prev. 4:24-32. 

253. Marottoli, R. A., Wagner, D. R., Cooney, L. M., 

& Tinetti, M. E. (1994). Predictors of Crashes 

and Moving Violations Among Elderly Drivers. 

Ann Int Med 121: 842-846. 

254. Sims, R. V., McGwin, G., Pulley, L., et al. 

(2001). Mobility impairments in crash-involved 

drivers. J Aging Health. 12:430.s. 

255. Ball, K. K., Roenker, D. L., Wadley, V. G., et al. 

(2006). Can high-risk older drivers be identified 

through performance-based measures in a 

Department of Motor Vehicles setting? J Am 

Geriatr Soc. 54:77-84. 

at-fault crash risk in a recent study.256 

Similarly, an examination of medically 

impaired drivers in Utah found an 

increased crash risk for drivers with 

musculoskeletal disorders, but not for 

those with muscle or motor weakness.257 

Conversely, patients with a specific 

diagnosis of osteoarthritis258 were no 

more at risk for a crash than controls in 

one study. Also reassuring was a recent 

study noting no increase in crash risk of 

drivers with cars that had been adapted 

for their musculoskeletal restrictions.259 

Thus, physicians can play a role in 

diagnosing, managing, and referring 

their patients with musculoskeletal 

disorders and, ideally, play a role in 

maintaining driving privileges and 

improving traffic safety. 

Rehabilitative therapies such as physical 

or occupational therapy and/or a consistent regimen of physical activity may 

improve the patient’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 patients with musculoskeletal 

disabilities who wish to continue 

driving. See Section 13 for 

recommendations on specific 

classes of medications. 

256. McGwin, G., Sims, R. V., Pulley, L., et al. 

(2000). Relations among chronic medical 

conditions, medications, and automobile crashes 

in the elderly: a population-based case-control 

study. Am J Epidemiol. 152: 424-431. 

257. Vernon, D. D., Diller, E. M., Cook, L. J., et 

al. (2002). Evaluating the crash and citations 

rates of Utah drivers licensed with medical 

conditions, 1992-1996. Accid Anal Prev. 34: 

237-246.s 

258. Koepsell, T., Wolf, M. , & McCloskey, L. 

(1994). Medical conditions and motor vehicle 

collision injuries in older adults. J Am Geriatr 

Soc. 42,695-700. 

259. Henriskkson, P. (2001). Drivers with Disabilities: A Survey of Adapted Cars, Driving 

Habits and Safety. VTI rapport 466. Linkoping, 

Sweden: Swedish National Road and Transport 

Research Institute. 

chapter 9—Medical Conditions and Medications That May Affect Driving 167 
Section 7: Musculoskeletal disabilities 

arthritis If symptoms of arthritis compromise the patient’s driving safety, referral to a 

physical or occupational therapist for rehabilitative therapy and/or to a driver 

rehabilitation specialist for driver evaluation (including on-road assessment) 

is recommended. The specialist may prescribe vehicle adaptive devices and train 

the patient in their use. 

See below for 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, and calluses) that 

affect the patient’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. The physician may also refer the patient to a driver 

rehabilitation specialist, who can prescribe vehicle adaptive devices and train the 

patient in their use. 

Limitation of cervical movement Some loss of head and neck movement is acceptable if the patient has sufficient 

combined rotation and peripheral vision to accomplish driving tasks (e.g., turning, 

crossing intersections, parking, backing up) safely. The physician may also refer the 

patient to physical or occupational therapist for rehabilitative therapy, and/or to a 

driver rehabilitation specialist, who can prescribe wide-angled mirrors and train the 

patient in their use. 

Limitation of thoracic or lumbar spine Patients with marked deformity, who wear braces or body casts, or who have painfully restricted motion in their thoracic or lumbar regions should be referred to a 

driver rehabilitation specialist. The specialist can prescribe vehicle adaptive devices 

such as raised seats and wide-angled mirrors, and train the patient in their use. The 

specialist can also prescribe seat belt adaptations as needed to improve the patient’s 

safety and comfort, and ensure that the patient is seated at least 10 inches from the 

vehicle air bags. 

Patients with acute spinal fractures, including compression fractures, should not 

drive until the fracture has been stabilized and painful symptoms cease to interfere 

with control of the motor vehicle. These types of fractures can be extremely painful 

and require large doses of narcotics for control of pain, which also can increase risk. 

(For paraplegia or quadriplegia, see Section 4.) 

Loss of extremities or loss of 

use of extremities 

For patients who have lost (or lost the use) of one or more extremities, referral 

to a driver rehabilitation specialist is highly recommended. These specialists can 

prescribe vehicle adaptive devices and/or adaptations to limb prostheses, and train 

the patient in their use. 

Note that the use of artificial limbs on vehicle foot pedals is unsafe because there 

is no sensory feedback (i.e., pressure and proprioception). For these patients, 

specialized hand controls in place of pedals are required. 

Driving should be restricted until the patient demonstrates safe driving ability 

(with the use of adaptive devices, as needed). 

168 chapter 9—Medical Conditions and Medications That May Affect Driving 
Muscle disorders If the physician is concerned that the patient’s symptoms compromise his/her driving safety, referral to a driver rehabilitation specialist for driver evaluation (including on-road assessment) is recommended. If needed, the specialist may prescribe 

vehicle adaptive devices and train the patient in their use. 

orthopedic procedures/surgeries 

Amputation See Loss of extremities (previous page). 

Anterior cruciate ligament (ACL) 

reconstruction 

Should not drive for four weeks following right ACL reconstruction. If the patient 

drives a vehicle with manual transmission, he/she should not drive for four weeks 

following right or left ACL reconstruction.260 

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, the patient may resume 

driving after the fracture heals or the splint/cast is removed, upon demonstration 

f the necessary strength and range of motion. 

Rotator cuff repair—open or arthroscopic Should not drive for four to six weeks following rotator cuff repair. If the patient’s 

vehicle does not have power steering, the waiting period may be much longer. 

Physicians should counsel patients to wear their seat belts properly (over the 

shoulder, rather than under the arm) whenever they are in a vehicle as a driver or 

passenger. 

Shoulder reconstruction 

Total hip replacement 

Should not drive for four to six weeks following shoulder reconstruction. If the 

patient’s vehicle does not have power steering, the waiting period may be much 

longer. 

Physicians should counsel patients to wear their seat belts properly (over the 

shoulder, rather than under the arm) whenever they are in a vehicle as a driver or 

passenger. 

Should not drive for at least four weeks following right total hip replacement. 

If the patient drives a vehicle with manual transmission, he/she should not drive 

for at least four weeks following right or left total hip replacement. 

Physicians should counsel patients to take special care when transferring into 

vehicles and positioning themselves in bucket seats and/or low vehicles, either 

of which may result in hip flexion greater than 90 degrees. Physicians should also 

counsel patients that reaction time may not return to baseline until eight weeks 

after the surgery, and that they should exercise extra caution while driving during 

this period. 261 

260. Gotlin, R. S., et al. (2000). Measurement of brake response time after right anterior cruciate ligament 

reconstruction. Arch Physical Med Rehabil. 81(2):201-204. 

261. MacDonald, W., & Owen, J. W. (1988). The effect of total hip replacement on driving reactions. J Bone 

Joint Surg. 70B(2):202-205 

chapter 9—Medical Conditions and Medications That May Affect Driving 169 
Total knee arthroplasty (TKA) Should not drive for three to four weeks following right TKA. If the patient drives 

a vehicle with manual transmission, he/she should not drive for three to four weeks 

following right or left TKA.262 

The physician should also counsel patients that reaction time may not return to 

baseline until eight weeks after the surgery, and that they should exercise extra 

caution while driving during this period.263 

262. Pierson, J. L., Ramsey, J., Clayton, R. T., & Stippich, K. T. (February 7, 1999). TKA improves drivers’ 

brake reaction time. The American Academy of Orthopaedic Surgeons: Academy News. 

263. Spalding, T. J., Kiss, J., Kyberd, P., Turner-Smith, A., & Simpson, A. H. (1994). Driver reaction times 

after total knee replacement. J Bone Joint Surg Br. 76(5):754–756. 

170 chapter 9—Medical Conditions and Medications That May Affect Driving 
Section 8: 


Peripheral vascular diseases 


1. Aortic aneurysm 

2. Deep vein thrombosis (DVT) 

3. Peripheral arterial aneurysm 

Section 8: Peripheral vascular diseases 

aortic aneurysm No restrictions to driving unless other disqualifying conditions are present. Individuals whose aneurysm appears to be at the stage of imminent rupture based on 

size, location, and/or recent change should not drive until the aneurysm has been 

repaired, if possible. 

deep vein thrombosis (dVt) Patients 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. 

The physician 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. Patients 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. 

chapter 9—Medical Conditions and Medications That May Affect Driving 171 
Section 9: Renal disease 

1. Chronic renal failure 

2. Renal transplant 

Section 9: Renal disease 

chronic renal failure No restrictions unless the patient experiences symptoms that are incompatible with 

safe driving (e.g., cognitive impairment, impaired psychomotor function, seizures, 

or extreme fatigue from anemia). If the physician is concerned that the patient’s 

symptoms compromise his/her driving safety, referral to a driver rehabilitation 

specialist for a driver evaluation (including on-road assessment) is recommended. 

Many patients with renal failure requiring hemodialysis can drive without restriction. However, management of renal failure requires that the patient be compliant 

with substantial nutrition and fluid restrictions, frequent medical evaluations, and 

regular hemodialysis treatments. Patients with a history of noncompliance should 

be advised against driving. Furthermore, certain medications used to treat side 

effects of hemodialysis may be substantially impairing (e.g., diphenhydramine for 

dialysis-associated pruritis), and dialysis itself may result in hypotension, confusion, 

or agitation in many patients. These effects may require that patients avoid driving 

in the immediate post-dialysis period. 

renal transplant Patients may resume driving four weeks following successful transplant on the 

recommendation of the physician. 

.
 

172 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

 

 

 

 

 

 

 

Section 10: 

Respiratory diseases 

1. Asthma 

2. Chronic obstructive pulmonary 

disease (COPD) 

3. Sleep apnea 

“Drowsy driving” or driving with fatigue 

or sleepiness is a common cause for a 

motor vehicle crash, and some estimate 

that more than 100,000 crashes a year 

may be attributed to this problem. 

Crash risk increases with diminishing 

sleep.264 Sleep disorder crash risk may be 

elevated further by medication use, such 

as narcotics or antihistamine.265 Sleep 

apnea patients have been noted to have 

as high as a seven-fold increased crash 

risk compared to controls depending 

on the study.266 Patients may also be at 

increased risk for serious injury.267 This 

264. Garharino, S., Nohili, L., Beelke, M., De Carli, 

F., & Ferrillo, F. (2001). The contributing role of 

sleepiness in highway vehicle accidents. Sleep. 

24:203-206. 

265. Howard, M.E., et al. ( 2004). Sleepiness, sleepdisordered breathing and accident risk factors 

in commercial vehicle drivers. Am J Respir Crit 

Care Med. 170:1014-1021. 

266. Teran-Santos, J., Jimenez-Gomez, A., & 

Cordero-Guevara, J. (1999). The association 

between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. 

N Engl J Med. 340(11):847-851. 

267. Medical News Today. (n.a.) Risk of severe 

car crashes greatly increased in sleep apnea 

patients. http://www.medicalnewstoday.com/ 

articles/71543.php. 

topic has been extensively reviewed 

elsewhere.268 Obstructive sleep apnea 

is one of the few medical conditions 

where treatment has been shown to 

reduce crash risk back to baseline levels.269 In addition, recent studies indicate a high prevalence of sleep disorders 

or daytime sleepiness in older adults270 

and in diabetic patients.271 

268. Charlton, J., et al. (2004). Influence of chronic 

illness on crash involvement of motor vehicle 

drivers, Monash University Accident Research 

Centre, Report No. 213. 

269. George, C. F. (2001). Reduction in motor 

vehicle collisions following treatment of sleep 

apnea with nasal CPAP. Thorax. 56(7):508-512. 

270. Vaz Fragoso, Arauio, K. L., Van Ness, P. H., & 

Marottoli, R. A. (2008). Prevalence of sleep 

disturbances in a cohort of older drivers. J 

Gerontol Series A Bio Sci Med Sci. 63:715-723. 

271. Hayashino, Y., Yamazaki, S., Nakayama, T., 

et al. (2008). Relationship between diabetes 

mellitus and excessive sleepiness during driving. 

Exp Clin Endocrinol Diabetes. 116:1-5. 

Section 10: Respiratory diseases 

asthma No restrictions. 

Patients should be counseled not to drive during acute asthma attacks, or while 

suffering transient side effects (if any) from their asthma medications. 

chronic obstructive pulmonary 

disease (copd) 

No restrictions if symptoms are well controlled, and the patient does not 

experience any significant side effects from the condition or the medication. 

The patient should not drive if he/she suffers dyspnea at rest or at the wheel (even 

with the use of supplemental oxygen), excessive fatigue, or significant cognitive 

impairment. If the patient requires supplemental oxygen to maintain a hemoglobin 

saturation of 90 percent or greater, he/she should be counseled to use the oxygen 

at all times while driving. Due to the often tenuous oxygenation status of these 

patients, they should also be counseled to avoid driving when they have other respiratory symptoms that may indicate concomitant illness or exacerbation of COPD 

(e.g., new cough, increased sputum production, change in sputum color, fever). 

Because COPD is often progressive, periodic reevaluation for symptoms and 

oxygenation status is recommended. 

If the physician is concerned that the patient’s symptoms compromise his/her 

driving safety, referral to a driver rehabilitation specialist for a driver evaluation 

(including on-road assessment) is recommended. The patient’s oxygen saturation 

may be measured during the course of the on-road assessment to provide additional 

information for patient management. 

chapter 9—Medical Conditions and Medications That May Affect Driving 173 
sleep apnea Patients with excessive daytime sleepiness, loud snoring (particularly if accompanied by witnessed apneic events), large neck circumference (≥ 16 inches in women, 

≥ 17 inches in men), elevated body mass index (above 35 kg/m2), and/or hypertension that requires two or more medications should be considered at risk for obstructive sleep apnea, and formal sleep study evaluation should be considered, especially 

in any patient who reports having fallen asleep while driving a vehicle. A patient 

diagnosed with sleep apnea (apnea/hypopnea index of 5 or greater) who has fallen 

asleep while driving, or a patient with severe obstructive sleep apnea (apnea/hypopnea index of 30 or greater) should be counseled to refrain from driving until he/ 

she is receiving effective treatment (via a positive airway pressure device) following 

a formal sleep study to confirm the diagnosis. If these patients undergo other treatments (surgery, oral appliances), they should be advised to have a post-treatment 

sleep study to confirm effectiveness. Physicians should counsel patients using 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., following substantial weight loss). 

174 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

 

Section 11: 

Effects of anesthesia 

and surgery 

1. Abdominal, back, and chest surgery 

2. Anesthesia 

a. General 

b. Local 

c. Epidural 

d. Spinal 

3. Neurosurgery 

4. Orthopedic surgery 

Physicians should be alert to peri- and 

post-operative risk factors that may 

affect the patient’s cognitive function 

post-surgery, or restrictions on limb 

movement or joint range of motion that 

place the patient at risk for impairments 

in driving performance. Risk factors 

include: 

• Pre-existing cognitive impairment 

• Duration of surgery 

• Age (over 60) 

• Altered mental status post-surgery 

• Presence of multiple comorbidities 

• Emergency surgery 

If the physician is concerned that 

residual visual, cognitive or motor 

deficits following surgery may impair the 

patient’s driving performance, referral 

to a driver rehabilitation specialist for 

a driver evaluation (including on-road 

assessment) is highly recommended. 

Physicians should counsel patients who 

undergo surgery—both inpatient and 

outpatient—not to drive themselves 

home following the procedure. Although 

they may feel capable of driving, their 

driving skills may be affected by pain, 

physical restrictions, anesthesia, 

cognitive impairment, and/or analgesics. (For specific recommendations 

on musculoskeletal restrictions and 

narcotic analgesics, please see Sections 

7 and 13, respectively.) 

In counseling patients about their 

return to driving after a surgical 

procedure, it is useful to ask whether 

the patient’s car has power steering 

and automatic transmission. Physicians 

can tailor their advice accordingly. 

As patients resume driving, they should 

be counseled to assess their comfort 

level in familiar, traffic-free areas before 

driving in heavy traffic. If the patient 

feels uncomfortable driving in certain 

situations, he/she should avoid these 

situations until his/her confidence level 

has returned. A patient should never 

resume driving before he/she feels ready 

to do so and has received approval from 

the physician. 

Section 11: Effects of anesthesia and surgery 

abdominal, back and chest surgery The patient may resume driving after demonstrating the necessary strength and 


range-of-motion for driving.
 

See Section 2 for recommendations for surgeries involving median sternotomy.
 

anesthesia	 Because anesthetic agents and adjunctive compounds (such as benzodiazepines) 

may be administered in combination, the patient should not resume driving until 

the motor and cognitive effects from all anesthetic agents have subsided. 

General Both the surgeon and anesthesiologist should advise patients against driving for at 

least 24 hours after a general anesthetic has been administered. Longer periods of 

driving cessation may be recommended depending on the procedure performed and 

the presence of complications. 

Local	 If the anesthetized region is necessary for driving tasks, the patient should not 

drive until he/she has recovered full strength and sensation (barring pain). 

Epidural The patient may resume driving after recovering full strength and sensation 

(barring pain) in the affected areas. 

Spinal The patient may resume driving after recovering full strength and sensation 

(barring pain) in the affected areas. 

chapter 9—Medical Conditions and Medications That May Affect Driving 175 
neurosurgery See recommendations for post intracranial surgery in Section 3. 

orthopedic surgery See the recommendations for orthopedic procedures/surgeries in Section 7. 

176 chapter 9—Medical Conditions and Medications That May Affect Driving 
Section 12: 

Miscellaneous conditions 

1. Cancer 

Section 12: Miscellaneous conditions 

cancer Patients 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 side effects of treatment 

(e.g., antiemetics for nausea) may impair driving performance. Physicians 

should counsel their patients accordingly. (See Section 13 for 

recommendations for specific medications.) 

chapter 9—Medical Conditions and Medications That May Affect Driving 177 
 

 

 

 

 

 

 

 

 

 

 

Section 13: Medications 

1. Alcohol 

2. Anticholinergics 

3. Anticonvulsants 

4. Antidepressants 

a. 	Bupropion 

b. 	Mirtazapine 

c. 	Monoamine oxidase 


(MAO) inhibitors
 

d. Selective serotonin reuptake 

inhibitors (SSRIs) 

e. 	Tricyclic antidepressants (TCAs) 

5. Antiemetics 

6. Antihistamines 

7. Antihypertensives 

8. Antiparkinsonians 

9. Antipsychotics 

10. Benzodiazepines and other 

sedatives/anxiolytics 

11. Muscle relaxants 

12. Nonsteroidal anti-inflammatory 

drugs (NSAIDs) 

13. Narcotic analgesics 

14. Stimulants 

Many commonly used prescription 

and over-the-counter medications can 

impair driving performance. In general, 

any drug with a prominent central 

nervous system (CNS) effect has the 

potential to impair an individual’s 

ability to operate a motor vehicle. The 

level of impairment varies from patient 

to patient, between different medications within the same therapeutic class, 

and in combination with other medications or alcohol. 

Many classes of medication have been 

associated with increased crash risk or 

impaired driving skills when assessed by 

simulators or road tests. These include, 

but are not limited to hypnotics, alcohol, 

antiepileptic agents, anti-emetic agents, 

narcotics, barbiturates, benzodiazepines, 

antihistamines, antidepressants, antipsychotics, and muscle relaxants. Some of 

the highest crash rates have been noted 

with long-acting benzodiazepines when 

prescribed to older adults.272 Other studies suggest that a significant number of 

272. Hemmelgarn, B., Suissa, S., Huang, A., et 

al. (1997). Benzodiazepine use and the risk 

of motor vehicle crash in the elderly. JAMA. 

278:27–31. 

older adults may be driving while under 

the influence of other medications.273, 274 

Potential driving impairing (PDI) medications is a relatively new term that 

identifies medications that have been 

associated with increased crash risk. 

Crash risk does increase when multiple 

PDI drugs are prescribed.275 Mechanisms 

whereby drugs may impair driving are 

myriad and include: sleepiness, fatigue, 

or sedation; lightheadness, dizziness, 

or low blood pressure; blackouts or 

syncope; or impaired judgment coordination. Medications can affect eyesight 

in numerous ways, including blurred 

vision, impaired visual fields, and 

nighttime vision.276 However, it should 

be noted that many medication and 

driving studies are usually correlational 

in nature, and may suggest increased 

crash risk but not necessarily causation. 

Whether it is the medication itself, the 

condition for which it is prescribed, 

the presence of other comorbidities, or 

a combination of these issues is often 

difficult to sort out.277 Clinicians should 

be aware of the risk and attempt to use 

the safest class of medications based on 

the most recent evidence. An excellent 

review of this subject for pharmacists 

may be of interest to physicians and is 

273. Higgins, J. P., Wright, S. W., & Wrenn, K. D. 

(1996). Alcohol, the elderly, and motor vehicle 

crashes. Am J Emerg Med. 14:265–267. 

274. Johansson, K., Bryding, G., Dahl, M. L., et 

al.(1997). Traffic dangerous drugs are often 

found in fatally injured older male drivers. J Am 

Geriatr Soc. 45:1029–1031. 

275. Leroy, A., & Morse, M. M. (N.A.). Exploratory 

Study of the Relationship Between Multiple 

Medications and Vehicle Crashes: Analysis 

of Databases. NHTSA Contract DTNH22­

02-C-05075. Publication under review. 

[Published as Multiple Medications and Vehicle 

Crashes: Analysis of Databases. (2008, May). 

NHTSA Report No. DOT HS 810 858. Washington, DC: National Highway Traffic Safety 

Administration. Available at www.nhtsa.dot.gov/ 

staticfiles/DOT/NHTSA/Traffic%20Injury%20 

Control/Articles/Associated%20Files/810858.pdf.] 

276. Wang, K.(2007). Adverse Ocular Side-Effects 

of Commonly Prescribed Systemic Medications. 

Online CE provided by Pacific University 

College of Optometry. www.Opt.pacifcu.edu/ce/ 

catalog/11466-PHWandgDrugs.html. Accessed 

October 21, 2007. 

277. Bramness, JG., Skurtvelt, S., Neutel, CI., et 

al. (2008). Minor increase in traffic accidents 

after prescriptions of antidepressants: a study 

of population registry data in Norway. J Clin 

Psychiatry. 69:1099–1103. 

available on-line.278 

Medication side effects that can affect 

driving performance include drowsiness, 

dizziness, blurred vision, unsteadiness, 

fainting, slowed reaction time, and extrapyramidal side effects. In many cases, 

these side effects are dose-dependent 

and may attenuate with time. 

Whenever possible, the physician 

should prescribe non-impairing medications. If the physician must prescribe 

or change the dosage of a medication 

that can potentially impair driving 

performance, he/she should counsel 

the patient about the side effects. The 

physician should also recommend that 

the patient take the first few doses in a 

safe environment to determine the presence and extent of any side effects, and 

that he/she temporarily cease driving as 

needed until the body has adjusted to 

the medication. 

In addition to being alert to potential 

side effects, the patient, caregivers, 

and physicians should also understand 

that with certain medications, subjective effects do not always correlate 

with impairment.279 Medications that 

cause drowsiness, euphoria, and/or 

anterograde amnesia may also diminish 

insight, and the patient may experience 

impairment without being aware of it. 

278. Walgreens Health Services. Continuing 

Pharmacy Education Web Site. MedicationRelated Impaired Driving: For Pharmacist. 

https://webapp.walgreens.com/cePharmacy/ 

programsHTML/transportation-tech.pdf. Accessed 

November 16, 2007. 

279. Mattila, M. (1988). Acute and subacute effects 

of diazepam on human performance: comparison 

of plain tablet and controlled release capsule. 

Pharmacol Toxicol. 63(5):369–374. 

Roache, JD., & Griffiths, R. R. (1985). 

Comparison of triazolam and pentobarbital: 

performance 

impairment, subjective effects and abuse liability. 

J Pharmacol Exp Therapeut. 234(1):120–133. 

Aranko, K., Mattila, M. J., & Bordignon, D. 

(1985). Psychomotor effects of alprazolam and 

diazepam during acute and subacute treatment, 

and during the follow-up phase. Acta Pharmacologica Toxicologica. 56(5):364–372. 

Weiler, JM., et al. (2000). Effects of fexofenadine, diphenhydramine, and alcohol on driving 

performance. a randomized placebo-controlled 

trial in the Iowa Driving Simulator. Ann Intern 

Med. 132(5):354–363. 

178 chapter 9—Medical Conditions and Medications That May Affect Driving 
When prescribing new medications, the 

physician should always consider the 

patient’s existing regimen of prescription 

and nonprescription medications. 

Combinations of drugs may affect drug 

metabolism and excretion, and produce 

additive or synergistic interactions. 

In fact, use of multiple psychoactive 

medications is a common cause of 

hospitalization for delirium among 

older adults.280 Because individuals 

react differently to drug combinations, 

280. Ray, W. A., Purushottam, B. T., Shorr, R. I. 

(1939). Medications and the older driver. 

Clin Geriatr Med. 9(2):413–438. 

the degree of impairment caused by 

polypharmacy may vary from patient 

to patient. With polypharmacy’s strong 

but unpredictable potential to produce 

impairment, physicians should add 

new medications at the lowest dosage 

possible, counsel the patient to be alert 

to any impairing side effects, and adjust 

the dosages of individual medications 

as needed to achieve therapeutic effects 

with a minimum of impairment. 

Section 13: Medications 

alcohol As little as one serving of alcohol (1.25 oz. 80-proof liquor, 12 oz. beer, 5 oz. wine) 

has the potential to impair driving performance in many individuals. Due to agerelated changes in body metabolism (e.g., increased body fat and decreases in lean 

muscle mass), the same weight-adjusted amount of alcohol (hydrophilic) is likely 

to result in higher blood levels of alcohol and functional impairment in advanced 

age. In many cases, individuals may be impaired without being aware of it. Furthermore, alcohol can potentiate the CNS effects of medications to produce profound 

and dangerous levels of impairment. physicians should always warn their patients 

against drinking and driving, and against combining alcohol and their cnsactive medications. 

For recommendations on substance abuse, see Section 5. 

anticholinergics When a patient takes single or multiple medications with anticholinergic activity, 

including some antidepressants, antihistamines, antiemetics, antipsychotics, 

and antiparkinsonian drugs, the physician should be alert to the possibility of 

anticholinergic toxicity and adjust medication dosages accordingly. 

Anticholinergic effects that can impair driving performance include blurred vision, 

sedation, confusion, ataxia, tremulousness, and myoclonic jerking. Patients should 

be counselled about these symptoms and should alert their physicians immediately 

if they occur. Patients should also be advised that psychomotor and cognitive 

impairment might be present even in the absence of subjective symptoms 

(this has been well documented for antihistamines). 

Subtle deficits in attention, memory, and reasoning may occur with therapeutic 

dosages of anticholinergic drugs without signs of frank toxicity. These deficits have 

often been mistaken for symptoms of early dementia in elderly patients. Physicians 

are advised to be aware of this possibility. 

chapter 9—Medical Conditions and Medications That May Affect Driving 179 
anticonvulsants The patient should temporarily cease driving during the time of medication 

initiation, withdrawal, or dosage change due to the risk of recurrent seizure and/or 

potential medication side effects that may impair driving performance. 

If there is significant risk of recurrent seizure during medication withdrawal or 

change, the patient should cease driving during this time and for at least three 

months thereafter. 

Note that many anticonvulsants (e.g., valproic acid, carbamazepine, gabapentine, 

lamotrigine and topiramate) are also being used as mood stabilizers for treatment of 

bipolar disorder, for agitation in dementia, and as sedating agents for anxiety. These 

agents are typically an adjunct to antidepressants, antipsychotics and/or anxiolytics. 

By themselves, anticonvulsants may be mildly impairing, but the combined medication effects on psychomotor performance tend to enhance their effects. When 

prescribing anticonvulsants and other psychoactive drugs, it is wise to start with low 

doses of each and gradually increase the dosage of each one separately to minimize 

significant side effects. In addition, this would allow for a clear identification of 

which drug may be producing a benefit or problem. 

antidepressants 

Bupropion 

Mirtazapine 

Impairing side effects vary among the different classes of antidepressants, and even 

within certain classes of antidepressants. (In general, antidepressants that possess 

antagonistic activity at cholinergic, alpha-1-adrenergic, and histaminergic receptors 

are the most impairing.) Recent data have also implicated venlafixine as being associated with motor vehicle crashes.281 Whenever possible, physicians should initiate 

antidepressant therapy with the least impairing medication possible. However, the 

data indicating increased crash risk with the specific use of certain medications may 

reveal associations but not necessarily causation. It is difficult to know whether 

increased risk is associated with the drug, a drug-drug interaction, or the disease 

itself (e.g., depression, which may independently impair attention, judgment, etc). 

Patients should be advised not to drive during the initial phase of antidepressant 

dosage adjustment(s) if they experience drowsiness, lightheadedness, or other side 

effects that may impair driving performance. Patients should also be advised that 

they might experience impairment in the absence of any subjective symptoms. 

Side effects of bupropion (also known as Wellbutrin® and Zyban®) include anxiety, 

restlessness, weight loss, and insomnia (leading to daytime drowsiness). Patients 

should be counseled about these side effects and their potential to impair driving 

performance. Because bupropion may cause seizures at high doses, it should not be 

prescribed to patients with epilepsy, brain injuries, eating disorders, or other factors 

predisposing to seizure activity. 

Mirtazapine (also known as Remeron®) is typically taken only at night due to its 

sedating effects. It has been shown to cause substantial impairment for many hours 

after dosing. If daytime sedation is noted as an adverse side effect, another antidepressant should be considered or driving discontinued. 

281. Walgreens Health Services. Continuing Pharmacy Education Web Site. Medication-Related Impaired 

Driving: For Pharmacist. https://webapp.walgreens.com/cePharmacy/programsHTML/transportation-tech.pdf. 

Accessed November 16, 2007. 

180 chapter 9—Medical Conditions and Medications That May Affect Driving 
 

Monoamine oxidase (MAO) inhibitors Side effects of MAO inhibitors that may impair driving performance include 

blurred vision, overstimulation, insomnia (leading to daytime drowsiness), 

orthostatic hypotension (with transient cognitive deficits), and hypertensive 

crisis (presenting with severe headaches and/or mental status changes). The latter 

can be caused by failure to adhere to dietary and medication restrictions. Patients 

should be counseled about these side effects and their potential to impair driving 

performance. 

Selective serotonin reuptake inhibitors 

(SSRIs) 

Common side effects of SSRIs that may impair driving performance include sleep 

changes (insomnia or sedation), headache, anxiety, and restlessness. While these 

side effects tend to be mild and well tolerated, physicians should counsel patients 

to be alert to their potential to affect driving performance. Special mention is made 

of serotonin syndrome, wherein mental status changes, autonomic hyperactivity, 

and neuromuscular side effects are observed due to excessive amounts of the drug or 

a drug-drug interaction. Treatment includes discontinuing the offending agent or 

hospitalization in severe cases. 

Tricyclic antidepressants (TCAs) Common side effects of TCAs that may impair driving performance include 

sedation, blurred vision, orthostatic hypotension, tremor, excitement, and heart 

palpitations. In studies involving healthy volunteers, the more sedating TCAs have 

been shown to impair psychomotor function, motor coordination, and open-road 

driving. Other studies appear to indicate an increased crash risk for drivers who 

take TCAs.282 

Whenever possible, other agents like SSRIs or TCA’s with a low propensity for 

anticholinergic effects (nortryptiline or desipramine) should be considered for 

those who wish to continue driving. If nonimpairing alternatives are not available, 

then the physician should advise patients of the potential side effects, and recommend temporary driving cessation during the initial phase of medication initiation/ 

dosage adjustment. Patients should also be advised that they might experience 

impairment even in the absence of subjective symptoms. 

antiemetics Numerous classes of drugs—including anticholinergics, antihistamines, antipsychotics, 

cannabinoids, benzodiazepines, 5HT antagonists, and glucocorticoids—are used 

for their antiemetic effect. Side effects of antiemetics that may impair driving 

performance include sedation, blurred vision, headache, confusion, and dystonias. 

Significant impairment may be present even in the absence of subjective symptoms; 

this has been well documented for many benzodiazepines and over-the-counter 

antihistamines. Patients should be counseled about side effects and their potential 

to impair driving performance, and should be advised that they may experience 

impairment even in the absence of subjective symptoms. 

For more detailed information, see also Anticholinergics, Antihistamines, 

Antipsychotics, and Benzodiazepines in this section. 

282. Ray, W. A., Purushottam, B. T., Shorr, R. I. (1993). Medications and the older driver. 

Clin Geriatr Med. 9(2):413–438. 

chapter 9—Medical Conditions and Medications That May Affect Driving 181 
 

antihistamines In many patients, the first generation antihistamines (such as diphenhydramine 

and chlorpheniramine) have pronounced CNS effects. In studies involving healthy 

volunteers, sedating antihistamines have been shown to impair psychomotor 

performance, simulated driving, and open-road driving.283 Furthermore, subjects 

may experience impairment even in the absence of subjective symptoms of impairment.284 In contrast, most nonsedating antihistamines do not produce these 

types of impairment after being taken in recommended doses.285 Even nonsedating 

antihistamines may cause impairments if taken in higher-than-recommended doses, 

however, and one of them (i.e., cetirizine) may be slightly impairing to certain 

patients in normal doses. 

Patients who take sedating antihistamines should be advised not to drive while 

on the medications. If these patients wish to continue driving, they should be 

prescribed a nonsedating antihistamine. 

antihypertensives With their hypotensive properties, common side effects of antihypertensives that 

may impair driving performance include lightheadedness, dizziness, and fatigue. In 

addition, antihypertensives with a prominent CNS effect, including beta-blockers 

and the sympatholytic drugs clonidine, guanfacine and methyldopa, may cause 

sedation, confusion, insomnia, and nervousness. 

Patients should be counseled about these side effects and their potential to 

impair driving performance. In addition, patients taking antihypertensives that 

may potentially cause electrolyte imbalance (i.e., diuretics) should be counseled 

about the symptoms of electrolyte imbalance and their potential to impair driving 

performance. 

antiparkinsonians Several medications and classes of medications, including levodopa, antimuscarinics 

(anticholinergics), amantadine, and dopamine agonists, may be used in the treatment 

of Parkinson’s disease symptoms. Common side effects of antiparkinsonian drugs that 

may impair driving performance include excessive daytime sleepiness, lightheadedness, dizziness, blurred vision, dyskinesias, on-off phenomenon, hallucinations, and 

confusion. (See also Anticholinergics in this section for more information.) 

Patients should be counseled about these side effects and advised not to drive if 

they experience side effects. The physician may also consider referring patients for 

formal psychomotor testing or for on-road assessment performed by a driver rehabilitation specialist. 

antipsychotics 

Most—if not all—antipsychotic medications have a strong potential to impair 

driving performance through various CNS effects. Some of the original or 

“classic” antipsychotics are heavily sedating, and all produce extrapyramidal 

side effects (EPS). Alhough the modern or “atypical” drugs have a lower 

tendency to cause EPS, they, too, are sedating. 

283. Ibid. 

284. Weiler, JM., et al. (2000). Effects of fexofenadine, diphenhydramine, and alcohol on driving performance. 

a randomized placebo-controlled trial in the Iowa Driving Simulator. Ann Intern Med. 132(5):354–363. 

285. Ray, W. A., Purushottam, B. T., Shorr, R. I. (1993). Medications and the older friver. Clin Geriatr Med. 

9(2):413–438. 

182 chapter 9—Medical Conditions and Medications That May Affect Driving 
antipsychotics (continued) Patients should be counseled about these side effects and advised not to drive if 

they experience side effects severe enough to impair driving performance. The 

physician should consider referring the patient for formal psychomotor testing or 

for on-road assessment performed by a driver rehabilitation specialist. If medication 

therapy is initiated while the patient is hospitalized, the impact of side effects on 

driving performance should be discussed prior to discharge. 

Benzodiazepines and other sedatives / 

anxiolytics 

Studies have demonstrated impairments in vision, attention, motor coordination, 

and driving performance with benzodiazepine use. Evening doses of long-acting 

benzodiazepines have been shown to markedly impair psychomotor function the 

following day, while comparable doses of short-acting compounds produce a lesser 

impairment.286 In contrast, benzodiazepine-like hypnotics (such as zolpidem and 

zaleplon) have a more rapid rate of elimination. Studies of driving performance 

and psychomotor function have shown that five hours after taking zaleplon and 

nine hours after taking zolpidem at recommended doses, it is generally safe to drive 

again.41 Recently, reports in the news media and some studies indicate that zolpidem has not uncommonly been found during serum toxicology testing of drivers 

involved in fatal accidents or arrested for driving under the influence of drugs.287 

Patients should be prescribed evening doses of the shortest-acting hypnotics whenever possible. Patients who take longer-acting compounds or daytime doses of any 

hypnotic should be advised of the potential for impairment, even in the absence 

of subjective symptoms. These patients should also be advised to avoid driving, 

particularly during the initial phase of dosage adjustment(s). 

Muscle relaxants Most skeletal muscle relaxants (e.g., carisoprodol and cyclobenzaprine) have 

significant CNS effects. Patients should be counseled about these side effects, and 

should be advised not to drive during the initial phase of dosage adjustment(s) if 

they experience side effects severe enough to affect safe driving performance. 

nonsteroidal anti-inflammatory drugs 	 Isolated case reports of confusion following the use of the NSAIDs phenylbutazone 

(nsaids)	 and indomethacin suggest that they may rarely impair driving performance.288 

Recent data reveal an association with motor vehicle crashes, although this could 

represent the effects of the disease and not specifically treatment.289 If the patient 

reports this side effect, the physician should consider adjusting the dosage or 

changing the medication. 

286. Ibid. 

287. Vermeeren, A., Danlou, P. E., O’Hanlon, J. F. (1999). Residual effects of aaleplon 10 and 20 mg on 

memory and actual driving performance following administration 5 and 2 hours before awakening. 

Br J Clin Pharmacol. 48:367–374.
 

Vermeeren, A., Muntjewerff, N. D., van Boxtel, M., et al. (2000). Residual effects of zaleplon and 


zopiclone versus the effects of alcohol on actual car driving performance. Eur Neuropsychopharmacol. 


10(suppl 3):S394.
 

Volkerts, E. R., Verster, J. C., Heuckelem, J. H. G., et al. (2000). The impact on car-driving performance 

of zaleplon and zolpiden administration during the night. Eur Neuropsychopharmacol. 10(suppl 3):S395. 

288. Jones, A. W., Holmgren, A., & Kugelberg, F. C. (2007). Concentrations of scheduled prescription drugs 

in blood of impaired drivers: considerations for interpreting the results. Ther Drug Monitor. 29:248–260. 

289. Ray, W. A., Gurwitz, J., Decker, M. D., & Kennedy D. L. (1992). Medications and the safety of the older 

driver: is there a basis for concern? Hum Factors. 34(1):33–47. 

chapter 9—Medical Conditions and Medications That May Affect Driving 183 
narcotic analgesics Patients should be counseled about the impairing effects of narcotic analgesics 

(i.e., opioids) and the potential for impairment even in the absence of subjective 

symptoms. They should also be advised not to drive while on these medications. 

In addition, many narcotic analgesics have a high potential for abuse. However, 

the literature also indicates that physicians often undertreat pain in the general 

population and with older adults. Accordingly, physicians should always be alert 

to signs of abuse. (For more information, see the recommendations for substance 

abuse in Section 5.) 

stimulants Common side effects of traditional stimulants (such as amphetamines and 

methylphenidate) that may impair driving performance include euphoria, 

overconfidence, nervousness, irritability, anxiety, insomnia, headache, and rebound 

effects as the stimulant wears off. Patients should be counseled about these side 

effects and advised not to drive during the initial phase of dosage adjustment(s) 

if they experience side effects severe enough to impair driving performance. 

(The novel stimulant, modafinil, is not euphorogenic, nor does it appear to 

cause rebound effects. However, its safety for use when driving has not yet 

been demonstrated.) 

In addition, many stimulants have a high potential for abuse. Accordingly, 

physicians should always be alert to signs of abuse. (For more information, 

see the recommendations for substance abuse in Section 5.5.) 

184 chapter 9—Medical Conditions and Medications That May Affect Driving 
chapter 10 

Moving Beyond This 

Guide: Future Plans to 

Meet the Transportation 

Needs of Older Adults 

 

 

 

 

 

 

chapter 10 

Moving Beyond This Guide: 

Future Plans to Meet the 

Transportation Needs of 

Older Adults 

The previous chapters provide physicians with recommendations and tools 

for enhancing the driving safety of their 

patients. As in other aspects of patient 

care, however, further research can lead 

to more effective care. We eagerly await 

further evaluation of in-office tools 

that can predict crash risk or determine 

fitness-to-drive, as well as improved access to driver assessment and rehabilitation. We also look forward to advanced 

technology in vehicles to assist drivers 

with navigation and safety issues. At 

the same time, we wish for safer roads, 

better transportation alternatives, increased crashworthiness of vehicles, and 

other vehicular improvements that can 

help keep our patients safe on the road 

as long as possible. 

In this chapter, the AMA advocates for 

coordinated efforts among the medical and transportation communities, 

policymakers, community planners, the 

automobile industry, and government 

agencies to achieve the common goal of 

safe transportation for the older population. As this population continues to 

expand and live longer, we all have 

the challenge of keeping pace with its 

transportation needs. 

Listed below is the AMA’s checklist 

of research, initiatives, applications, 

and system changes that we believe are 

crucial for improving and increasing the 

safe mobility of the older population. 

We encourage readers of this guide to 

use this list as a launching pad to boost 

your future plans and efforts. 

1. Improved physician tools for the 

assessment of driving safety 

Physicians need an assessment tool that 

reliably identifies patients who are at 

increased risk for a car crash. This test 

battery must assess the primary functions 

that are related to driving, and must 

form a basis for medical interventions to 

correct any functional deficits that are 

identified. In addition, this tool must be 

brief, inexpensive, easy to administer, 

and validated to predict crash risk and/or 

the ability to pass a performance-based, 

standardized, reliable and valid road test. 

At present, no comprehensive tool is 

available. Individual functional tests 

(such as the Trail Making Test, Part B; 

see Chapters 3 and 4) have been repeatedly shown to correlate with crash risk, 

yet there is still not a universal cut-off 

or score on these tests that can determine fitness-to-drive. Researchers are 

currently studying other tests in relation 

to driving. The field has focused on 

heterogeneous groups of older adults 

with modest correlations in functional 

batteries.290 Further steps will likely 

require a focus on different batteries or 

tests in a given specific older population 

with a specific disease (e.g., glaucoma, 

dementia). 

While researchers work toward achieving 

a comprehensive test battery, physicians 

can best evaluate their patients’ driving 

290. Ball, K. K., Roenker, D. L., Wadley, V. G., et al. 

(2006). Can high-risk older drivers be identified 

through performance-based measures in a 


Department of Motor Vehicles setting?
 

J Am Geriatr Soc. 54:77–84.
 

safety by assessing the functions related 

to driving (see the Assessment of Driving Related Skills [ADReS] in Chapter 

3) and reviewing the presence and/or 

severity of important medical illnesses 

(Chapter 9). The AMA will continue 

to promote awareness of the most 

recent assessment and rehabilitation 

tools, and we encourage physicians to 

stay informed on these developments. 

2. Increased availability and 

affordability of driver rehabilitation 

When the results of physician assessment are unclear, or when further 

correction of functional deficits through 

medical management is not possible, 

driver rehabilitation specialists (DRSs) 

are an excellent resource. DRSs can 

perform a focused clinical assessment, 

observe the patient in the actual driving task, and train him/her in the use 

of adaptive techniques or devices to 

compensate for functional deficits. (See 

Chapter 5 for more information.) 

Unfortunately, access and cost remain 

major barriers to the utilization of DRSs 

by older drivers and their referring 

physicians. DRSs are not available in 

all communities, and there are presently 

too few to provide services to all older 

drivers who are in need of their services 

Furthermore, driver assessment and 

rehabilitation are expensive, and Medicare and private insurance companies 

rarely pay for these services. 

187 
The American Occupational Therapy 

Association (AOTA) is addressing 

these issues through two initiatives. 

First, AOTA is devising a framework to 

increase the number of DRSs within the 

occupational therapy (OT) profession. 

This framework will include strategies 

to promote older driver practice among 

current OT practitioners, curriculum 

content for continuing education 

programs, and training modules for 

entry-level OT educational programs. 

Secondly, AOTA is actively lobbying 

for consistent Medicare coverage of 

OT-performed driver assessment and 

rehabilitation, under the assertions that 

these services fall under the scope of 

OT practice and that driving is an instrumental activity of daily living. Individual DRS programs have also pursued 

insurance coverage from Medicare and 

other providers, with varying degrees of 

success. 

In the effort to keep older drivers on 

the road safely as long as is reasonable, 

increased access to and affordability of 

driver assessment and rehabilitation 

are essential. We support the AOTA’s 

initiatives, and suggest that physicians 

use DRSs as a resource for their patients 

whenever possible. We also encourage 

research in this field to create standardized off-road and on-road tests that have 

respectable levels of reliability, validity, 

and test stability. Correlating results 

on road tests with prospective at-fault 

crash data remains an important area 

of future study. Finally, the added value 

of physicians referring their patients to 

an OT driving program, in comparison 

to “usual care,” would be an important 

step in the process of obtaining Medicare and insurance company support for 

funding these types of evaluations. 

3. Increased investigation into the 

use of simulators and comprehensive assessment methods techniques 

Validated driver assessment technologies may help make driver assessment 

more widely available to older drivers. Preliminary research with a commercially available driving simulator 

has demonstrated a strong correlation 

between simulated driving performance 

and on-road performance in cognitively 

impaired and healthy older drivers.291 

Certainly, limitations exist with the use 

of simulators, such as lack of standardization in the field, use of different crash 

scenarios, expense, need for technological support, and simulator-induced 

sickness. However, unlike on-road 

assessment, simulators can evaluate 

performance in driving situations that 

would otherwise be infeasible or dangerous.292 293 In addition, there have been 

recent attempts to study their validity294 

and reliability.295 Yet, a recent study was 

not able to correlate simulator findings 

with crash data in a cohort of sleep 

apnea patients, who have one of the 

highest crash rates associated with any 

medical conditions.296 Further research 

and experience may confirm that driving simulators are safe, effective, and 

readily acceptable to the public. It will 

also be useful to discover if familiarity 

with computers and games by successive 

aging cohorts affects the outcome of 

simulator performance and/or reduces 

crashes. 

We applaud recent efforts to further 

understand the complex role the central 

nervous system plays in operating a mo291. Freund, B., Gravenstein, S., Ferris, R. (2002). 

Evaluating driving performance of cognitively 

impaired and healthy older adults: a pilot study 

comparing on-road testing and driving simulation (letter to the editor). J Am Geriatr Soc. 

50:1309. 

292. Reimer, B., D’Ambrosio, L., Coughlin, J., et al. 

(2006). Using self-reported data to assess the 

validity of driving simulation data. Behav Res 

Method. 38(2):314–324. 

293. Uc, E. Y., Rizzo, M. , Anderson, S. W., et al. 

(2006). Unsafe rear-end collision avoidance 

in Alzheimer’s disease. J Neurol Sci. 251 

(1–2):35–43. 

294. Reimer, B., D’Ambrosio, L., Coughlin, J., et al. 

(2006). Using self-reported data to assess the 

validity of driving simulation data. Behav Res 

Method. 38(2):314–24. 

295. Contardi, S., Pizza, F., Sancisi, E., et al. (2004). 

Reliability of a driving simulation task for 

evaluation of sleepiness. Brain Res Bull. 

63(5):427-431. 

296. Turkington, P. M., Sircar, M. , Allgar, V., & 

Elliott, M. W. (2001). Relationship between 

obstructive sleep apnoea, driving simulator 

performance, and risk of road traffic accidents. 

Thorax. 56(10):800–805. 

tor vehicle.297, 298 We encourage State 

licensing authorities and driver rehabilitation programs to investigate the use of 

technologies to increase the availability 

of reliable driver assessment services 

to the public. Such technologies, if 

integrated into or aligned with current 

practices, could help form an intermediate step between physician assessment 

and driver rehabilitation or increase the 

licensing authority’s capacity to offer 

specialized driver assessment to medically at-risk drivers. 

4. The enhanced role of the driver 

licensing agency in promoting the 

safety of older drivers 

As the agency that ultimately awards, 

renews, restricts and revokes the driver’s 

license, each State’s driver licensing 

agency has the task of distinguishing 

unsafe drivers from safe drivers. While 

each State has its own procedures, 

which are highly variable, potentially 

unsafe drivers are usually identified by 

one of four means: (1) failure of the 

individual to meet licensing or license 

renewal criteria; (2) report from the 

individual or family; (3) report from 

physicians, DRSs, law enforcement officers, and others; and (4) judicial report. 

To meet the standards for licensing, 

the driver licensing agency initially 

requires individuals to pass assessments 

of knowledge, vision, and driving 

skills. License renewal tends to be less 

stringent, with many States permitting 

renewal by mail. In recent years, certain 

States have increased their efforts to 

identify older drivers who are at risk 

for unsafe driving by stipulating special 

renewal procedures for this population. 

These procedures include shortened renewal intervals, in-person renewal, and 

mandatory reassessment of knowledge, 

vision, and driving skills. 

297. Walter, H., Vetter, SC., Grothe, J., et al. (2001). 

The neural correlates of driving. Neuroreport. 

12(8):1763–1767. 

298. Ott, B. R., Heindel, W. C., Whelihan, W. 

M., et al. (2000). A single-photon emission 

computed tomography imaging study of driving 

impairment in patients with Alzheimer’s disease. 

Dement Geriatr Cogn Disord. 11(3):153–160. 

188 chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults 
 

 

 

 

We encourage all States to maintain 

or adopt renewal procedures for the 

most effective identification of at-risk 

older drivers. (See also Enhanced role 

of the Medical Advisory Board below.) 

We also encourage States to base their 

standards for licensing on current scientific data. For example, visual acuity 

standards that are based on outdated 

research may be unnecessarily restrictive to all drivers and to older drivers in 

particular. As noted in Chapter 7, the 

only recent licensing renewal procedure 

that has been associated with decreased 

crash risk is the requirement for inperson renewal. 

In addition to the vision screens that 

are currently in use, driver licensing 

agencies may also wish to utilize newer 

tools (such as contrast sensitivity and 

the useful field-of-view test) that have 

been shown to correlate with crash 

risk.299, 300 Some of these tools, along 

with other tests of function and driving 

skills, are currently being field-tested 

by the California Department of Motor 

Vehicles as part of its three-tier assessment system.301 Future findings from 

this system may be useful to some driver 

licensing agencies that are interested in 

establishing similar tier systems. 

Many individuals are understandably 

reluctant to report themselves to the 

driver licensing agency as unsafe drivers. Although there are few data on 

this issue, recent research on referrals 

for fitness-to-drive in Missouri suggests 

that few if any drivers take this step.302 

Driver licensing agencies can do their 

part by creating a more supportive sys299. Owsley C., Stalvey BT., Wells J., Sloane M. 

E., McGwin G. Visual risk factors for crash 

involvement in older drivers with cataract. Arch 

Ophthalmol. 119:881–887. 

300. Owsley C., Ball K., McGwin G., Sloane M. E., 

Roenker DL., White M. F., Overley ET. Visual 

processing impairment and risk of motor vehicle 

crash among older adults. JAMA.
 

279(14):1083–1088.
 

301. Personal correspondence with Mary Janke, 

Ph.D., September 26, 2002; and 

Janke M. K., & Eberhard J. W. Assessing 

medically impaired older drivers in a licensing 

agency setting. Accid Anal Prev. 30(3):347–361. 

302. Personal communication, Dr. Tom Meuser, 

Director of Aging, University Missouri St. 

Louis. 

tem for older drivers. For example, the laws that provide immunity from breach 

agency can work more closely with the of confidentiality lawsuits for physicians 

at-risk drivers’ physicians or the Medi­ and others who report impaired drivers 

cal Advisory Board to correct functional to their State licensing authority. 

deficits through medical treatment, if 

possible. Drivers with a high potential for rehabilitation can be referred 5. Enhanced role of the Medical 

by the licensing agency to a DRS to Advisory Board 

learn adaptive techniques and devices. A Medical Advisory Board (MAB) is 

Licensing agencies can also consider generally composed of State-licensed 

the patient’s driving needs by issuing physicians who work in conjunction 

restricted licenses whenever possible to with the driver licensing agency to 

help the driver maintain mobility while determine whether mental or physical 

protecting his/her safety. For those driv­ conditions may impair an individual’s 

ers who must relinquish their license, ability to drive safely. MABs vary 

the agency can provide guidance in among States in size, role, and level of 

seeking alternative transportation. involvement. For example, the MAB of 

the Maryland Motor Vehicle AdminisAt-risk drivers can also be brought to tration reviews the fitness of individuthe attention of the driver licensing als to drive safely, while California’s 

agency by physician referral. How- MAB provides recommendations to 

ever, many physicians are not aware of DMV staff for use in developing policies 

their State’s referral procedures,303 and that affect medically and functionally 

others fear legal liability for breach of impaired drivers.304 Many States lack 

confidentiality. With the advent of the an MAB altogether or have one that is 

Health Insurance Portability and Ac­ ineffective. 

countability Act (HIPAA), physicians 

may have questions about the extent We encourage each State driver licensand detail of patient information they ing agency to enhance the role of its 

should provide in a referral. Driver MAB in order to provide a greater 

licensing agencies can encourage physi­ capacity for assessment, rehabilitacian referral by establishing clear guide­ tion and support to older drivers. We 

lines and simple procedures for referral also encourage States that lack MABs 

(e.g., comprehensive referral forms to create a multi-disciplinary team of 

that can be accessed over the Internet) medical experts to develop and impleand promoting physician awareness of ment recommendations on the medical 

these guidelines and referral procedures. fitness of their State’s licensed drivers. 

In many States, physicians who refer Such recommendations should be based 

patients to their State’s driver licensing on the most current scientific data, and 

agency are not granted legal protec­ should be implemented in an efficient 

tion against liability for breaching the review process. 

patient’s confidentiality. Indeed, several 

States encourage or require physicians Recently, the National Highway and 

to report impaired drivers without spe- Traffic Safety Administration and 

cifically offering this legal protection. the American Association of Motor 

Physicians should join advocacy groups Vehicle Administrators (AAMVA) 

in their States to pass fair laws that pro- completed a study of each State’s 

tect physicians who report in good faith 

and ensure anonymity for reporting. 

State legislatures are encouraged to establish or maintain good-faith reporting 

303. 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. J Am 

Geriatr Soc. 48(1):14–17. 

304. Raleigh, R., & Janke, M. (2001). The role of 

the medical advisory board in DMVs: protecting 

the safety of older adult drivers. Maximizing 

Human Potential: Newsletter of the Network 

on Environments, Services and Technologies for 

Maximizing Independence. American Society on 

Aging 9(2):4–5. 

chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults 189 
MAB practices.305 This project detailed 

the function of each State’s MAB, 

its regulatory guidelines, and barriers 

to the implementation of screening, 

counseling, and referral activities. The 

executive summary of this study had 

many important recommendations for 

States that license medically impaired 

drivers, such as: each State should have 

an active board to set standards and 

guidelines and to be involved in fitnessto-drive evaluations; board members 

should be adequately compensated; 

immunity for physicians for reporting 

should be granted; and national standards and forms, and referrals for mobility counseling and/or DRSs, should be 

considered. 

7. Increased public awareness of 

medication side effects that may 

impair driving performance 

Many prescription and over-the-counter 

medications have the potential to 

impair driving performance. Despite 

warnings on the label and counseling 

by physicians and pharmacists, many 

patients are unaware of these risks. 

To address this problem, the National 

Transportation Safety Board (NTSB) 

has recommended (in its Safety Recommendation I-00-5) 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 the individual’s ability to operate a vehicle. This recommendation was the focus of a FDA/NTSB 

joint public meeting held in November 

2001. This meeting hosted presentations of epidemiological and controlled 

data on the effects of sedating drugs and 

crash risk, as well as presentations from 

innovators of devices that are designed 

to test the degree to which drugs may 

impair driving. 

305. Lococo, KH., & Staplin, L. (2005). Strategies 

for Medical Advisory Boards and Licensing 

Review. DOT HS 809 874. Washington, DC: 

National Highway Traffic Safety Administration. www.nhtsa.dot.gov/people/injury/research/ 

MedicalAdvisory/pages/Executive.html. Accessed 

November 14, 2007. 

As a result of the meeting, the FDA 

and NTSB concluded that steps must 

be taken to better educate the public 

and prescribing physicians on the effects on driving of potentially sedating 

drugs. Only limited steps have been 

taken thus far, but we support efforts to 

increase patient and physician education and clarify labeling for consumers. 

One recent educational effort informs 

pharmacists about potentially drivingimpairing drugs, and offers an extensive curriculum that reviews causes of 

crashes and the mechanisms whereby 

drugs may impair driving.306 Physicians 

are encouraged to review this excellent resource, given the trend toward 

polypharmacy and the myriad problems 

associated with adverse drug events. 

Currently, manufacturers of medications 

do not routinely test their products for 

effects on driving, nor are they required 

to do so. We support the identification and routine use of effective testing 

parameters to identify medications that 

may interfere with the ability to safely 

operate a motor vehicle. Similarly, 

such parameters could be utilized in the 

identification of medications that do 

not impair drivers when typically used 

as directed. 

8. Promote self-awareness and 

appropriate self-regulation. 

Our society relies on self-regulation at 

every level, including driving. Most 

drivers with adequate cognitive function and some modest assistance with 

compensatory behaviors and alternatives will choose to preserve safety. 

Some preliminary data from California indicate that drivers with greater 

impairment were actually safer drivers, 

perhaps because they had perceived the 

need to make adjustments and had successfully done so. More research must be 

done on appropriate self-regulation, and 

productive use must be made of results 

as a part of a comprehensive solution. 

A recent study suggests this may be a 

306. Lococo, K., et al. Pharmacist Curriculum Drugs 

and Driving . https://webapp.walgreens.com/ 

cePharmacy/programsHTML/transportation-tech. 

pdf. Accessed November 12, 2007. 

fruitful area that warrants additional 

investigation.307 

9. Vehicle designs that optimize 

the safety of older drivers and 

their passengers 

Age-related changes in vision, cognition, and motor ability may affect an 

individual’s ability to enter/egress a 

motor vehicle with ease, access critical 

driver information, and handle a motor 

vehicle safely. Older persons are also 

less able to endure and recover from injuries sustained in an automobile crash. 

We encourage vehicle manufacturers to 

explore and implement enhancements 

in vehicle design that address and compensate for these physiological changes. 

In particular, vehicle designs based on 

the anthropometric parameters of older 

persons—that is, their physical dimensions, strength, and range of motion— 

may be optimal for entry/egress; 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 in-vehicle 

displays, may help compensate for agerelated changes in vision.308 In addition, 

prominent analog gauges may be easier 

to see and interpret than small digital 

devices.309 Computers have revolutionized the motor vehicle industry by managing airbag safety systems, anti-lock 

brakes, and global positioning systems. 

In-vehicle assessment tools to assess for 

high-risk conditions may be developed 

in the future. 

In the event of a crash, increasingly 

crashworthy vehicle designs and 

307. Bedard, M. , Porter, M. M., Marshall, S., et 

al. (2008). The combination of two training 

approaches to improve older driver safety Traff 

Inj Prev. 9:70–76. 

308. Schieber, F. (1994). High-priority research and 

development needs for maintaining the safety 

and mobility of older drivers. Exp Aging Res. 

20:35–43. 

309. Koonce, JM., Gold, M. , & Moroze, M. (1986). 

Comparison of novice and experienced pilots 

using analog and digital flight displays. Aviat 

Space Environ Med. 57(12 pt. 1):1181–1184. 

190 chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults 
restraint systems designed for fragile 

occupants may enhance the safety of 

older drivers and passengers. Furthermore, certain add-on features may make 

current vehicle designs safer and more 

accessible for older drivers. For example, 

handholds and supports on door frames 

may facilitate entry/egress for drivers 

and their passengers. Padded steering 

wheels and seat adjuster handles (rather 

than knobs) may benefit drivers with 

decreased hand grip, while adjustable 

steering wheels and foot pedals may aid 

drivers with limited range of motion.310 

Other adjustable controls and displays 

may allow older drivers to tailor their 

vehicle to their changing abilities and 

needs. New safety features with the 

potential to prevent injury in older 

adults include: tire pressure monitoring systems, adaptive cruise control/ 

collision mitigation systems, blind 

spot detection/collision warning, lane 

departure warnings, rollover prevention, 

occupant-sensitive airbags, emergency 

brake assist, rearview cameras, and 

on-demand emergency response systems 

(e.g., OnStar).311 

10. Optimal environments for older 

drivers and pedestrians 

Many older road users are at a 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 significant problem. Other commonly 

identified problems included traffic congestion, crime, and fast traffic.312 

These problems may be ameliorated 

through traffic law enforcement and 

better road and traffic control designs. 

310. Ageing and Transport: Mobility Needs 

and Safety Issues. (2001). Organisation for 

Economic Co-Operation and Development; 

p. 69–71. 

311. Edmunds.Com. Top 10 High-Tech Car Safety 

Technologies; 2007. www.edmunds.com/reviews/ 

list/top10/114984/article.html. Accessed November 15, 2007. 

312. Ritter, AS., Straight, A., & Evans, E. (2002). 

Understanding Senior Transportation: Report 

and Analysis of a Survey of Consumers Age 

50+. American Association for Retired Persons. 

One of the top requests of the nearly Existing forms of transportation clearly 

200 Iowans (older drivers, transporta­ need to be optimized for use by older 

tion professionals, and senior-related persons. In a telephone survey of 2,422 

professionals) attending the Iowa people 50 and older, ride-sharing was 

Older Drivers Forum was the enhanced the second most common mode of 

enforcement of speed and aggressive transportation (after driving); however, 

driving laws.313 In terms of road and nearly a quarter of the survey particitraffic engineering, the Federal High- pants cited feelings of dependency and 

way Administration (FHWA) has concerns about imposing as a barrier to 

recognized and addressed the needs of use. Public transportation was the usual 

older road users in its Highway De­ mode of transportation for fewer than 

sign Handbook for Older Drivers and 5 percent of survey participants, with 

Pedestrians, a supplement to existing many citing unavailable destinations, 

standards and guidelines in the areas problems with accessibility, and fear of 

of highway geometry, operations, and crime as barriers to use. Fewer than 5 

traffic control devices.314 These design percent used taxis as their usual mode of 

features may be implemented in new transportation due to their high cost.317 

construction, renovation and mainte- Until these barriers are addressed, these 

nance of existing structures, and “spot” forms of transportation will remain 

treatment at certain locations where inaccessible to many older persons. 

safety problems exist or are anticipated.315 Recent positive news is a trend or Transportation programs created specifireduction in highway deaths for the first cally for the older population, such as 

time since 1992, which in part has been senior shuttles and vans, exist in certain 

attributed to installation of median communities. Certain States have 

guard cable on busy highways, building adopted the independent transportation 

better roads, and the addition of rumble network (ITN) model developed by Dr. 

strips to the shoulders of roads.316 The Katherine Freund initially in Maine.318 

FHWA handbook will soon be updated These programs address the Five A’s of 

to incorporate the latest research on the Senior-Friendly Transportation; namely, 

effectiveness of design and engineering availability, accessibility, acceptabilenhancement to accommodate older ity, affordability, and adaptability (see 

road users. Figure).319 As the older population 

continues to grow, we encourage the 

creation of new programs or the expan11. Better alternatives to driving sion of existing ones to keep pace with 

For the older population, alternatives to passengers’ needs. We also encourage 

driving are often less than ideal or non- stronger community outreach to inexistent. When faced with the choice crease awareness of such programs. 

of driving unsafely or losing mobility, 

many risk their safety by continuing 

to drive. 

313. Iowa Safety Management System: Safe Mobility 

Decisions for Older Drivers Forum. June 19-20, 

2002. 

314. Staplin, L., Lococo, K., Byington, S., Harkey, D. 

(2001, October). Highway Design Handbook 

for Older Drivers and Pedestrians. FHWA­ 317. Ritter, AS., Straight, A., & Evans, E. (2002). 

RD-01-103. Washington, DC: Federal Highway Understanding Senior Transportation: Report 

Administration. and Analysis of a Survey of Consumers Age 

315. Ageing and Transport: Mobility Needs and 

Safety Issues. (2001). Organisation for Economic Co-Operation and Development; p. 60. 

50+. American Association for Retired Persons; 

Policy and Strategy Group, Public Policy 

Institute. 

316. Tom Warne Report. (2007). Missouri Highway 

Deaths Decline. http://tomwarnereport.com/twr/ 

318. ITN America. (2007). www.itnamerica.org. 

Accessed November 12, 2007. 

twr_v4n28.html. Accessed November 15, 2007. 319. Supplemental Transportation Programs for Seniors. (2001, June). By the Beverly Foundation, 

prepared for AAA Foundation for Traffic Safety. 

chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults 191 
Figure 10.1 

The Five A’s of Senior-Friendly 

Transportation 

(Reproduced from Supplemental 

Transportation Programs for Seniors, 

The Beverly Foundation) 

Availability: Transportation exists and 

is available when needed (e.g., 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) 

12. Education and training tools 

Additional resources 

The following resources contain additional information on meeting the 

mobility needs of the older population: 

Ritter, A. S., Straight, A., and Evans, 

E. Understanding Senior Transportation: Report and Analysis of a Survey of 

Consumers Age 50+. AARP, Policy and 

Strategy Group, Public Policy Institute, 

2002. This paper was created to explore 

the problems of people 50 and older, in 

particular, those 75and older with relation to transportation. May be used in 

the development of policies that expand 

and improve transportation options for 

older persons. 

Staplin, L., Lococo, K., Byington, S., 

and Harkey, D. Highway Design Handbook for Older Drivers and Pedestrians. 

FHWA-RD-01-103, October 2001. This 

applications-oriented handbook provides detailed design recommendations 

for five types of sites: (1) intersections 

(at grade); (2) interchanges (grade separation); (3) roadway curvature and passing zones; (4) construction/work zones; 

and (5) highway-rail grade crossings. 

This handbook is primarily intended 

for highway designers, traffic engineers, 

and highway safety specialists involved 

in the design and operation of highway 

facilities. It may also be of interest to researchers concerned with issues of older 

road user safety and mobility. 

Ageing and Transport: Mobility Needs 

and Safety Issues. Organisation for 

Economic Co-Operation and Development (OECD), 2001. The OECD, an 

international organization dedicated to 

addressing the economic, social, and 

governance challenges of a globalized 

economy, produced this investigation 

of the travel patterns, transport and 

safety needs, and mobility implications 

of tomorrow’s elderly. It is intended to 

inform strategists, policy-makers, regulators, and the general public of the aging 

population’s safety and mobility needs; 

dispel myths and misconceptions about 

older road users; and present the latest 

research findings to assist decisionmakers in formulating sound policies 

and programs for the safe mobility of 

the aging population. 

Supplemental Transportation Programs 

for Seniors. By the Beverly Foundation, prepared for AAA Foundation for 

Traffic Safety, June 2001. This report 

contains the findings of the Supplemental Transportation Program for Seniors 

project, which was initiated in 2000 by 

the AAA Foundation for Traffic Safety, 

a philanthropic foundation in Washington, DC, and the Beverly Foundation, a private foundation in Pasadena, 

California. This project was designed as 

a nine-month effort to gather information about community-based transportation programs for seniors in the United 

States. In describing and evaluating 

these programs in order to provide their 

findings to interested organizations, the 

project staff recognized the importance 

of five criteria for senior-friendly transportation, which are listed. 

Lococo , K., Tyree, R. Medication-Related Impaired Driving. By NHTSA and 

co-sponsored by Walgreens, 2007. 

By NHTSA and co-sponsored by 

Walgreens, this excellent review of 

potential driving-impairing drugs 

provides credits or CEUs for pharmacy 

technicians. However, this curriculum 

is useful reading for any clinician who 

prescribes drugs to older adults. The 

manual covers causes of motor vehicle 

crashes, reviews functional abilities that 

are key for operating a motor vehicle, 

and lists reasons why medications may 

impair driving. There is a discussion 

of the term “potentially impairing 

medications” and an updated review of 

the literature that identifies high risk 

drugs. Ethical and legal issues in drug 

prescribing are addressed. Although the 

curriculum was created for pharmacists, 

much of the information is helpful to 

physicians. 

Lococo, K., Staplin, L. Strategies for 

Medical Advisory Boards and Licensing 

Review. DOT HS 809 874 , July 2005. 

This NHTSA-funded project, written 

by Lococo and Staplin, reviews the current operations and practices of MABs. 

A summary of what each State is currently doing in this area is provided. 

192 chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults 
An executive summary is especially 

useful in outlining the direction States 

and MABs should pursue in order to 

enhance their usefulness and viability, 

and have an impact on public safety. 

Maintaining Safe Mobility in an Aging 

Society. The overarching objective 

of this book is to provide a concise, 

comprehensive, and up-to-date resource 

on aging and transportation. Specifically, it has the following goals: Enable 

readers to understand the issues related 

to aging and mobility and to respond 

to the often heard comment “Just take 

their driver license away”; describe the 

skills related to safe driving and how 

they can be affected by aging; critically 

examine the current evidence on how 

medical conditions and medications 

affect driving skills; provide a comprehensive description of screening and 

assessment practices, issues, and tools; 

provide information to help older adults 

transition from full driving to driving 

cessation; and explore various means by 

which an aging individual can maintain 

safe mobility. (Eby, D.W., Molnar, L.J., 

& Kartje, P.S.. Maintaining Safe Mobility in an Aging Society. New York, NY: 

CRC Press. ISBN: 9781420064537. 

In press.) 

chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults 193 

appendix a 

CPT® Codes 

 

 

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®). 4th ed., Professional ed. Chicago, IL: 

American Medical Association; 2009. 

When selecting the appropriate CPT® codes for driver 

assessment and counseling, first determine the primary reason 

for your patient’s office visit, as you would normally. The 

services described in this Guide will most often fall under 

Evaluation and Management (E/M) services. Next, select 

the appropriate E/M category/subcategory. If you choose to 

apply codes from the Preventive Medicine Services category, 

consult Table 1 for the appropriate codes. If any additional 

services are provided over and above the E/M services, codes 

from Table 2 may be additionally reported. 

Table 1: Evaluation and Management—Preventive Medicine Services 

If the primary reason for your patient’s visit falls under the E/M category of Preventive Medicine Services, 

choose one of the following codes: 

99386 40-64 years 

99387 65 years and older 

new patient, initial comprehensive preventive Medicine 

Evaluation and management of an individual including an age and gender 

appropriate history, examination, counseling/anticipatory guidance/risk factor 

reduction interventions, and the ordering of appropriate immunizations(s), 

laboratory/diagnostic procedures. 

These codes can be used for a complete Preventive Medicine history and physical exam for 

a new patient (or one who has not been seen in three or more years), which may include 

assessment and counseling on driver safety. If significant driver assessment and counseling 

take place during the office visit, Modifier-25 may be added to the codes above. 

99396 40-64 years 

99397 65 years and older 

established patient, periodic comprehensive preventive Medicine 

Reevaluation and management of an individual including an age and gender 

appropriate history, examination, counseling/anticipatory guidance/risk factor 

reduction interventions, and the ordering of appropriate immunization(s), 

laboratory/diagnostic procedures. 

Codes from the Preventative Medicine Services 99386-99387 and 99396-99397 can only be 

reported once per year. If driver assessment and counseling take place during the office visit, 

Modifier-25 may be added to the codes above. 

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. 

99401 Approximately 15 minutes 

99402 Approximately 30 minutes 

99403 Approximately 45 minutes 

99404 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 upon the amount of time spent counseling 

the patient. Driver safety or driving retirement counseling fall under the category of injury 

prevention. Please note that for driving retirement counseling, a copy of the follow-up letter 

to your patient can be included in the patient’s chart as additional documentation. A sample 

letter can be found in Chapter 6. 

appendix a—CPT® Codes 197 
 

99420 

95831 

99172 

99173 

99406 

99407 

99408 

99409 

Table 2: Additional codes 

The codes below can be used for administration of ADReS (see Chapter 3). If you complete the entire assessment, you can 

include codes 99420, 95831 and either 99172 or 99173. The ADReS Score Sheet can serve as the report. 

administration and interpretation of health risk assessment instrument 

Muscle and range of Motion testing 

Muscle testing, manual (separate procedure)with report; extremity 

(excluding hand)or trunk. 

Visual Function screening 

Automated or semi-automated bilateral quantitative determination of visual 

acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of 

vision (may include all or some screening of the determination(s) for contrast 

sensitivity, vision under glare). 

screening test of Visual acuity, quantitative, bilateral 

The screening used must employ graduated visual acuity stimuli that allow a 

quantitative estimate of visual acuity (e.g., Snellen chart). 

New CPT® codes for the Revised Physician’s Guide: 

Smoking and tobacco use cessation counseling visit; intermediate, greater than 

3 minutes up to 10 minutes 

Smoking and tobacco use cessation counseling visit; intensive, greater than 

10 minutes 

Alcohol and/or substance (other than tobacco) abuse structured screening 

(eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes 

Alcohol and/or substance (other than tobacco) abuse structured screening 

(eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes 

appendix a—CPT® 198 Codes 
appendix B 

Patient and Caregiver 


Educational Materials
 

appendix B 

Patient and Caregiver 


Educational Materials
 

These handouts were designed to be user-friendly and simple to read. All patient education materials were written at or below 

a 6th grade reading level, and all family and caregiver material was written at a 7th grade reading level. 

We encourage physicians to make copies of these handouts for their patients, have them available in the office setting, educate 

office staff to distribute them when appropriate, and use them as talking points when discussing driving issues with patients. 

appendix B—Patient and Caregiver Educational Materials 201 

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. 

If you have checked any  I have difficulty backing up. of the boxes, your safety 

 I have had accidents that were my fault in the past year. may be at risk when you 

 I am too cautious when driving. drive. 

 I sometimes forget to use my mirrors or signals. Talk to your doctor about 

 I sometimes forget to check for oncoming traffic. ways to improve your 

 I have more trouble parking lately. safety when you drive. 

appendix B—Patient and Caregiver Educational Materials 203 

Appendix B—Patient and Caregiver Educational Materials 205

Successful Aging Tips

Tip #1: Take care of your health.

Visit your doctor regularly.

Ask about tests and immunizations that are right 

for your age group.

Consider testing for cancer that is right for your 

age group.

Treat any risk factors for atherosclerosis or 

“hardening of the arteries.”

Eat a healthy diet. Your diet should be low in fat 

and high in fiber.

• Eat plenty of vegetables, fruits, beans and whole 

grains. 

• Eat low fat proteins in the form of lean red meat, 

poultry and fish. 

• Get enough calcium by drinking low fat milk 

and eating low fat yogurt and cheese.

• Eat a variety of foods to get enough vitamins 

and minerals in your diet.

• Drink lots of water.

Exercise to stay fit. Be active every day at your 

own level of comfort. 

• Walk, dance, or swim to improve your 

endurance. 

• Work out with weights to increase your strength.

• Stretch to maintain your flexibility or consider 

joining group classes that will help you stay fit 

(e.g., yoga, tai chi). 

Don’t drink too much alcohol. It is recommended 

that people over the age of 65, not have more than 

one drink per day. (A drink is one glass of wine, 

one bottle of beer, or one shot of hard liquor.) 

Never drink alcohol with your medicines!

Don’t use tobacco in any form. This means 

cigarettes, cigars, pipes, chew or snuff. If you 

need help quitting, talk to your doctor.

Tip #2: Keep yourself safe.

Make your home a safe place.

• Keep your home, walkways and stairways well 

lit and uncluttered. 

• Keep working smoke detectors and a fire 

extinguisher in your home.

• Adjust the thermostat on your hot water tank 

so that you don’t burn yourself.

• Remove firearms from the house.

Prevent falls.

• Make sure all throw rugs have non-slip backs 

so they don’t throw you!

• Slip-proof your bathtub with a rubber mat.

• Consider grab bars and a shower chair for 

the bathtub.

• Consider a raised toilet seat.

• Consider an occupational therapy home 

safety evaluation.

Stay safe in the car.

• Wear your seat belt—and wear it correctly! 

(It should go over your shoulder and across 

your lap.) 

• Never drink and drive!

• Don’t drive when you are angry, upset, 

sleepy or ill. 

• If you have concerns about your driving safety, 

talk to your doctor.

• Do not use a cell phone while driving.

• Do not do other activities such as eating, 

reading, and shaving when driving.

(over)
206 Appendix B—Patient and Caregiver Educational Materials

Tip #3: Take care of your 

emotional health.

Keep in touch with family and friends. 

It’s important to maintain your social life!

Exercise your mind. Keep your mind active 

by reading books, doing crossword puzzles, 

and learning about computers.

Stay active by joining groups and keeping your 

mind alert. 

• Consider doing crosswords, puzzles, computer 

games, card games, etc.

• Join a club, organization, or religious group and 

participate in volunteer activities. 

• Consider volunteering to drive an older adult 

who no longer has a license!

Keep a positive attitude! 

Remember to smile and laugh. 

• Focus on the good things in your life, and don’t 

dwell on the bad.

• Stay active with the activities that make you 

happy.

• If you’ve been feeling sad lately or no longer 

enjoy the things you used to, ask your doctor 

for assistance.

Tip #4: Plan for your future.

Keep track of your money. Even if someone else 

is helping you manage your bank accounts and 

investments, stay informed. 

Know your own health. This is important for 

receiving good medical care.

• Know what medical conditions you have.

• Know the names of your medicines and how 

often you take them.

• If you are having trouble remembering taking 

your medication, use a pillbox, calendar, or 

family member to help you stay on track.

• Make a list of your medical conditions, medicines, drug allergies (if any), and the names 

of your doctors. Keep this list in your wallet.

Make your health care wishes known to your 

family and doctors.

• Consider filling out an advance directives form. 

This form lets you state your health care choices 

or name someone to make these choices for you 

in case you are unable to do so.

• Give your family and doctors a copy of the 

advanced directives form. This way, they have 

a written record of your choices in case you are 

unable to tell them at the time.

• If you need help with your advance directives, 

talk to your doctor or your lawyer.

Create a transportation plan. If you don’t drive, 

know how to get around.

• Ask family and friends if they would be willing 

to give you a ride.

• Find out about buses, trains, and shuttles in your 

area.

• If you need help finding a ride, contact your 

local Area Agency on Aging.
Appendix B—Patient and Caregiver Educational Materials 207

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. 

• 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.

(over)
208 Appendix B—Patient and Caregiver Educational Materials

Tip #2: Take care of your car.

• Make sure you have enough gas in your car. 

• Make sure your tires have the right amount of 

air and check them each month for any wear 

or damage.

• Get your car tuned up regularly.

• Keep your windshields and mirrors clean.

• Keep a cloth in your car for cleaning windows.

• Replace your windshield wiper blades when they 

get worn out. 

• Consider using Rain-X or a similar product to 

keep your windows clear. 

• If you are shopping for a new car, look for a car 

with power steering and automatic transmission. 

• If you own a computer you can check to see 

how well a car will do if it is involved in a crash. 

This information is on the following Web site 

of the National Highway 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.”

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:

AAA Foundation for Traffic Safety

Safe Driving for Mature Operators (course)

www.seniordrivers.org/driving/driving.cfm?button=

publication&selection=MO

AARP Driving Safety Program

The classic course with information on how to 

locate an educational venue in your community.

www.aarp.org/families/driver_safety/

wrapper_driver.py

Driving School Association of the 

Americas, Inc.

1-800-270-3722

These classes usually last several hours. These 

classes do not cost much money—some are even 

free. As an added bonus, you might receive a 

discount on your car insurance after taking one 

of these classes. Talk to your insurance agent and 

company to determine if they offer a discount.
Appendix B—Patient and Caregiver Educational Materials 209

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

• 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.

(over)
210 Appendix B—Patient and Caregiver Educational Materials

• If the person you are concerned about does not 

want to talk about driving at that time, bring 

it up again later. Your continued concern and 

support may help your loved one feel more 

comfortable with this topic. 

• Be a good listener. Take your loved one’s 

concerns seriously.

• Consider using a handout like the Hartford’s 

“We Need to Talk” which can be accessed at the 

following website; www.thehartford.com/

talkwitholderdrivers/brochure/brochure.htm or 

writing the Hartford and requesting brochures at;

The Hartford

We Need to Talk

200 Executive Boulevard

Southington, CT 06489

Help make plans for transportation. When your 

loved one is ready to talk about his/her driving 

safety, you can work together to create plans for 

future safety.

• Make a formal agreement about driving. In this 

agreement, your loved one chooses a person to 

tell him/her when it is no longer safe to drive. 

This individual then agrees to help your loved 

one make the transition to driving retirement. 

(You can 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*):

The Association for Driver Rehabilitation 

Specialists (ADED*)

Information on the Association.

www.aded.net/i4a/pages/index.cfm?pageid=1

Also provides a locating tool for finding a 

DRS near you.

www.aded.net/custom/directory/

?pageid=209&showTitle=1 

If a DRS is not available in your area, contact a 

local driving school or your State’s Department of 

Motor Vehicles to see if they can do a driving test.

* The acronym ADED was retained when the association 

changed its name from the Association of Driver Educators 

for the Disabled to its current name.
Appendix B—Patient and Caregiver Educational Materials 211

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 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-todoor shuttle service for older passengers.

• The names and phone numbers of volunteer 

drivers. Call your community center, church, or 

synagogue to see if they have a volunteer driver 

program.

• If you need help 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.

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 or synagogue 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. 

If you can’t go out to get something, 

have it come to you. 

Many stores can deliver their products straight to 

your door. 

•	 have your groceries delivered. Many stores 

deliver for free or for a low fee. You can even call 

your family and friends, or volunteers from your 

local community center, church or synagogue to 

see if someone can pick up your groceries 

•	 order your medicines by mail. Not only is this 

more convenient—it’s often less expensive, too. 

Order only from pharmacies that you know and 

trust. Some pharmacists will also deliver 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-onWheels, 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 on-line, with the most recent selections 

available from Internet Web sites. 

(over) 

appendix B—Patient and Caregiver Educational Materials 213 
Who can tell me more about services 

in my area? 

The following agencies can provide you with 

information to get you started: 

area agency on aging (aaa) eldercare Locator 

www.eldercare.gov 

800-677-1116 weekdays 

Call this toll-free number and ask for the phone 

number of your local Area Agency on Aging 

(AAA). Your local AAA can tell you more 

about ride options, Meals-on-Wheels, and senior 

recreation centers in your area. 

administration on aging resource directory 

for older people 

www.aoa.gov/eldfam/How_to_Find/ 

ResourceDirectory/ ResourceDirectory.pdf 

800-222-2225 

Call this toll-free number and ask the National 

Institute on Aging to send you their Resource 

Directory for Older People. This 120-page 

directory lists organizations that provide 

services for older people. 

214 appendix B—Patient and Caregiver Educational Materials 
Where Can I Find More 


Information?
 

We’ve listed additional resources on the 

following pages to help you assess and 

enhance driving safety for the retired 

driver. Some resources can help you 

create a transportation plan for your 

loved one. 

national association of private 

geriatric care Managers (napgcM) 

520-881-8008 

www.caremanager.org 

A geriatric care manager can help 

older people and their families arrange 

long-term care, including transportation 

services. Call the phone number or visit 

the Web site above to 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. 

Additional clinician, patient, 

and caregiver resources 

Clinician resources 

american occupational therapy 

association (aota) 

Information on occupational therapists 

and their role in driving assessment and 

rehabilitation. 

www1.aota.org/olderdriver/ 

the association for driver 

rehabilitation specialists (aded*) 

Information on the Association. 

www.aded.net/i4a/pages/ 

index.cfm?pageid=1 

Also provides a locating tool for finding 

a DRS near you. 

www.aded.net/custom/directory/ 

?pageid=209&showTitle=1 

national highway traffic safety 

administration 

Many links to resources for 

older drivers. 

www.nhtsa.dot.gov 

and 

Adapting Motor Vehicles for People 

with Disabilities 

www.nhtsa.dot.gov/cars/rules/ 

adaptive/brochure/brochure.html 

american Medical association (aMa) 

Physician’s Guide to Assessing and 

Counseling Older Drivers 

www.ama-assn.org/ama/pub/ 

category/10791.html 

General older driver information 

provided by the AMA. 

www.ama-assn.org/ama/pub/ 

category/8925.html 

candrive 

Dementia and Driving Toolkit: 

The Dementia Network of Ottawa 

www.candrive.ca/En/ 

Physician_Resources/toolkit.asp 

canadian Medical association (cMa) 

Determining Medical Fitness to Operate a Motor Vehicle 

CMA Driver’s Guide, 7th edition 

www.cma.ca/index.cfm/ci_id/18223/ 

la_id/1.htm 

*	 The acronym ‘ADED’ was retained when the 

association changed its name from the Association of Driver Educators for the Disabled to its 

current name. 

administration on aging (aoa) 

Information and resources for older 

drivers. 

www.aoa.gov 

Summary of Internet resources 

for the older driver. 

www.aoa.gov/prof/notes/Docs/ 

Older_Drivers.doc 

insurance institute for 

highway safety (iihs) 

A frequently-updated site on older 

driver laws for driver licensing. 

www.iihs.org/laws/olderdrivers.aspx 

older drivers: Fact sheets 

General information on the older driver 

from the Centers for Disease Control 

and Prevention, AARP and the National Highway Traffic Safety Administration. 

www.cdc.gov/ncipc/factsheets/older. 

htm 

www.aarp.org/families/driver_safety/ 

www-nrd.nhtsa.dot.gov/Pubs/ 

809475.PDF 

aaa Foundation for traffic safety 

Older driver brochures.
 

Safe Driving For Mature Operators 


(course).
 

www.seniordrivers.org/driving/ 

driving.cfm?button=publication& 

selection=MO 

Caregiver and patient resources 

granddriver program 

Resources and information on other 

older driver sites. 

www.granddriver.info/ 

american society on aging 

Information on DriveWell, an older 

driver educational program that may be 

offered in your community. 

www.asaging.org/asav2/drivewell/ 

index.cfm 

appendix B—Patient and Caregiver Educational Materials 215 
Road map to driving wellness. 

Information on staying fit. 

www.asaging.org/CDC/module4/ 

home.cfm 

Caregiver and patient resources 

(continued) 

aaa Foundation for traffic safety 

Older driver brochures and the 

Safe Driving For Mature 

Operators course. 

www.seniordrivers.org/driving/ 

driving.cfm?button=publication& 

selection=MO 

carFit and general information 

www.seniordrivers.org/home/ 

toppage.cfm 

roadWise review 

www.roadwisereview.com/ 

university of Massachusetts Boston 

center for gerontology 

Keep moving longer: features for safe 

driving. A video program that offers 

advice on staying mobile. 

www.geront.umb.edu/inst/projects/ 

promoting.jsp 

national highway traffic safety 

administration 

Older Road Users; other older driver 

information and materials. 

www.nhtsa.dot.gov/people/injury/ 

olddrive 

Driving Safely while Aging Gracefully 

Reviews the skills and problems that 

may face older drivers. 

www.nhtsa.dot.gov/people/injury/ 

olddrive/Driving Safely Aging Web/ 

index.html 

the hartford 

We Need to Talk 

At the Crossroads: A Guide to 

Alzheimer’s Disease, Dementia, 

and Driving 

State-of-the-art educational materials 

for older drivers. 

www.thehartford.com/ 

talkwitholderdrivers 

www.thehartford.com/alzheimers/ 

brochure.html 

new york department for the aging 

When You Are Concerned—
 

A Handbook for Families, Friends, 


and Caregivers 


A handbook for those worried about the 

safety of an aging driver. 

http://aging.state.ny.us/caring/ 

concerned 

aarp driving safety program 

The classic course with information on 

how to locate an educational venue in 

your community. 

www.aarp.org/families/driver_safety/ 

wrapper_driver.py 

australia 

Handbooks on older adults from the 

provinces of Victoria and Tasmania in 

Australia and the Australian Capital 

Territory. 

www.transport.tas.gov.au/licence_information_folder/the_tasmanian_older_drivers_handbook?SQ_DESIGN_ 

NAME=printer_friendly 

www.vicroads.vic.gov.au/NR/ 

rdonlyres/B15A81F1-2047-45B0­

821C-7AB3317029B6/0/victorianolderdrivershandbook5.pdf. 

www.act.gov.au/living/roads/older/contents.html 

www.cota-act.org.au/Download_Documents/PDFS/Older_Drivers_Hbook_ 

web_0703.pdf 

drivers.com 

General information on older drivers. 

www.drivers.com/ 

Top_Older_Drivers.html 

Mobilise 

Disabled Drivers Information Website 

(United Kingdom) 

www.mobilise.info/Information.asp 

american occupational therapy 

association (aota) 

Information on occupational therapists 

and their role in driving assessment and 

rehabilitation. 

www1.aota.org/olderdriver/ 

the association for driver 

rehabilitation specialists (aded) 

Information on the Association. 

www.aded.net 

Also provides a locating tool for finding 

a DRS in your community. 

www.aded.net/custom/directory/?pagei 

d=209&showTitle=1 

university of Michigan transportation 

institute 

Driving Decisions Workbook 

A self-awareness guide to identify areas 

of concern for older driver safety. 

http://deepblue.lib.umich.edu/ 

handle/2027.42/1321 

Alternative Transportation Options 

american administration on aging 

(aoa) 

Eldercare locator 

Assists in 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 

www.easterseals.com/site/ 

PageServer?pagename=ntl_trans_care 

national center for senior 

transportation 

www.seniortransportation.net/ 

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 

216 
Alternative Transportation Options 

(continued) 

national association of social 

Workers (nasW) 

Locate a social worker near you. 

www.socialworkers.org/register/ 

default.asp 

united We ride 

Coordination of transportation services. 

www.unitedweride.gov 

Research and Statistics 

Federal highway administration 

Information on older drivers 

http://safety.fhwa.dot.gov/older_driver/ 

older_quiz.htm 

Guidelines and recommendations to accommodate older drivers and pedestrians. 

Information on environmental design. 

www.tfhrc.gov/humanfac/01105/ 

cover.htm 

Putting it all together. 

older road users 

General information on older drivers. 

www.nhtsa.dot.gov/people/injury/olddrive/ 

research agenda for older drivers 

www.nhtsa.dot.gov/people/injury/ 

olddrive/pub/Chapter3.html 

safe Mobility for older people: Model 

driver screening and evaluation 

program 

www.nhtsa.dot.gov/people/injury/ 

olddrive/safe/ 

Further analysis of drivers Licensed 

with Medical conditions in utah 

www.nhtsa.dot.gov/people/injury/ 

olddrive/utah/utah_index.htm 

the road information program 

(trip) 

A research community on transportation. 

www.tripnet.org 

www.tripnet.org/ 

olderdriversstudyoct2000.pdF 

older driver involvements in police 

reported crashes and Fatal crashes: 

trends and projections 

Duke University Science News 

http://unisci.com/stories/ 

20022/0624023.htm 

transportation safety 

Center for Injury Prevention Policy and 

Practice 

San Diego State University 

www.injuryprevention.org/links/ 

links-trans.htm 

aaa Foundation for traffic safety 

Research on older driver safety 

www.seniordrivers.org 

Fill out the table below with names and numbers of services in your area. Keep this information at your fingertips by placing it 

next to your phone or posting it on your refrigerator. 

Service Phone number Cost 

appendix B—Patient and Caregiver Educational Materials 217 

appendix c 

Continuing Medical 

Education Questionnaire 

and Evaluation 

221

CME Questionnaire: 

Instructions: The Physician’s Guide for Assessing and Counseling 

Older Drivers contains the correct answers to the following 

questions. Circle your answer to each question. 

1. Compared to drivers age 25 to 69, 

older drivers experience—

a. A higher fatality rate in motor vehicle crashes

b. A higher fatality rate per vehicle mile driven

c. A higher crash rate per vehicle mile driven

d. All of the above

2. The majority of older Americans do not rely on 

driving as their primary form of transportation.

a. True

b. False

3. Compared to younger drivers, older drivers are more 

likely to wear seatbelts and are less likely to drive at 

night, speed, tailgate, and consume alcohol prior to 

driving.

a. True

b. False

4. Medications that have the potential to impair driving 

ability include—

a. Anticonvulsants

b. Antidepressants

c. Muscle Relaxants

d. a and b only

e. All of the above

5. Aspects of vision that are most important for safe 

driving include—

a. Visual acuity

b. Visual fields

c. Contrast sensitivity

d. b and c only

e. All of the above

6. Match the cognitive skill to the appropriate 

driving situation:

7. Research has demonstrated that drivers with 20/70 visual acuity have a significantly greater crash risk than 

drivers with 20/40 visual acuity.

a. True

b. False

8. All of the following are important for viewing the driving environment EXCEPT—

a. Visual acuity

b. Visual fields

c. Memory

d. Neck rotation

9. A Driver Rehabilitation Specialist (DRS) can—

a. Revoke a client’s drivers license for poor performance on a clinical exam

b. Evaluate a client’s driving skills through an on-road 

assessment

c. Assess the client’s vehicle and recommend adaptive 

equipment to enhance the client’s comfort and driving safety

d. b and c only

e. All of the above

Appendix C

Physicians Guide to 

Assessing and Counseling 

Older Drivers

1. Applying the brake at a green 

light because a child runs into 

the path of your vehicle.

2. Listening to the traffic report 

on the radio while keeping an 

eye on the road.

3. Recalling that a particular 

street is a one-way street.

4. Determining the distance 

from your car to the stop sign.

___ Memory

___ Visuospatial skills

___ Divided attention

___ Executive skills

Appendix C—Physicians Guide to Assessing and Counseling Older Drivers
222 Appendix C—Physicians Guide to Assessing and Counseling Older Drivers

10. Driving cessation has been associated with an increase 

in depressive symptoms in the elderly.

a. True

b. False

11. Which of the following is NOT recommended as 

an initial technique to help your patients retire 

from driving?

a. With the patient’s permission, involve family 

members and caregivers.

b. Explain to the patient why you have recommended 

that they retire from driving.

c. Provide your patient with information on 

alternatives to driving.

d. Tell the patient’s relatives to hide the car keys.

12. ‘Physicians are required to report patients with 

dementia to their State Department of Motor Vehicles’ 

is an example of—

a. Mandatory Medical Reporting Laws

b. Physician Reporting Laws

c. Physician Liability

d. None of the above

13. Physician-patient privilege can be used to prevent 

physicians from abiding by their State’s Physician 

Reporting Laws.

a. True

b. False

14. All States protect the identity of the individual who 

reports an unsafe driver to the DMV.

a. True

b. False

15. Key functions that are important for safe driving 

include—

a. Vision

b. Cognition

c. Motor function

d. a and b only

e. All of the above

16. What conditions are in part responsible for the increase 

vulnerability to injury in a motor vehicle crash?

a. osteoporosis 

b. atherosclerosis of 

c. left-hand turn crashes

d. cars with no air bags

e. All of the above

17. What eye disease when treated has been shown to 

lower crash risk in older adults?

a. glaucoma

b cataract

c. macular degeneration

d. diabetic retinopathy

e. All of the above

18. What neurological illness in late life carries the highest 

crash risk for those that continue to drive?

a. Alzheimer’s Disease

b. Seizure disorder

c. Stroke

d. Brain Injury

19. Which of the following medications has been shown to 

be associated with impaired driving?

a. Valium

b. Anti-depressants

c. Narcotics

d. Benadryl

e. All of the above.

20. Which of the following conditions carries the highest 

crash risk?

a. a driver with a spinal cord affecting his arms and legs 

that uses a joystick to drive

b. a stroke patient that has to use hand controls on the 

steering wheel to drive

c. an amputee that uses hand controls on the steering 

wheel to drive

d. an older adult with restricted neck range of motion

21. What are the most common road conditions when 

older adults have crashes?

a. wet pavement, morning rush hour, and going 

up a hill

b. dry pavement, mid-morning, on a flat roadway

c. snowy weather, at night, going around a curve

d. icy conditions, at night, trying to pass another 

vehicle

22. What vehicle modifications have been shown to reduce 

crashes or injuries?

a. infrared brakes

b. side air bags

c. enlarged side view mirrors 

d. On-STAR

e. All of the Above
 

 

23. What is true about laws for reporting unsafe drivers? 

a. Physicians prefer to have civil immunity for protection and anonymity when reporting 

b. States with mandatory reporting laws appear to have 

higher number of reports 

c. Physicians have been sued for not reporting unsafe 

drivers and they have been sued for reporting. 

d. Almost all States require a physician evaluation for 

medical fitness-to-drive if a driver is reported to the 

State authorities as being unsafe 

e. All of the above 

24. What types of crash scenarios are common for 

older adults? 

a. high speed crashes 

b. low speed and/or left hand turn crashes 

c. head-on collisions 

d. failure to yield 

e. Answer B, D 

25. What common medical condition is often undiagnosed and likely carries the highest crash rate if 

left untreated? 

a. Sleep apnea 

b. Alzheimer’s Disease 

c. Diabetes Mellitus 

d. Parkinson’s Disease 

Please print and include all information requested. 

Name and title _________________________________________________________________________________________ 

Address _______________________________________________________________________________________________ 

City _______________________________________________________ State _____ Zip _____________________________ 

Phone ( ) ________________________________Fax ( )________________________________________ 

E-mail ________________________________________________________________________________________________ 

Medical specialty _______________________________________________________________________________________ 

Please mail the completed form to: 

Lela Manning, MPH, MBA 

Project Coordinator, Older drivers Project 

American Medical Association 

515 N. State Street 

Chicago, IL 60654 

(312) 464-4111 (Fax) 

appendix c—Physicians Guide to Assessing and Counseling Older Drivers 223 
224

Please complete this evaluation by circling your response or writing your 

comments in the spaces provided. 

Overall Impression

1. I feel I can define the safety risks of older drivers as a public health issue. 

Strongly agree Agree Undecided Disagree Strongly disagree

2. This guide is a useful and effective physician education tool.

Strongly agree Agree Undecided Disagree Strongly disagree

3. This guide has raised my awareness of driving as a public safety issue.

Strongly agree Agree Undecided Disagree Strongly disagree

4. I have a better understanding of the medical conditions and medications that may impair my patient’s ability to 

drive safely.

Strongly agree Agree Undecided Disagree Strongly disagree

5. I feel comfortable identifying patients who may be at risk for unsafe driving.

Strongly agree Agree Undecided Disagree Strongly disagree

6. I feel comfortable using the various clinical screens to assess patients’ level of function for driving fitness.

Strongly agree Agree Undecided Disagree Strongly disagree

7. I feel comfortable using counseling techniques for patients who are no longer fit to drive.

Strongly agree Agree Undecided Disagree Strongly disagree

8. I have a better understanding of driver rehabilitation options and alternatives to driving. 

Strongly agree Agree Undecided Disagree Strongly disagree

9. I feel comfortable utilizing referral and treatment options for patients who are no longer fit to drive.

Strongly agree Agree Undecided Disagree Strongly disagree

10. I have a better understanding of my State’s reporting laws and legal/ethical issues surrounding patients who may not 

be safe on the road.

Strongly agree Agree Undecided Disagree Strongly disagree

As a result of participating in this educational activity:

❏ I will change my practice How? ____________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Continuing Medical Education 

Evaluation Form

Appendix C—Physicians Guide to Assessing and Counseling Older Drivers
______________________________________________________________________________________________________ 

______________________________________________________________________________________________________ 

______________________________________________________________________________________________________ 

 

______________________________________________________________________________________________________ 

______________________________________________________________________________________________________ 

 

 

 

 

 

 

______________________________________________________________________________________________________ 

______________________________________________________________________________________________________ 

______________________________________________________________________________________________________ 

 

 

❏ I will not change my practice ______________________________________________________________________ Why? 

❏ This activity reinforced my current practice__________________________________________ ❏ Other (please explain) 

i perceived commercial bias in this activity. (“Commercial bias” is defined as a personal judgment in favor of a specific proprietary 

business interest of an entity that produces, markets, sells or distributes healthcare goods or services consumed by, or used on, patients.) 

❏ Yes ❏ No If yes, please comment: ______________________________________________________ 

Please the usefulness of the following guide materials on a scale of 1 to 5. 

1. physicians’ plan for older drivers’ safety (ppods) Very useful 1 2 3 4 5 Not useful at all 

2. red Flags for Further assessment Very useful 1 2 3 4 5 Not useful at all 

3. assessment of driving-related skills (adres) Very useful 1 2 3 4 5 Not useful at all 

4. state Licensing and reporting Laws (chapter 8) Very useful 1 2 3 4 5 Not useful at all 

5. Medical conditions that May affect driving (chapter 9) Very useful 1 2 3 4 5 Not useful at all 

6. patient education Materials (appendix) Very useful 1 2 3 4 5 Not useful at all 

Please include any additional comments you feel would be helpful. 

Only physician participants (MD, DO, or equivalent international medical degree) are eligible to receive AMA PRA Category 

1 CreditTM. Physicians will receive a certificate of credit, indicating one credit for each hour of participation, rounded to the 

nearest quarter credit (or hour). Physicians must complete this form to receive AMA PRA Category 1 Credit. 

Non-physician participants may complete this form to obtain a certificate of participation indicating that this activity was 

approved for AMA PRA Category 1 Credit. 

check one: ❏ Physician: Certificate of Credit ❏ Non-physician: Certificate of Participation 

FOR PHYSICIANS ONLY. Please check one below: 

❏ U.S. Licensed Physician Medical Education Number*:__________________________________________ 

❏ Non-U.S. Licensed Physician Date of Birth (mm/dd/yyyy)**:_________________________________________ 

Specialty:_____________________________________________________________________________________________ 

Please Send Completed Questionnaires and Evaluation Forms to: Lela Manning, MPH, MBA 

Project Coordinator 

Older Drivers Project 

American Medical Association 

515 N. State Street 

Chicago, IL 60654 

(312) 464-4111 (Fax) 

appendix c—Physicians Guide to Assessing and Counseling Older Drivers 225 

Index
 

Index
 

A 

AAA Foundation for Traffic Safety, 


Safe Driving for Mature Operators course........................ 208
 

AARP Driving Safety Program ........................................ 208
 

Accommodation and adaptation of lens of eye.................. 22
 

Acute events of older drivers
 

conditions requiring counseling associated with, ........... 15
 

counseling following ....................................................... 13
 

red flags for further assessment after.................... 11, 14–15
 

Adaptive devices, vehicle............................... 36, 37, 42, 155
 

Additional resources for driving safety ..................... 215–217
 

Administration on Aging Resource Directory for Older 


People................................................................................ 214
 

Adult protective services (APS) ........................................ 55
 

Affective disorders ............................................................ 163
 

Alabama, licensing and reporting procedures in................ 71
 

Alaska, licensing and reporting procedures in ................... 72
 

Alcohol ............................................................. 164, 178, 179
 

Alzheimer’s Association...................................................... 43
 

Policy Statement on Driving and Dementia by ............... 158
 

Alzheimer’s disease. See also Dementia
 

evaluation by another health professional 

for patient with................................................................ 45
 

mandatory reporting of drivers with ............................... 62
 

repeat driving tests for patients with............................. 157
 

AMA Ethical Opinion E-2.24, 


“Impaired Drivers and Their Physicians” ........................... 62
 

Am I a Safe Driver?..................................................... 20, 203
 

American Academy of Neurology recommendations ...... 157
 

American Association of Motor Vehicle Administrators 


(AAMVA), study by NHTSA and........................... 189–190
 

American Occupational Therapy Association (AOTA). 188
 

Amputation....................................................................... 169
 

Anesthesia and surgery ............................................. 175–176
 

Angular movement vision test ........................................... 22
 

Anterior cruciate ligament (ACL) reconstruction .......... 169
 

Anterograde amnesia ........................................................ 178
 

Anticholinergics ............................................................... 179
 

Anticonvulsants................................................................ 180
 

Antidepressants................................................. 178, 180–181
 

Antiemetics............................................................... 178, 181
 

Anti-epileptic drug therapy ...................................... 161, 178
 

Antihistamines ......................................................... 178, 182
 

Antihypertensives............................................................. 182
 

Antiparkinsonians ............................................................ 182
 

Antipsychotics .................................................. 178, 182–183
 

Anxiety disorders...................................................... 162, 163
 

Aortic aneurysm................................................................ 171
 

Area Agency on Aging............................................. 211, 214
 

Arizona, licensing and reporting procedures in............ 69, 73
 

Arkansas, licensing and reporting procedures in................ 74
 

Arthritis ............................................................................ 168
 

Assessment of driving-related skills (ADReS) 

case study of scores on..................................................... 33
 

cognitive skill ................................................ 23–25, 34–36
 

CPT codes for ....................................................... 21, 27, 198
 

discussion of results of ..................................................... 50
 

import of impairment in functions tested by .................. 21
 

motor and sensory function................................. 26, 36–37
 

repeat administration of .................................................. 38
 

score sheet for............................................................ 27–30
 

sequence of test administration in .................................. 27
 

use of................................................................................ 61
 

vision ....................................................... 21–22, 27, 33–34
 

Association for Driver Rehabilitation Specialists (ADED)
 

certification of DRSs by .................................................. 41
 

online directory of........................................................... 43
 

referrals to DRS by ........................................................ 210
 

Asthma.............................................................................. 173
 

Atrial flutter/fibrillation.................................................... 152
 

Atrio-ventricular (AV) block, high grade ........................ 153
 

Attentional functioning ..................................................... 24
 

Attention deficit disorder/
 

attention deficit hyperactivity disorder .................... 162, 164
 

Automatic transmission, encouraging 


use of vehicle having .................................................. 37, 167
 

B 

Barbiturates............................................................... 167, 178
 

Benzodiazepines and other sedatives/anxiolytics...... 178, 183
 

Bipolar disorder................................................................. 163
 

Blepharospasm .................................................................. 149
 

Blurred vision. See Visual acuity
 

Brain tumor....................................................................... 158
 

Bupropion ......................................................................... 180
 

C 

California
 

licensing and reporting procedures in....................... 75–76
 

mandatory reporting requirements 


of medical impairments in............................................... 62
 

Canadian Consensus Conference on Dementia............... 158
 

Cancer............................................................................... 177
 

Cardiac arrest.................................................................... 153
 

Cardiac surgery involving median sternotomy................. 154
 

Cardiovascular diseases............................................. 151–154
 

Index 229
 
Cardioverter defibrillator, internal ................................... 154
 

CarFit program.................................................................... 44
 

Caregiver burnout............................................................... 51
 

Case study of dementia patient (Allen)
 

diagnosis of Alzheimer’s disease for................................. 59
 

report of driving issues by daughter of............................. 49
 

State notification requirements for ................................. 59
 

Case study of older driver (Clayton Phillips)
 

assessment of functional capabilities of........................... 19
 

follow-up counseling in................................. 41, 49, 50, 52
 

observation of driving risk and existing conditions of.... 11
 

performance on ADReS of.............................................. 33
 

physician letter for driving cessation in.......................... 56
 

referral to DRS in...................................................... 41, 44
 

Cataracts ........................................................................... 147
 

Central nervous system (CNS) ........................................ 178
 

Cerebrovascular disorders ......................................... 155–156
 

Certified driver rehabilitation specialists (CDRSs) ........... 41
 

Cervical movement limitations........................................ 168
 

Chronic conditions, driving safety for patients having
 

formal assessment of ........................................................ 13
 

red flags for further assessment in.................................... 11
 

Chronic obstructive pulmonary disease (COPD) ............ 173
 

Chronic renal failure......................................................... 172
 

Civil damages, protection against....................................... 62
 

Clock Drawing Test (CDT).......................................... 24, 27
 

correlation with impaired driving performance of.......... 35
 

score sheet for.................................................................. 29
 

Cognitive domains.............................................................. 25
 

Cognitive skills 

identifying cause of decline in......................................... 35
 

tested for driving ............................................... 23–25, 153
 

tested to diagnose dementia.......................................... 157
 

Colorado, licensing and reporting procedures in ......... 69, 77
 

Color detection in vision test............................................. 22
 

Color vision, defective...................................................... 150
 

Compliance with driving cessation .................................... 63
 

Confidentiality issues. See Patient confidentiality
 

Congestive heart failure (CHF)........................................ 154
 

Connecticut, licensing and reporting procedures in .... 78–79
 

Contrast sensitivity............................................................. 21
 

correlation with crash risk of......................................... 189
 

definition of ................................................................... 150
 

red flags for further assessment with................................ 14
 

Copiloting ........................................................................... 36
 

Counseling for patient not safe to drive ....................... 49–56
 

key points addressed in.................................................... 49
 

by physicians, fulfilling duty in ................................. 62, 63
 

to prepare for driving cessation..................................... 157
 

situations requiring additional .......................... 53–55, 146
 

by social worker............................................................... 54
 

CPT codes for driver assessment and counseling ..... 197–198
 

in functional abilities testing of ADReS........... 21, 27, 198
 

new ................................................................................ 198
 

for preventive medicine services................................... 197
 

Crash risk 

cardiac disease and ........................................................ 151
 

contrast sensitivity correlated with............................... 189
 

detection of impairment correlated with ........................ 24
 

increases in, physical frailty and...................................... 26
 

medications associated with.................................. 167, 178
 

musculoskeletal disorders correlated with..................... 167
 

visual testing and....................................................... 33, 69
 

D 

Deep vein thrombosis (DVT)........................................... 171
 

Delaware
 

licensing and reporting procedures in............................. 80
 

mandatory reporting requirements of 


medical impairments in................................................... 62
 

Dementia. See also Alzheimer’s disease
 

cessation of driving by patient having .................... 36, 159
 

cognition affected by....................................................... 26
 

correlation with impaired driving performance 


of degenerative ................................................................ 35
 

detection of...................................................................... 35
 

incidence of..................................................................... 36
 

family involvement in deciding risk level from ............ 158
 

lack of decision-making capacity in........................ 54, 157
 

test results of patients with...................................... 35, 157
 

Department of Motor Vehicles (DMV)
 

driving assessment by ...................................................... 45
 

form for reporting medical condition(s) to..................... 63
 

physician reporting requirements for ................ 52, 59, 189
 

self-reporting of impairment to ....................................... 52
 

State laws for driving safety of ........................................ 20
 

Depression......................................................................... 163
 

discussing symptoms of.................................................... 54
 

questions to assess............................................................ 54
 

signs of ............................................................................. 52
 

Depth perception vision test .............................................. 22
 

Diabetes mellitus............................................................... 165
 

Diplopia............................................................................. 150
 

District of Columbia, licensing and 


reporting procedures in................................................. 81–82
 

Doctor-patient relationship. See Patient-physician 


relationship
 

Driver rehabilitation, increased availability of......... 187–188
 

Driver rehabilitation specialist (DRS) ......................... 41–45
 

barriers to using ............................................................. 187
 

certification of ................................................................. 41
 

clients of .......................................................................... 42
 

clinical assessment by...................................... 42, 155, 187
 

consulting ............................................................ 19, 20, 65
 

costs of services by........................................................... 43
 

definition of..................................................................... 41
 

on-road assessment by ..................... 34, 35, 37, 38, 42, 167
 

physician use of ............................................................. 188
 

prescription of adaptive devices by ......................... 37, 145
 

referral to ....................................... 33, 36, 38, 44, 155, 167
 

refusal of assessment by ................................................... 44
 

report by, physician documentation of............................ 63
 

230 Index 
selecting, questions to ask in..................................... 43–44
 

services provided by................................................. 42, 145
 

sources for finding...................................................... 43–44
 

Driver retraining ................................................................. 42
 

Driving assessment. See also Driver rehabilitation specialist 


(DRS)
 

age-based ......................................................................... 69
 

discussion of results of ............................................... 50–53
 

by non-DRS individual ............................................. 44–45
 

patient refusal to take...................................................... 20
 

purpose in driving as influencing .................................. 146
 

ways to suggest................................................................. 19
 

Driving cessation
 

counseling to prepare for....................................... 157, 159
 

losses from........................................................................ 49
 

view as step in health promotion of................................ 54
 

Driving cessation recommendation.............................. 38, 42
 

basis of ................................................................. 45, 62–63
 

documenting.............................................................. 63, 64
 

economic arguments supporting ..................................... 52
 

medication use prompting............................................. 145
 

for patients having dementia .......................................... 36
 

reasons physicians avoid making..................................... 49
 

reinforcement of........................................................ 51–52
 

Driving Decisions Workbook ............................................. 20
 

Driving educational specialists ........................................... 45
 

Driving Health Inventory (DHI) ................................. 24–25
 

Driving safety addressed in diagnosis/treatment plan ........ 15
 

Driving School Association of the Americas, Inc............ 208
 

Drowsiness, medications causing...................................... 178
 

Duty to protect as physician responsibility................... 59–60
 

E 

Early Treatment Diabetic Retinopathy Study (ETDRS) ... 22
 

Educational materials for 


patient and caregiver .................... 20, 44, 192–193, 201–217
 

Eldercare Locator.......................................... 51, 55, 211, 214
 

Epilepsy ............................................................... 61, 160–161
 

Ethical and legal responsibilities for reporting ............. 59–66
 

situations involving................................................... 63–65
 

Ethical opinion E-2.24, 


“Impaired Drivers and Their Physicians” (AMA) ............. 62
 

Euphoria, medications causing ......................................... 178
 

Executive skills, uses in driving of ...................................... 26
 

Extremities, loss of or loss of use of................................... 168
 

Eyesight. See Visual acuity
 

F 

Family member or caregiver
 

assistance with physician’s evaluation by................ 35, 158
 

counseling, patient permission for .................................. 62
 

transportation plan developed with involvement of ...... 51
 

Family member’s concerns about patient’s driving safety
 

further assessment addressing.......................................... 14
 

How to Assist the Older Driver addressing ........................ 20
 

Federal Highway Administration (FHWA) ..................... 191
 

Five A’s of Senior-Friendly Transportation............... 191, 192
 

Florida, licensing and reporting procedures in ....... 61, 83–84
 

Follow-up appointment following 


driving cessation recommendation............................... 52–53
 

Food and Drug Administration (FDA), 


meeting by NTSB and ...................................................... 190
 

Foot abnormalities ............................................................ 168
 

Freund Clock Scoring Criteria ........................................... 35
 

Functional ability
 

assessing older driver’s ............................................... 17–30
 

detailed history and examination of ............................... 35
 

G 

Geographic orientation ...................................................... 25
 

Georgia, licensing and reporting procedures in.................. 85
 

Getting By Without Driving .................................... 213–214
 

Glaucoma.......................................................................... 149
 

Glossary of terms for State licensing 


and reporting laws......................................................... 65–66
 

H 

Hawaii, licensing and reporting procedures in................... 86
 

Head injury, closed............................................................ 158
 

Health Insurance Portability and Accountability 


Act of 1996 (HIPAA)
 

patient rights and confidentiality issues under.......... 60–61
 

reporting protected health information under................ 62
 

Health risk assessment of older driver
­

conditions requiring ........................................................ 14
 

definition of ..................................................................... 12
 

inquiries about driving in.......................................... 12–13
 

Hearing loss....................................................................... 151
 

Hemianopia/quadrantanopia ............................................ 149
 

Highway Design Handbook for 

Older Drivers and Pedestrians .......................................... 191
 

Hip replacement, total...................................................... 169
 

How to Assist the Older Driver.................... 20, 51, 209–211
 

Hypertension..................................................................... 151
 

Hyperthyroidism ............................................................... 166
 

Hypertrophic obstructive cardiomyopathy....................... 154
 

Hypnotics.......................................................................... 178
 

Hypothyroidism ................................................................ 166
 

I
 

Idaho, licensing and reporting procedures in ..................... 87
 

Illinois, licensing and reporting procedures in ............. 88–89
 

Independent transportation network (ITN) model ......... 191
 

Indiana, licensing and reporting procedures in ............ 90–91
 

Inpatient setting, counseling driver in ............................... 12
 

Insulin dependent diabetes mellitus (IDDM) .................. 165
 

Index 231
 
Insurance Information Institute ......................................... 70
 

Insurance Institute for Highway Safety .............................. 70
 

Iowa, licensing and reporting procedures in....................... 92
 

K 

Kansas, licensing and reporting procedures in ................... 93
 

Kentucky, licensing and reporting procedures in ............... 94
 

Keratoconus ...................................................................... 148
 

Knee arthroplasty, total (TKA)........................................ 170
 

L 

Language skills for driving .................................................. 25
 

Lawsuit by patient................................................... 59, 63–64
 

Liability protection for physician, 


State legislation for..................................................... 64, 189
 

License renewal practices
 

international.................................................................... 70
 

for older drivers ............................................................... 69
 

State........................................................................... 69–70
 

Licensing agencies, role in driving safety of. 


See also Department of Motor Vehicles (DMV).......189-190
 

Licensing and unsafe driver reporting laws, 


State-by-State descriptions of............................... 45, 69–141
 

Limb fractures ................................................................... 169
 

Listening to patient’s concerns ........................................... 53
 

Local Agency on Aging .................................................... 211
 

Loss of consciousness, cardiac conditions causing.... 152–153
 

Louisiana, licensing and reporting procedures in............... 95
 

M 

Macular degeneration ....................................................... 148
 

Maine, licensing and reporting procedures in .................... 96
 

Mandatory fitness-to-drive reporting requirements 


for physicians
 

compliance with........................................................ 63, 64
 

States requiring................................................................ 62
 

Manual Test of Motor Strength.................................... 25, 27
 

results of..................................................................... 36–37
 

Manual Test of Range of Motion test........................... 25, 27
 

scoring of ......................................................................... 37
 

Maryland, licensing and reporting procedures in............... 97
 

Massachusetts, licensing and reporting procedures in.. 98–99
 

Medical Advisory Board ........................................... 189–190
 

Alabama .......................................................................... 71
 

Arizona ............................................................................ 73
 

California ........................................................................ 76
 

Connecticut..................................................................... 79
 

Delaware.......................................................................... 80
 

Florida.............................................................................. 84
 

Georgia ............................................................................ 85
 

Hawaii ............................................................................. 86
 

Idaho................................................................................ 87
 

Illinois.............................................................................. 89
 

Indiana ............................................................................ 91
 

Iowa ................................................................................. 92
 

Kansas.............................................................................. 93
 

Kentucky ......................................................................... 94
 

Louisiana ......................................................................... 95
 

Maine .............................................................................. 96
 

Maryland ......................................................................... 97
 

Massachusetts .................................................................. 99
 

Michigan ....................................................................... 101
 

Minnesota...................................................................... 102
 

Mississippi...................................................................... 103
 

Missouri ......................................................................... 105
 

Nebraska........................................................................ 108
 

Nevada........................................................................... 109
 

New Jersey ..................................................................... 111
 

New Mexico .................................................................. 112
 

New York....................................................................... 114
 

North Carolina.............................................................. 115
 

North Dakota ................................................................ 116
 

Oklahoma...................................................................... 119
 

Oregon........................................................................... 121
 

Pennsylvania ................................................................. 123
 

Rhode Island ................................................................. 124
 

South Carolina.............................................................. 125
 

South Dakota ................................................................ 126
 

Tennessee....................................................................... 127
 

Texas.............................................................................. 129
 

Utah .............................................................................. 131
 

Virginia.......................................................................... 134
 

West Virginia................................................................. 137
 

Wisconsin...................................................................... 139
 

Medical conditions that may affect driving.............. 146–177
 

Medication dose, reducing................................................ 145
 

Medications interfering with 


driving performance............................................ 37, 178–184
 

Medications review for patient............................... 11–12, 35
 

Medications, side effects of......................................... 26, 178
 

public awareness of, increasing ..................................... 190
 

review of .......................................................................... 35
 

Medications with strong potential to affect 


driving safety............................................................. 145–184
 

types of............................................................................. 15
 

Memory tests................................................................. 23, 24
 

Metabolic disorders................................................... 165–166
 

Michigan, licensing and reporting 


procedures in....................................................... 69, 100–101
 

Migraine headaches .......................................................... 159
 

Minnesota, licensing and reporting procedures in ........... 102
 

Mirtazapine ....................................................................... 180
 

Mississippi, licensing and reporting procedures in ........... 103
 

Missouri
 

license retention following evaluations in...................... 61
 

licensing and reporting procedures in................... 104–105
 

Mobility needs of patient.................................................... 13
 

Model Driving Impairment Law......................................... 62
 

Monoamine oxidase (MAO) inhibitors ........................... 181
 

232 Index 
Monocular vision.............................................................. 149
 

Montana, licensing and reporting procedures in.............. 106
 

Motor abilities for operating vehicle .................................. 26
 

results of tests of .............................................................. 36
 

Motor Strength, manual test of .................................... 25, 27
 

score sheet for.................................................................. 28
 

Movement disorders.......................................................... 159
 

Multiple sclerosis .............................................................. 159
 

Muscle disorders................................................................ 169
 

Muscle relaxants ............................................... 167, 178, 183
 

Musculoskeletal disabilities ................................ 26, 167–170
 

N 

Narcolepsy......................................................................... 161
 

Narcotic analgesics ........................................................... 184
 

Narcotics........................................................................... 167
 

National Association of Social Workers Register of Clinical 

Social Workers .................................................................... 54
 

National Family Caregivers Association (NCFA)............. 51
 

National Highway Traffic Safety Administration (NHTSA)
 

data on medically impaired drivers ................................. 61
 

meeting by FDA and ..................................................... 190
 

study by AAMVA and .......................................... 189–190 

Nebraska, licensing and reporting procedures in ..... 107–108 

Neglect or self-neglect 

adult protective services to address................................. 55
 

signs of ............................................................................. 54
 

Neurologic diseases ................................................... 157–162
 

Nevada
 

licensing and reporting procedures in........................... 109
 

mandatory reporting requirements of 

medical impairments in................................................... 62
 

New Hampshire, licensing and reporting 


procedures in..................................................................... 110
 

New Jersey
 

licensing and reporting procedures in........................... 111
 

mandatory reporting requirements of 

medical impairments in................................................... 62
 

New Mexico, licensing and reporting procedures in........ 112
 

New York, licensing and reporting procedures in..... 113–114
 

Night vision
 

medications affecting .................................................... 178
 

poor................................................................................ 150
 

N-methyl d-aspartate (NMDA) receptor blockers........... 157
 

Non-insulin dependent diabetes mellitus (NIDDM)....... 165
 

Nonsteroidal anti-inflammatory agents (NSAIDs).......... 167
 

possible effects on driving of ......................................... 183
 

North Carolina, licensing and reporting procedures in ... 115
 

North Dakota, licensing and reporting procedures in...... 116
 

Nystagmus......................................................................... 148
 

O 

Observations of patient throughout office visit.................. 11
 

Occupational therapists off-road tests 


and/or mobility counseling by ............................................ 44
 

Occupational therapy (OT) profession ............................ 188
 

Ohio, licensing and reporting procedures in ...... 69, 117–118
 

Oklahoma, licensing and reporting procedures in ........... 119
 

Older drivers
 

educational materials for................................. 20, 201–217
 

increasing number of......................................................... 1
 

optimal environments for.............................................. 191
 

plans for alternate transportation of ..................... 187–193
 

vehicle designs to improve safety of...................... 190–191
 

Oregon
 

licensing and reporting procedures in................... 120–121
 

mandatory reporting requirements of 


medical impairments in................................................... 62
 

reports of medically impaired drivers in.......................... 61
 

Orthopedic procedures/surgeries............................... 169–170
 

Osteoarthritis .................................................................... 167
 

P 

Pacemaker insertion or revision ....................................... 154
 

Paraplegia, adapted vehicle for driving with .................... 159
 

Parkinson’s disease .................................................... 159–160
 

Paroxysmal supraventricular tachycardia (PSVT) ........... 152
 

Patient concerns about driving safety................................. 14
 

Patient confidentiality
 

exceptions to maintaining............................................... 62
 

in impaired driver situations ....................... 60–61, 64, 189
 

reducing impact of breaching.......................................... 62
 

Patient-physician relationship
 

confidentiality of health information in ................... 60, 61
 

effects of reporting fitness to drive reports on........... 61–62
 

reducing impact of breach of confidentiality on............. 63
 

Pedestrians, optimal environments for............................. 191
 

Pennsylvania
 

licensing and reporting procedures in................... 122–123
 

mandatory reporting requirements of 


medical impairments in................................................... 62
 

provider compliance in ....................................... 59–60, 61
 

Percutaneous transluminal coronary 


angioplasty (PTCA) ......................................................... 154
 

Peripheral arterial aneurysm............................................. 171
 

Peripheral neuropathy ...................................................... 160
 

Peripheral vascular diseases .............................................. 171
 

Personality disorders ......................................................... 164
 

Physical activity regimen............................................ 37, 167
 

Physician assessment tools for effects on driving ............. 1–2
 

future improved ............................................................. 187
 

Physician documentation of patient’s driving ability... 20, 63
 

Physician intervention.................................................. 33–38
 

cognitive abnormal results prompting ...................... 34–35
 

course of action for.................................................... 37–38
 

Index 233
 
documenting.................................................................... 63
 

motor ability results prompting....................................... 36
 

summary of ...................................................................... 63
 

visual acuity results prompting.................................. 33–34
 

visual field loss prompting ............................................... 34
 

Physician-patient privilege
 

definition of ..................................................................... 64
 

as not preventing report to DMV ................................... 64
 

Physician responsibilities for reporting unsafe driver
 

DMV requirements as............................................. 52, 59, 63
 

ethical and legal ........................................................ 59–66
 

when State has no reporting laws ................................... 64
 

Physician’s Plan for Older Drivers’ Safety (PPODS)
 

algorithm of ................................................................. 6, 19
 

documenting steps of....................................................... 63
 

formal assessment in............................................ 19–29, 63
 

observation in...................................................... 11–15, 63
 

Physician, threat by unsafe-driving patient 


to find another .............................................................. 64–65
 

Polypharmacy.................................................................... 179
 

Post intracranial surgery ................................................... 155
 

Potential driving impairing (PDI) medications ............... 178
 

Power steering, recommending use of 


vehicle providing ........................................................ 37, 167
 

Prescription reinforcement stating “Do Not Drive”..... 51, 52
 

Pre-syncope or syncope, risk of................................. 153–154
 

Psychiatric disorders.................................................. 163–164
 

Psychotic illness................................................................ 164
 

Ptosis or lid redundancy.................................................... 149
 

Public safety ........................................................................ 60
 

Public transportation statistics ......................................... 191
 

Q 

Quadriplegia, adapted vehicle for driving with................ 159
 

R 

Range of motion ................................................................. 26
 

manual test of............................................................ 25, 27
 

score sheet for.................................................................. 28
 

Rapid Pace Walk test.................................................... 24, 27
 

correlation between future at-fault crash and performance 


on..................................................................................... 36
 

functions assessed by ....................................................... 36
 

score sheet for.................................................................. 28
 

Referral of patient for fitness-to-drive evaluation
 

to DRS................................................... 33, 36, 38, 44, 167
 

physicians’ confidentiality concerns in ..................... 61–62
 

physicians’ problems with ............................................... 61
 

retention of license following ......................................... 61
 

Referral of patient to DMV for testing ......................... 20, 45
 

Release of information, patient consent for ....................... 62
 

Renal disease..................................................................... 172
 

Renal transplant................................................................ 172
 

Renewal rates for licenses ............................................. 69–70
 

Resources, driving safety..................................... 20, 215–217
 

CarFit .................................................................................. 44
 

DRS............................................................................... 43–33
 

handout ................................................................. 201–217
 

Resources, mobility needs......................................... 192–193
 

Respiratory diseases................................................... 173–174
 

Restricted driving.................................................... 34, 38, 42
 

for cardiac conditions.................................................... 154
 

medication use prompting..................................... 145, 178
 

recommendation basis for ............................................... 45
 

Retinitis pigmentosa ......................................................... 149
 

Review of systems (ROS)
 

comprehensive................................................................. 12
 

symptoms affecting driving safety revealed by................ 15
 

Rhode Island, licensing and reporting procedures in ....... 124
 

Ride-sharing statistics ....................................................... 191
 

Roadwise Review CD of AAA........................................... 20
 

Rotator cuff repair............................................................. 169
 

S 

Safe Driving Tips ................................................................ 45
 

SAFER Driving survey........................................................ 20
 

Safety features, new vehicular .......................................... 191
 

Safety of older driver having functional 


or medical impairments
 

examples of issues for............................................. 1, 11, 19
 

overview of .................................................................... 1–7
 

Seizure disorder ......................................................... 160–161
 

Selective serotonin reuptake inhibitors (SSRIs).............. 181
 

Self-awareness and self-regulation of driving safety ......... 190
 

Self-screening tool, Am I a Safe Driver? .................... 20, 203
 

Sensory deprivation conditions ................................ 147–151
 

Shopping from home ........................................................ 211
 

Shoulder reconstruction ................................................... 169
 

Sick sinus syndrome.......................................................... 153
 

Simulators, driving............................................................ 188
 

Sinus brachycardia/sinus exit block/sinus arrest............... 153
 

Sleep apnea ....................................................................... 174
 

Sleep disorders .......................................................... 161, 174
 

Snellen E chart test of visual acuity ............................. 22, 27
 

Social history/health risk assessment, driving on............... 12
 

South Carolina, licensing and reporting procedures in69, 125
 

South Dakota, licensing and reporting procedures in...... 126
 

Spine limitations, thoracic or lumbar............................... 168
 

State laws for referrals to DMV .............................. 20, 45, 52
 

compliance with.............................................................. 63
 

State licensing and physician reporting laws........ 45, 69–141
 

Stimulants......................................................................... 184
 

Stroke.................................................................. 61, 155–156
 

Subarachnoid hemorrhage................................................ 156
 

Substance abuse ........................................................ 164, 179
 

Successful Aging Tips ................................... 20, 45, 205–206
 

Support systems................................................................... 53
 

Surgery, abdominal, back, and chest................................. 175
 

Suspension of driver’s license, driving subsequent to......... 64
 

Syncope..................................................................... 153–154
 

effects on driving of....................................................... 156
 

234 Index 
T 

Taxi use statistics............................................................... 191
 

Telescopic lens .................................................................. 148
 

Tennessee, licensing and reporting procedures in ............ 127
 

Texas, licensing and reporting procedures in ........... 128–129
 

Tips for Safe Driving ........................................... 20, 207–208
 

Tourette’s syndrome .......................................................... 162
 

Traffic Safety Course (AARP)............................................ 20
 

Trail-marking test, Part B ............................................. 23, 27
 

driving performance on............................................. 34–35
 

score sheet for............................................................ 29, 30
 

Transient ischemic attacks (TIA) .................................... 156
 

Transportation alternatives
 

discussed with patient ....................................... 50–51, 146
 

follow-up of patient’s success using ................................. 63
 

future plans for....................................................... 187–193
 

list of................................................................................ 50
 

Transportation needs of older adults......................... 187–193
 

Tricyclic antidepressants (TCAs)..................................... 181
 

U 

Unsafe drivers 

identifying ..................................................................... 188
 

patient’s recognition of.................................................... 53
 

referral requirements of providers for.............................. 20
 

reporting. See Physician responsibilities for reporting 


unsafe driver
 

Unstable coronary syndrome ............................................ 152
 

Useful Field of View (UFOV)............................................. 24
 

U.S. Public Health Service guidelines on musculoskeletal 

ability and driving............................................................... 37
 

Utah, licensing and reporting procedures in ............ 130–131
 

V 

Valvular disease................................................................. 154
 

Vascular malformation...................................................... 156
 

Vehicle designs to optimize safety ............................ 190–191
 

Vehicle modification....................................... 36, 37, 42, 155
 

Ventricular tachycardia (VT)
 

prolonged, nonsustained ............................................... 152
 

sustained ................................................................ 152–153
 

Vermont, licensing and reporting procedures in, 132
 

Vertigo............................................................................... 162
 

Vigilance (sustained attention) .......................................... 25
 

Virginia, licensing and reporting procedures in ....... 133–134
 

Visual acuity
 

correlation with crash risk of........................................... 33
 

frequency of assessing ...................................................... 34
 

greater than 20/40 ..................................................... 33–34
 

lessening impact on driving of decreased...................... 147
 

less than 20/70................................................................. 34
 

less than 20/100............................................................... 34
 

medical conditions decreasing .............................. 147–148
 

medications affecting .................................................... 178
 

State requirements for drivers’ .................................. 33, 69
 

in vision assessment................................................... 21–23
 

Vision assessment, visual acuity and visual fields in..... 21–23
 

Visual Fields by Confrontation test .............................. 23, 27
 

Visual fields deterioration ................................................... 34
 

medical conditions causing ................................... 148–149
 

Visual perception, visual processing, and 


visuospatial skills........................................................... 23–24
 

Voluntary reporting laws, liability of 


physicians in States having................................................. 62
 

W 

Walking......................................................................... 26, 36
 

Washington, licensing and reporting 


procedures in............................................................. 135–136
 

“We Need to Talk” (Harford)........................................... 210
 

West Virginia, licensing and reporting procedures in ...... 137
 

Wisconsin, licensing and reporting procedures in.... 138–139
 

Wolf-Parkinson-White (WPW) syndrome ...................... 152
 

Wyoming, licensing and reporting procedures in............. 140
 

Index 235