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Published by NHTSA and the American Geriatrics Society, the Clinician's Guide to Assessing and Counseling Older Drivers (3rd Edition) is designed to help healthcare professionals in assessing older drivers at risk for crashes and counseling older drivers to help enhance their driving safety.

This Guide offers recommendations, tools, and resources for the clinical team involved in the care of older adults for use in multiple care settings by providing:

  • A clinically based assessment of medical fitness to drive, presented in the algorithm Plan for Older Drivers’ Safety (PODS).
  • A toolbox of practical, office-based functional assessment tests for driving-related skills, the Clinical Assessment of Driving Related Skills (CADReS) (see Chapter 3). The clinical team can choose among these tests, depending on the outcomes of screening tests and the individual older adult’s abilities (see Chapter 2).
  • Information to help navigate the legal and ethical issues regarding patient driving safety, including information on patient reporting, with a State-by-State list of licensing agency contact information, and additional resources for locating license renewal criteria and reporting laws and procedures (see Chapters 7 and 8).
  • A reference listing of medical conditions and medications that may affect driving, with specific recommendations for each (see Chapter 9).
  • Recommended Current Procedural Terminology (CPT) codes for assessment and counseling procedures (see Appendix A).
  • Handouts for older adults and their caregivers that include a self-screening tool for driving safety, safe driving tips, driving alternatives, and a resource sheet for concerned caregivers (see Appendix B). Links for accessing recommended resources from reputable organizations are also provided.
  • Sample approaches in subsequent chapters for conversations about driving assessment, rehabilitation, restriction, and cessation.

This webpage includes selections and highlights from the Guide. You can download the Guide in its entirely using the link in the following paragraph or by chapter of interest in the sections below. The Guide can also be accessed from Geriatrics Care Online by free registration.  A mobile app is also available and can be obtained for Android devices and Apple devices.

Download entire PDF of The Clinician's Guide to Assessing and Counseling Older Drivers (3rd Edition) here.







The Clinician’s Role








Clinical Levels of Care for Driving Health

There are three clinical levels of care regarding driving ability in older adults as shown in the graphic. 

Assessing and managing potential driving disability can be challenging and time consuming, especially because it is often considered a personal rather than a clinical issue. Legal and ethical questions may also deter clinical team members from addressing driving ability in older adults. Yet as medical conditions arise and progress with advancing age, older adult drivers and their caregivers will increasingly turn to clinical team members for guidance on safe driving. The challenge is in balancing the safety of older adults against their transportation needs and the safety of society. This guide is intended to help answer the following questions and, if necessary, help clinical team members counsel patients about driving cessation and alternative means of transportation.

  • At what level of severity do medical conditions impair safe driving?
  • What can be done to help older adults prolong their driving life expectancy (time behind the wheel)?
Plan for Older Drivers' Safety (PODS)

Plan for Older Drivers' Safety (PODS)

 

Clinical team members can help older adult drivers maintain safe driving skills using the Plan for Older Driver Safety (PODS) algorithm, and may also influence older adult drivers’ decisions to modify or stop driving if they develop functional disability which affects driving skills.

Although primary care providers may have access to the most resources to perform the PODS, other clinicians and specialists also have a responsibility to discuss driving with older adults. 

When advising older adults, clinical team members may wish to consult the reference list of medical conditions in Chapter 9.

 

Click the image to the right to open a PDF of the algorithm.


Read Chapter 1 in the Guide to learn more. For Florida specific information visit the Aging Road User page.











 

How to Assess/Counsel an Older Adult





Things to observe:

  • Sensory deprivation such as impaired vision, hearing or decreased sensation in the extremities
  • Inattention or loss of insight regarding personal care (e.g., poor hygiene and grooming)
  • Impaired ambulation (e.g., difficulty walking or getting into and out of chairs)
  • Difficulty with way finding (e.g., getting to or out of the office)
  • Impaired attention, memory, language expression, or comprehension
  • Difficulties or lack of insight related to managing medical encounters, such as missed appointments, repeated phone calls for the same issues, or appearing on the wrong day.


Clinical Risk Factors for Impaired Driving

Physical capabilities

History of falls
Impaired ambulation
Vision and/or hearing impairment
Functional impairment with regard to use of gas or brake pedals
Decreased ability to turn the head to fully visualize an area

Cognitive ability

Decreased short-term memory
Decreased or impaired way finding
Easily distracted
Inability to learn new information quickly
Inability to recognize unsafe situations

Driving ability

Not using turn signals appropriately
Difficulty turning the wheel and making turns
Difficulty staying in the correct driving lane
Difficulty judging the space between cars or upcoming exits
Hitting curbs when parking or backing up
Stopping in traffic inappropriately
Not following stop signs, yield signs, traffic lights, etc.
Not noticing workmen or activity on side of the road
Inappropriate speeds for the weather/driving conditions
History of traffic violations, minor crashes, or warnings





Questions to Ask About Driving

A health risk assessment is a series of questions intended to identify potential health and safety hazards in the older adult’s behaviors, lifestyle, and living environment (Table 2.2). The health risk assessment is tailored to the older adult and generally focuses on physical activity, falls, drinking (alcohol), medication management, and driving. Questions about driving should be integrated into the health risk assessment.

Access the questions by clicking the image to the right.







Red Flags for Further Assessment


Older Adult Driver's or Caregiver's Concern

Regardless of the setting of care, older adult drivers and their caregivers may express concerns about driving safety. If so, the cause of concern should be investigated, specifically if there have been recent motor vehicle crashes, near-crashes, traffic tickets, instances of becoming lost, poor night vision, forgetfulness, or confusion.

Acute Events

Any acute event, whether requiring hospitalization or not, is a red flag for immediate assessment of driving safety. If the older adult has been hospitalized, it is particularly important to counsel him or her as well as caregivers on driving safety issues. Acute disease exacerbations can serve as an opportunity to address, or re-address driving concerns.

Red Flag Symptoms

The review of systems can reveal symptoms or conditions that may impair driving performance. Symptoms associated with acute and chronic medical problems are critically important red flags and should be carefully explored.

For detailed information on chronic medical conditions related to these and other symptoms see Chapter 9, Medical Conditions, Functional Deficits, and Medications That May Affect Driving Safety.





Medications

Many nonprescription and prescription medications have the potential to impair driving ability, either by themselves or in combination with other drugs. Combinations of drugs may affect drug metabolism and excretion, and dosages may need to be adjusted accordingly. In addition, clinicians should always ask about alcohol use and timing of intake (for more information on each medication class that may affect driving, see Chapter 9). Medications with strong potential to affect driving ability include:

  • Anticholinergics
  • Anticonvulsants
  • Antidepressants
  • Antiemetics
  • Antihistamines
  • Antihypertensives
  • Antiparkinsonian agents
  • Antipsychotics
  • Benzodiazepines and other sedatives/anxiolytics
  • Muscle relaxants
  • Narcotic analgesics
  • Stimulants
  • Hypnotics
  • Other agents with anticholinergic side effects


Read Chapter 2 in the Guide to learn more. For Florida information, visit the Health Care Provider Resources page.






Screening, Assessment, and Evaluation


This chapter focuses on the functional abilities needed for driving. It is important to distinguish between screening older adults for functional disability that may impair driving and conducting a more detailed assessment that identifies at-risk drivers who may benefit from intervention strategies. The goal is to optimize the ability of older adults to continue to drive safely for as long as possible.

The Transportation Research Board Committee for Safe Mobility for Older Persons has developed definitions for screening, assessment, and evaluation.    Access the definitions by clicking the image to the right.

Functional Areas to Assess

Three key functional areas are considered as the foundation for fitness to drive. Any impairment in these areas has the potential to increase the older adult’s risk of being involved in a crash. Once these areas are assessed, the health care provider can determine if more information is required in one or all areas or if referral to a specific specialist for further evaluation or intervention is needed (e.g., ophthalmologist, neuropsychologist, driver rehabilitation specialist).



Visual Acuity. Visual acuity should be measured using the Snellen E chart because it is the legal criteria for most State licensing agencies. 

Visual Field. The examiner sits or stands 3 feet in front of the patient. The patient is asked to close his or her right eye, 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.  This measures visual field.

Contrast Sensitivity. Many charts are commercially available (e.g., Pelli-Robson contrast sensitivity chart) to test the ability to perceive objects in contrast to the environment.

Rapid Pace Walk and Get Up and Go. These tests are measures of lower limb strength, endurance, range of motion, and balance. The Rapid Pace Walk has been linked with driving outcomes, whereas Get Up and Go has been more closely linked with falls and future disability and long term care placement. Because falls have been associated with poor driving outcomes, either of these tests would be appropriate measures for assessing overall motor abilities.

These tests are measures of lower limb strength, endurance, range of motion, and balance. The Rapid Pace Walk has been linked with driving outcomes, whereas Get Up and Go has been more closely linked with falls and future disability and long term care placement. Because falls have been associated with poor driving outcomes, either of these tests would be appropriate measures for assessing overall motor abilities.

Range of Motion. Performing a functional range of motion test is important for examining if and how the motor vehicle can be adapted to meet limitations of the older adult. Mirrors and education/training can accommodate limitations of the neck. Limitations in any of the extremities can be accommodated by adaptive equipment recommended by driver rehabilitation specialists.

Montreal Cognitive Assessment (MoCA) www.mocatest.org.  This is a brief cognitive test designed to assist health care professionals in detecting mild cognitive impairment. It may be administered by anyone, but the results should only be interpreted by an individual with expertise in the cognitive field.  It tests memory, attention, language, abstract, recall, orientation, as well as visuospatial skills by incorporating a shorter Trails B and a clock-making task.  

Trails B. This test assesses working memory, visual processing, visuospatial skills, selective and divided attention, and psychomotor coordination. Numerous studies have demonstrated an association between poor performance on the Trail-Making Test Part B and poor driving performance.

Clock-Drawing Test. This test may assess 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.

Maze Test. There are several versions of maze testing, including online versions. Depending on the type of test, it assesses visual perception, visuospatial skills, abstract thinking, and executive skills. The Snellgrove maze is a one-page cognitive screen for driving competence that was validated with older adults with mild cognitive impairment or early dementia.





Clinical Team Assessment Tools

Assessments range from simple paper and pencil tools performed by clinicians in their offices to complex assessments. 

For the clinical team member who is screening or assessing an older driver, Chapter 3 includes a summary that describes a toolbox of practical, office-based functional assessment tools in the major areas of vision, cognition, and motor/sensory function related to driving, the Clinical Assessment of Driving Related Skills (CADReS).  Clinical team members should choose the tool in each area that best fits the practice setting in which they care for older adults and document their encounters.



No single assessment can accurately predict fitness to drive; an array of assessment tools should be used to determine risk in older adults.


General

  • Driving History

A brief driving history can be useful as an initial screen to identify the older adult’s perception of his or her driving as well that of a caregiver if available. Recent traffic violations, crashes (including unreported), or near misses are all red flags for concern.

  • IADLs (Instrumental Activities of Daily Living) Questionnaire

A checklist of IADLs can be used as an initial screen to identify if the older adult is having difficulties with other complex tasks of daily living. As an IADL, driving uses underlying functions (e.g., visual processing, executive functioning, memory) similar to financial management, shopping, or cooking. If the older adult is having difficulty with those tasks, further screening or assessment is warranted. A report from a caregiver may also be helpful.

  • Medication Change

Certain medications clearly affect driving, and new or changing doses may affect assessment findings, perhaps triggering red flags that are temporary.


The Evolution of Computer-Based Tools

The following computer-based assessment tools are commercially available. More in-depth descriptions are available in Chapter 3.  

  • Useful Field of View

This is the most widely studied instrument for detection of impairment in processing speed, divided attention, and selective attention that has been moderately correlated with crash risk in older adult drivers. This assessment tool is available for purchase (information is available on the Visual Awareness web site (www.visualawareness.com/Pages/whatis.html). Cost, time, and ability to bill, as well as limited studies in a primary care setting, might be potential barriers to utilization.

  • Driving Health Inventory (DHI)

This computerized set of tests that assess key functional abilities for driving was developed using data from individual assessments in the Maryland Pilot Older Driver Study. It is intended for use by health care professionals to assess older adults, but individual users may download single-use licenses for personal use.  This assessment tool is available for purchase (information is available on the DrivingHealth website http://drivinghealth.com/screeningassessment.html).

  • DriveABLE

This assessment is only of cognitive abilities for driving; it is computer-based and electronically scored(available at www.driveable.com/).  There is minimal independent research evidence using DriveABLE that supports the claims of predicting driving risk accurately and this approach does not provide the clinician with information which can be used to identify clinical solutions for potential problems. Older adults who score in the middle of the range may require further evaluation such as on-road assessment, reliance on caregiver information, recent driving history, or further in-office testing.


Read Chapter 3 in the Guide to learn more. For Florida information, visit the Driving Skills page.






Clinical Interventions


The goal of clinical evaluation is to identify, correct, or stabilize any functional deficits that may impair the older adult's driving performance and to consider referral to a driver rehabilitation specialist (DRS), if appropriate.

Screening for visual field cuts is important, because most older adults with visual field loss are unaware of the deficit until it becomes quite significant.


The Clinical Assessment of Driver-Related Skills (CADReS)

Failure to pass any measure of cognition in the Clinical Assessment of Driver-Related Skills (CADReS) toolbox should elicit a referral to provide opportunities for older adults to optimize cognitive function and perhaps explore their potential to continue to drive safely. Local resources will vary and may include occupational therapy, speech-language pathologists, neuropsychologists, driving rehabilitation specialists, or other medical specialists.

If the only problems are with motor and/or somatosensory areas, these individuals should be referred to a DRS to take advantage of advancements in technology and possible adaptive equipment for the vehicle.

Click on the functional area below to see the recommended actions.


  • Refer to a vision specialist (ophthalmologist or optometrist) for diagnosis and treatment. The older adult should obtain and use the appropriate glasses or contact lenses.
  • Recommend restricting travel to low-risk areas and conditions (e.g., familiar surroundings, non-rush hour traffic, low speed areas, daytime, and good weather conditions).
  • The older adult may require more frequent (e.g., yearly) assessment of visual acuity to detect further visual decline caused by chronic, progressive diseases such as age-related macular degeneration and glaucoma.
  • All the above
  • Recommend an on-road assessment performed by a driver rehabilitation specialist (DRS), where permitted and available.
  • Refer to a vision specialist for diagnosis and treatment
  • Recommend an on-road assessment performed by a DRS who may be able to prescribe equipment such as enlarged side- and rear-view mirrors and train the older adult in their use.
  • Recommend minimizing low-light driving conditions (at night, in bad weather).
  • Gather more information to include detailed history and examination.
  • Identify or interview a reliable informant (e.g., family member or caregiver) to assist with the evaluation.
  • Work with the clinical team on identifying the cause of the decline.
  • Evaluate for reversible causes of cognitive decline.
  • Screen for depression and treat if positive.
  • Review the medication regimen and the adverse effects of the medications.
  • Refer to a neurologist, psychiatrist, or neuropsychologist as needed.
  • Recommend a comprehensive driving evaluation performed by a DRS.
  • Recommend alternative forms of transportation.
  • Encourage use of a vehicle with power steering and automatic transmission.
  • Recommend a consistent regimen of general physical activity, including cardiovascular exercise, strengthening exercises, and stretching.
  • Refer to a physical therapist as needed.
  • Provide effective pain control if pain is limiting range of motion or mobility and advise to refrain from driving when first taking these medications until they know whether the medications are tolerated well.
  • Refer to a specialist for management of any joint disease, podiatry issues, or neuromuscular problems.



Next Course of Action

After administering CADReS assessment tools, three courses of action are possible (see also Plan for Older Drivers’ Safety, Chapter 1).


  • Advise there are no medical contraindications to safe driving and offer counseling regarding health maintenance and future transportation plans.
  • Gather more information to include detailed history and examination.
  • Medically Correctable?
    • If the older adult performs poorly on any area of CADReS, but on clinical specialist evaluation the causes of poor performance are medically correctable, medical treatment and intervention should be pursued until function has been optimized.
  • Not Medically Correctable?
    • Refer to a DRS.




Read Chapter 4 in the Guide to learn more. For Florida information, visit the Driving Skills page.












Driver Rehabilitation Specialists







Although there may be improvement in visual, cognitive, or physical abilities, older adults may still demonstrate functional impairments that affect their driving performance. In these cases, a driver rehabilitation specialist (DRS) is an excellent resource to explore solutions supporting continued driving.

Read Chapter 5 the Guide to learn more. For Florida information, visit the Health Care Provider Resources page.









Transitioning From Driving







For most of us, driving is a symbol of independence and a source of self-esteem. When we retire from driving, we lose not only a form of transportation but also all the emotional and social benefits derived from driving. In primary preventive care, the transition to cessation of driving may be discussed during the Medicare Annual Wellness Visit.


Within the clinical team, the physician is often considered key for driver licensing and assessment referral.

Read Chapter 6 in the Guide to learn more. For Florida information, visit the Family and Caregiver Resources page.









Ethics, Laws, Regulations







Ethical and Legal Issues

Laws, regulations, and policies vary not only by State but also by local jurisdiction and are subject to change. Health care professionals should seek legal advice on specific issues or questions.

It is important to know and comply with State requirements to avoid being subject to a third-party lawsuit.  For Florida-specific licensing information go to the Laws and Regulations page.

Some States (CA, DE, NJ, NV, OR, PA) have mandatory reporting requirements that may give rise to liability for failure to report.

The ethical responsibility to maintain patient confidentiality as well as the ethical responsibility to public safety is not limited to physicians; all health care professionals have the same obligation.

Patient permission should be obtained before contacting caregivers, and this should be documented in the patient’s health record. If the patient maintains decisional capacity and denies permission, their wishes must be respected.

Read Chapter 7 in the Guide to learn more. For Florida information, visit the Laws and Regulations page.









State Licensing and Reporting Laws





Each State has its own licensing and license renewal criteria. A database of driver licensing policies and practices for licensing requirements, license renewal procedures, reporting procedures, medical advisory board information, and more can be found at http://lpp.seniordrivers.org/lpp/index.cfm?selection=visionreqs.

Licensing and license renewal information is subject to change, and statues for specific States should be checked for up-to-date changes in laws or requirements.

Read Chapter 8 in the Guide to learn more. For Florida information, visit the Laws and Regulations page.








Conditions That May Affect Driving Safety





Many medical conditions, functional deficits, and/or medications may potentially impair driving. This chapter contains reference tables of the conditions and medications that may impair driving skills, with associated consensus recommendations. Whenever scientific evidence supports the recommendations, it is included. These recommendations apply only to drivers of private motor vehicles and should not be applied to commercial drivers.

General Recommendations

  • Treat the underlying medical condition and/or functional deficit to improve the condition/impairment or limit progression.
  • If the functional deficit is due to an identifiable offending agent (e.g., medication with PDI effects), remove the offending agent or reduce the dose, if possible.
  • If the functional deficit can be addressed through compensation or modification (e.g., hand controls, left foot accelerator), refer for a comprehensive driving evaluation.
  • Advise the older adult about the risks to his or her driving safety, consider referral for assessment of driving performance, recommend driving restrictions or driving cessation as needed, and document the discussion in the health record.
  • For acute or episodic illnesses (e.g., seizure disorder and/or diabetes with hypoglycemia), clinical judgment and subspecialist input is recommended, in addition to following specific State statutes.

Medical Conditions, Functional Deficits, and Medications That May Affect Driving Safety

  • Vision and Hearing Loss
  • Cardiovascular Disorders
  • Cerebrovascular Disorders
  • Neurologic Disorders
  • Psychiatric Disorders
  • Metabolic Disorders
  • Musculoskeletal Disorders
  • Peripheral Vascular Disorders
  • Renal Disorders
  • Respiratory and Sleep Disorders
  • Effects of Anesthesia and Surgery
  • Cancer
  • Medications

Read Chapter 9 in the Guide to learn more. For Florida information, visit the Driver Wellness page.









Meeting Future Transportation Needs of Older Adults




Chapters one through nine of the Clinician's Guide to Assessing and Counseling Older Drivers provide the clinical team with recommendations and tools for enhancing the driving safety of older adults. As in other aspects of patient care, however, further research can lead to more effective care. Coordinated efforts among the health care and transportation communities, policymakers, community planners, the automobile industry, and government agencies are needed to achieve the common goal of safe transportation for the older population.

As this population continues to expand and live longer, the challenge is to keep pace with its transportation needs. Chapter 10 discusses the research, initiatives, applications, and system changes deemed essential for improving driving safety of older adults. Readers are also encouraged to review the National Highway Traffic Safety Administration’s Traffic Safety for Older People – 5-Year Plan   to address traffic concerns of older adults for additional ideas.

Read Chapter 10 in the Guide to learn more. For Florida information, visit the Aging In Place page.









Clinical Resources







CPT Codes Image

CPT Codes

Codes that can be used for driver assessment and counseling, when applicable.












CADRes Score Sheet


Clinical Assessment of Driving Related Skills (CADReS) Score Sheet

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













Montreal Cognitive Assessment (MoCA)

The Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for mild cognitive dysfunction. It assesses different cognitive domains:

  • attention and concentration,
  • executive functions,
  • memory,
  • language,
  • visuoconstructional skills,
  • conceptual thinking, calculations, and
  • orientation.

Time to administer the MoCA is approximately 10 minutes. 









Snellgrove Maze Test

The Maze Test was developed as a pencil and paper test of attention, visuoconstructional ability, and executive functions of planning and foresight. The participants complete a simple demonstration maze first in order to establish the rule set, then complete the Maze Task. Performance is measured in time (in seconds), using a stop watch, and the total number of errors. Errors are determined by the number of times the participant enters a dead-end or fails to stay in the lines.

Time to administer is 1 to 4 minutes.

 

 

 

 

Trail-Making Test

This test of general cognitive function specifically assesses working memory, visual processing, visuospatial skills, selective and divided attention, and psychomotor coordination. In addition, numerous studies have demonstrated an association between poor performance on the Trail- Making Test, Part B, and poor driving performance.







Adaptive Equipment

The use of equipment to compensate for impairments in motor performance may help an older driver continue to drive longer.

Click on the image to read about the Leg Lifter and other devices and where to obtain them in Adaptive Equipment to Compensate for Impairments in Motor Performance from Appendix C.












Read Appendix A, Appendix B, and Appendix C in the Guide to learn more.