Workshop Proceedings - AAA Foundation for Traffic Safety

Seniors face serious 

driving safety and 

mobility issues. 

2008 North American 

License Policies 

Workshop Proceedings 

June, 2008 

607 14th Street, NW, Suite 201 | Washington, DC 20005 | AAAFoundation.org | 202-638-5944

ABOUT THE RESEARCHERS 

David W. Eby and Lisa J. Molnar of the University of Michigan Transportation Research 

Institute and the Michigan Center for Advancing Safe Transportation throughout the 

Lifespan served as the organizers and “proceedings” editors for The North American 

License Policies Workshop. 

ABOUT THE SPONSOR 

This workshop was funded by the AAA Foundation for Traffic Safety in Washington, 

D.C. Founded in 1947, the AAA Foundation is a not-for-profit, publicly supported 

charitable research and education organization dedicated to saving lives by preventing 

traffic crashes and reducing injuries when crashes occur. Foundation funding is 

provided by voluntary contributions from AAA/CAA and their affiliated motor clubs, 

individual members, AAA-affiliated insurance companies, and other organizations and 

sources. 

The AAA Foundation for Traffic Safety distributes this publication at no charge, as a 

public service. It may not be resold or used for commercial purposes without the explicit 

permission of the Foundation. It may, however, be copied in whole or in part and 

distributed for free via any medium, provided the AAA Foundation is given appropriate 

credit as the source. 

The opinions, findings, conclusions, and recommendations expressed in this publication 

represent the views of the authors and are not necessarily those of the AAA Foundation 

for Traffic Safety or of any individual who reviewed this publication. The AAA 

Foundation for Traffic Safety assumes no liability for the use or misuse of any 

information, opinions, findings, conclusions, or recommendations contained in this 

publication. 

If trade or manufacturers’ names are mentioned, it is only because they are considered 

essential to the object of this publication, and their mention should not be construed as 

an endorsement. The AAA Foundation for Traffic Safety does not endorse products or 

manufacturers. 

© 2008 AAA Foundation for Traffic Safety

TABLE OF CONTENTS 

FOREWORD (J. Peter Kissinger) ................................................................................. 2 

PART I: OVERVIEW OF WORKSHOP ACTIVITIES AND OUTCOMES (D. Eby & L. 

Molnar) .......................................................................................................................... 4 

INTRODUCTION .................................................................................................................... 4 

METHODS ............................................................................................................................. 5 

Workshop Participants .................................................................................................. 5 

Workshop Structure and Process ................................................................................. 5 

WORKSHOP OUTCOMES ................................................................................................... 7 

General Themes ........................................................................................................... 8 

Consensus-Based Recommendations .......................................................................... 9 

Recommended Elements of Model Licensing Systems ............................................ 11 

SUMMARY ............................................................................................................................ 12 

CONVERGENCE WITH PREVIOUS WORK ........................................................................ 13 

NEXT STEPS ........................................................................................................................ 14 

APPENDIX A: NHTSA OVERVIEW OF OLDER DRIVER SAFETY CURRENT AND 

UPCOMING PROJECTS ...................................................................................................... 16 

APPENDIX B: AUTHOR BIOGRAPHICAL SKETCHES ..................................................... 21 

APPENDIX C: WORKSHOP AGENDA ................................................................................ 29 

APPENDIX D: RECOMMENDATIONS NOT CONSIDERED HIGH PRIORITY OR 

GENERALLY LACKING CONSENSUS ............................................................................... 32 

PART II: PAPERS COMMISSIONED FOR WORKSHOP ............................................ 36 

ROLES AND RESPONSIBILITIES OF LICENSING AGENCIES (K. SNOOK) ................... 37 

CURRENT KNOWLEDGE ON MEDICAL FITNESS-TO-DRIVE: THE ROLE OF THE 

CLINICIAN (D. CARR) .......................................................................................................... 39 

ALZHEIMER’S DISEASE AND FITNESS TO DRIVE (N. SILVERSTEIN) .......................... 71 

DRIVER SCREENING AND ASSESSMENT IN THE 21ST CENTURY (L. STAPLIN) ........ 86 

LICENSE RENEWAL POLICY & REPORTING OF MEDICALLY UNFIT DRIVERS: 

DESCRIPTIVE REVIEW & POLICY RECOMMENDATIONS (T. MEUSER) ..................... 105 

LICENSING AGENCY OPTIONS FOR INTERVENTIONS (C. SODERSTROM) .............. 123 

REMEDIATION FROM THE OCCUPATIONAL THERAPIST’S PERSPECTIVE (E. 

SCHOLD-DAVIS) ................................................................................................................ 127 

REMEDIATION FROM THE PHYSICAN’S PERSPECTIVE (R. MAROTTOLI) ................. 131 

MODEL STATE PROGRAMS ON LICENSING OLDER DRIVERS (S. CLASSEN & K. 

AWADZI) ............................................................................................................................. 140 

‘LICENSING AUTHORITIES’ OPTIONS FOR MANAGING OLDER DRIVER SAFETY – 

PRACTICAL ADVICE FROM THE RESEARCHERS’: REPORT FROM THE TRB 

WORKSHOP, 21 JANUARY 2007, WASHINGTON D.C. (J. LANGFORD) ...................... 161 

OUTCOMES OF THE AAMVA/CCMTA FORUM--CHALLENGING MYTHS AND 

OPENING MINDS: AGING AND THE MEDICALLY AT-RISK DRIVER (J. DOW) ............ 165 

OUTCOMES OF THE CANADIAN DRIVING AND FUNCTIONS FORUM (B. DOBBS) ... 167 

License Policies Workshop Proceedings-- 1

Foreword 

J. Peter Kissinger 

As we age, we are more likely to have functional limitations and more likely to require 

medications that can negatively impact safe driving, but we all age differently. Many 

older people recognize their limitations and stop or limit their driving, while others 

continue to drive even though they’re not able to do so safely. It’s a big problem now 

and it will be bigger in the future. It is projected by 2025, people aged 65 and older will 

account for 25 percent of drivers, up from 15 percent in 2005. The number of traffic 

crashes will increase proportionately unless we, as a society, take action to reduce the 

traffic risks facing these individuals. 

Seniors and their families face serious challenges in maintaining personal mobility, 

including determining whether they can improve their driving and thus their safety with 

an educational or training intervention, whether they have reached the end of their 

driving career, and—when they are unable to drive—how they can continue to be 

mobile. Moreover, some people also give up driving prematurely, when they can still 

drive safely under certain conditions or with adaptations. There is currently no uniformly 

accepted strategy or program for determining when and how to evaluate driving skills 

and abilities. Families are reluctant to take the keys from aging parents or grandparents 

for a variety of reasons, including the impact lack of mobility can have on mental health 

and quality of life. 

Just as families are reluctant to “rock the boat,” politicians and state agencies are often 

reluctant to tackle senior driving issues head-on because of political sensitivities and the 

power wielded by seniors. One of the fundamental roles of the Department of Motor 

Vehicles (DMV) is to ensure that drivers are capable of driving safely, and to restrict, 

suspend, or revoke licenses when drivers demonstrate that they are incapable or 

uninterested in driving safely. However, the DMV is also one of the state agencies that 

taxpayers deal with frequently; keeping costs down, keeping waiting lines short, and 

angering as few constituents as possible are very important. Add to that the tendency of 

some legislators to pass feel-good laws that are not based on scientific evidence or to 

use the DMV and license suspension as a way to collect everything from library fines to 

child support payments, and you have agencies that face numerous challenges. 

Other groups are reluctant to enter the fray. For instance, not wanting to lose patients or 

breach doctor-patient confidentiality, clinicians often shy away from making strong 

statements questioning their patient’s ability to drive, much less making referrals for 

driver testing. Anecdotally, it appears that law enforcement officers are more reluctant to 

give tickets to seniors; thus even though a senior may have a history of driving 

problems, this may not be reflected in his or her driving record. In short, a host of factors 

have led to the present situation, where we have a rapidly growing aging population and 

yet have ineffective policies and practices to identify and deal with seniors who have 

functional impairments that limit their ability to drive safely, while treating everyone 

fairly. 


To ensure that seniors can remain mobile after they stop driving and to improve safety 

for all members of society, we need model systems of licensing and we need to have 

alternatives to driving in one’s own car, when that is no longer possible. Consequently, 

in 2006, our Research and Development Advisory Committee selected “senior safety 

and mobility” as a priority areas for long-term research emphasis. Issues surrounding 

the licensing of older drivers are considered an important component of efforts in this 

area. 

To inform policy makers in the licensing community about what is known on a range of 

relevant issues, and to guide the development of a robust long-term research agenda in 

our ongoing research program of senior safety and mobility, AAAFTS sponsored a twoday 

workshop with experts in traffic safety and other relevant disciplines in Washington, 

DC. The “North American License Policies Workshop,” had three primary objectives: 

� Synthesize the present state of knowledge regarding older driver safety as it 

relates to the ability of aging drivers to continue to drive safely, methods or 

criteria for screening or assessing drivers, and interventions (including but not 

limited to licensing actions) appropriate for drivers identified as “high risk.” 

� Develop a consensus-based set of recommendations that could be used by 

policymakers and stakeholders to inform the development of licensing policies 

based upon the best available science. As envisioned, these recommendations 

would focus on specific criteria that could be used to identify high-risk drivers and 

appropriate measures or interventions for such drivers. 

� Identify the most important knowledge gaps and research needs related to older 

driver safety—particularly with regard to questions of licensing—and recommend 

specific lines of research that AAAFTS could pursue over the next several years 

to address them. 

After reviewing several proposals, we selected David Eby and Lisa Molnar to help plan, 

conduct, and disseminate major findings from the workshop. A key aim in planning the 

workshop was to build on the body of knowledge that has been amassed in this area in 

recent years. To that end, findings from several past efforts were reviewed and 

incorporated into the framework of the workshop, and we commissioned twelve new 

papers and presentations relevant to older driver licensing (see Part 2 of this 

document). 

Thanks to all the participants, and especially to David Eby and Lisa Molnar, for making 

the workshop a great success! 


PART I: OVERVIEW OF WORKSHOP ACTIVITIES AND OUTCOMES 

DAVID W. EBY AND LISA J. MOLNAR 

INTRODUCTION 

As a starting point for planning the conference, we reviewed the main issues that 

licensing agencies must deal with in relation to aging driver safety and mobility. These 

include accurate identification of high-risk drivers and implementing appropriate and 

effective interventions (see Table 1). 

Table 1: Licensing Agencies’ Older Driver Safety and Mobility 

Responsibilities 

Identification of High Risk Drivers Interventions 

Triggers 

Normal review process 

Referrals 

Incidents 

Screening/Assessment Process 

Screening in licensing agency 

-Visual, cognitive, etc. 

Medical review boards 

License restrictions 

License revocation 

Shortened renewals 

Remediation/training/education 

The workshop was also specifically planned to build upon several recent 

complementary events focusing on licensing policies for older adults. The first event 

was sponsored by the American Association of Motor Vehicle Administrators (AAMVA) 

and was called “Challenging Myths and Opening Minds Forum: Aging and the Medically 

At-Risk Driver,” which was held on March 4-6, 2006 in Austin, Texas. This forum 

addressed a variety of topics, including medical and legal considerations for licensing 

practices, funding options, and ways to build partnerships. AAMVA’s Aging Driver Task 

Force summarized the results, which can be found at: 

http://www.aamva.org/Events/Materials/2006ChallengingMythsRecap.htm. 

The second event took place in Vancouver, British Columbia on June 15-16, 2006 and 

was sponsored by the Office of the Superintendent of Motor Vehicles (OSMV) and the 

Traffic Injury Research Foundation (TIRF). The event was called the “Driving and 

Function Forum.” The purpose of the forum was to develop the background to revise the 

British Columbia Guide for Physicians in Determining Fitness to Drive a Motor Vehicle 

(the Guide to Drive), so that recommended guidelines would be based on the best 

available evidence that links the guidelines to functional driving ability. The forum 

included presentations on a number of topics and workshops that focused on the 

following questions: What key functions are needed for driving? How strong is the 

existing scientific evidence regarding the level of functioning needed for the safe 

operation of a motor vehicle? What are the most valid and useful protocols for 

assessing functional impairment and for which functions? What are the limitations of 

current assessment protocols and what research is needed to overcome them? 

Presentation and recaps can be found here: 

http://www.trafficinjuryresearch.com/driving_and_function/forum_overview.htm. 


The third event was a workshop that took place at the Transportation Research Board 

(TRB) Annual Meeting on January 21, 2007, called the “Licensing Authorities’ Options 

for Managing Older Driver Safety—Practical Advice from the Researchers.” The 

workshop, led by Jim Langford, included presentations and discussions on a variety of 

topics related to licensing older drivers. Papers derived from the workshop 

presentations will be appearing in 2008 (Volume 9, Issue 4) in a special issue of Traffic 

Injury Prevention. 

Several other documents were also reviewed including the 2005 report “Strategies for 

Medical Advisory Boards and Licensing Review” by Kathy H. Lococo and Loren Staplin 

(see http://www.nhtsa.dot.gov/people/injury/research/MedicalAdvisory/) and the 

National Highway Traffic Safety Administration’s overview of current and upcoming 

older driver safety projects (see Appendix A). 

METHODS 

Workshop Participants 

Participants in the workshop included authors of the commissioned papers and 

presentations (see Appendix B for biographical sketches), as well as a larger group of 

invited experts who are involved in older adult licensing policy, practice, and research. 

Participants and their roles in the workshop are shown in Table 2. 

Workshop Structure and Process 

Prior to the workshop, all participants were sent a package of materials to review, 

including the commissioned papers and presentation summaries, and electronic links to 

information on the previous events on licensing policy. The two-day workshop was held 

on December 6-7, 2007 at the Washington, DC offices of AAAFTS and was divided into 

three parts: identification of at-risk drivers (Day 1); interventions with at-risk drivers (Day 

1); and elements of model licensing systems (Day 2). Each part of the workshop began 

with a set of presentations and was followed by one or more breakout sessions to 

provide an opportunity for focused discussion on each topic (see Appendix B for 

workshop agenda). 

The workshop was organized around four breakout sessions – two in the first part, and 

one in each of the remaining parts. The breakout sessions focused on developing 

consensus guidelines for: 

1. Screening and assessment 

2. License renewal and physician reporting 

3. Interventions for “at-risk” drivers 

4. Elements of model driver license systems 

As part of each breakout session, three separate discussion groups were held 

concurrently. The makeup of the three discussion groups remained the same for all 


eakouts, with members chosen to ensure that each group included a broad spectrum 

of disciplines and backgrounds. In each discussion group, a facilitator guided discussion 

and a note-taker recorded key discussion points. After each breakout session, the three 

discussion groups came back together and facilitators reported on their group’s 

outcomes. 

Table 2: Names, Affiliations, and Roles of Workshop Participants 

Name Affiliation Role 

Michel Bédard Lakehead University Discussant 

Keli Braitman Insurance Institute for Highway Safety Discussant 

David Carr Washington University at St. Louis Presenter/Paper Author 

Neil Chaudhary Preusser Research Group Discussant 

Sherrilene Classen University of Florida Paper Author 

Lori Cohen AARP Discussant 

Peter Delahunt Posit Science Discussant 

Ann Dellinger Centers for Disease Control and Prevention Discussant 

Anne Dickerson East Carolina University Facilitator 

Bonnie Dobbs University of Alberta Presenter/Facilitator 

Jamie Dow Société de l’Assurance Automobile Presenter 

David Dunn British Columbia Automobile Association Discussant 

David Eby Univ. of MI Transportation Research Institute Workshop Manager 

Dan Foley US Department of Health and Human Services Discussant 

Barbara Freund Eastern Virginia Medical School Discussant 

David Hennessy California Department of Motor Vehicles Discussant 

Peter Kissinger AAA Foundation for Traffic Safety Discussant/Sponsor 

Jim Langford Monash University Presenter 

Richard Marottoli Yale University Presenter/Paper Author 

Dennis McCarthy University of Florida Discussant 

Thomas Meuser University of Missouri Presenter/Paper Author 

Kit Mitchell Institution of Highways and Transportation Discussant 

Lisa Molnar Univ. of MI Transportation Research Institute Workshop Manager 

Scott Osberg AAA Foundation for Traffic Safety Discussant/Sponsor 

Cynthia Owsley University of Alabama Discussant 

Elin Schold-Davis American Occupational Therapy Association Presenter 

Dannielle Sherrets AAA National Discussant 

Kathy Sifrit National Highway Traffic Safety Administration Discussant 

Nina Silverstein University of Massachusetts, Boston 

Presenter/Paper/ 

Facilitator 

Kim Snook Iowa Department of Motor Vehicles Presenter 

Carl Soderstrom Maryland Department of Motor Vehicles Presenter 

Loren Staplin TransAnalytics Presenter/Paper Author 

Jane Stutts University of North Carolina Discussant 

Brian Tefft AAA Foundation for Traffic Safety Note Taker/Sponsor 

Gudmundur Ulfarsson Washington University at St. Louis Discussant 

Bill Van Tassel AAA National Discussant 

For the first three breakout sessions, the starting point for each group’s discussion was 

a preliminary list of recommendations related to the breakout session topic, compiled 

prior to the workshop from the commissioned background papers and presentations. 

Recommendations were organized into three categories: (1) policy recommendations; 

(2) practice guidelines; and (3) research needs. Because many authors had similar 


ecommendations, when appropriate, the workshop managers combined 

recommendations, taking some liberty to clarify and simplify the wording of the 

recommendations. Discussion group participants were asked to reach consensus on 

each recommendation in terms of both priority (high, medium, or low) and the timeframe 

over which the recommendation could or should be implemented (short-term or longterm). 

Participants were also asked to identify additional recommendations that they 

considered important. 

The final breakout session on elements of model licensing systems was designed to 

build on the outcomes of the discussion from the first day of the workshop and was 

therefore conducted differently than the previous breakout sessions. Prior to the final 

breakout session, participants were provided with a summary of the Day 1 breakout 

sessions. This was followed by presentations focusing on the outcomes of the three 

previously held events on licensing mentioned earlier. Participants were asked to 

identify important elements of model licensing systems. 

After the final session, the facilitators reported back to the workshop on the system 

elements generated by their group. These were written on flipcharts and discussed by 

all workshop participants. The 10-4 Method was used to prioritize the consensus system 

elements; each workshop participant was given 10 sticker dots, which he or she could 

use to vote for his or her top choices on the flipcharts, and each participant could put no 

more than four stickers on any single element. The total number of votes indicated the 

relative priority the workshop placed on each element. 

After the meeting, the workshop managers synthesized the overall results, based on the 

written outcomes of individual breakout sessions and discussion groups, as well as 

notes taken during the breakout and plenary sessions. To ensure that more nuanced 

areas of agreement and disagreement were captured, the workshop managers also 

discussed key themes with AAAFTS staff and breakout group facilitators. The draft 

proceedings were then sent out to all workshop participants for review, and comments 

were incorporated into the final proceedings, as appropriate. 

WORKSHOP OUTCOMES 

Several outcomes of the workshop are highlighted in this section including: general 

themes that emerged during presentations and general discussion; specific policy, 

program, and research recommendations relative to screening and assessment, license 

renewal and physician reporting, and interventions for at-risk drivers; recommended 

elements of model licensing systems; and areas of convergence and divergence with 

previous meetings (mentioned above) in the area of older adult driver licensing. 


General Themes 

A number of general themes emerged from the papers, presentations, and workshop 

discussion and provide a useful context for thinking about the specific recommendations 

endorsed by participants. Themes included: 

� Driving is considered a privilege but mobility is a human right. In other words, 

people who cannot drive safely should not be allowed to drive, but there must be 

good options for them to get around once they stop driving. 

� Licensing agencies should have a role in assisting older adults’ transition from 

driving to other mobility options but the nature and extent of that role is still an 

open question. Current practices vary across jurisdictions and barriers may exist 

in terms of cost and feasibility. 

� Screening and assessment represent different and distinct domains of driver 

evaluation. Screening is the first step in a multi-tiered process and should not be 

used to make final licensing decisions. Assessment provides the basis for 

identifying reasons for functional deficits, determining the extent of driving 

impairment, recommending license actions, and identifying options for driving 

compensation or remediation. 

� Screening and assessment tools used in licensing settings must be valid and 

reliable, and also efficient, easily adopted, and cost effective. They need to 

balance scientifically sound means to identify potentially at-risk drivers against 

the practical limitations and cost of what is reasonable for a licensing agency to 

accomplish, while at the same time treating individuals in a fair and dignified 

manner. 

� Appropriate members of the medical community, through medical advisory 

boards, should be involved in decisions on individual competency to drive. 

� The issue of age-based driver screening or testing is complex and controversial. 

While certain declines are generally associated with aging, consensus is lacking 

on whether or at what age individuals should be required to be screened or 

tested. Regardless, it is generally accepted that final licensing decisions should 

be based on functional performance, not age, as there is wide variation in how 

individuals age. 

� Data are lacking on the effectiveness of many screening methods, assessment 

programs, and associated licensing policies and practices, as well as 

interventions for at-risk drivers making it difficult to implement relevant policies 

and practices at this time. 

� Randomized, controlled clinical trials and evaluations are considered the “gold 

standard” for research but are not always possible. Nonetheless, this is 


something to strive for in conducting research to evaluate best practices or 

interventions. 

� There is an opportunity to build on and take advantage of research that has been 

conducted outside the US and assess its applicability to US licensing agencies. 

� Licensing personnel at the counter can play a key role in screening; however, 

better screening tools and training are needed. Personnel must avoid “profiling” 

and they need the tools and training to be able to recognize behaviors and or 

characteristics that predict bad driving. 

� The implementation of the REAL ID Act of 2005 will have important implications 

for many of the issues addressed in the workshop and will drive a number of 

changes in licensing policy and practice. 

Consensus-Based Recommendations 

The following high-priority policy recommendations, practice guidelines, and research 

needs were identified by the workshop participants. We considered there to be 

consensus whenever at least two of the three discussion groups for a breakout session 

assigned a “high priority” rating to a recommendation. In most cases, the 

recommendations listed below were rated as high priority by all three discussion groups. 

Policy recommendations: 

� Base final licensing decisions on functional and medical fitness to drive (and not 

chronological age). 

� To the extent possible based on available scientific research, develop and 

implement across jurisdictions empirically defensible criteria and guidelines on 

medical and functional fitness to drive. 

� Enact standard reporting laws that provide civil immunity for clinicians and 

licensing personnel who report people they think may be medically unfit to drive. 

Such laws will help reduce one barrier to reporting – fear of lawsuits. 

� Establish and fund active medical advisory boards, which should be an integral 

element of state licensing agencies, and should be involved in both case review 

and policy development. 

� Expand the role of licensing agencies to include assisting at-risk drivers transition 

from driving themselves to the use of other community mobility options. 

� Expand reimbursement for assessment and remediation services. 

Reimbursement is often limited or unavailable for full driving assessments and 

driver retraining, so we need to get private and government insurance entities to 

cover these preventive services. 


Best practice guidelines: 

Despite the fact that workshop participants were experts in older driver issues, it 

became clear in the discussions that a lot of the knowledge being shared was new to 

participants. It was the first time that many participants had heard about best practices 

carried out in certain states and provinces, highlighting the need to share these 

practices more widely and effectively. 

� Provide standardized education and training for clinicians, police officers, and 

licensing personnel on fitness-to-drive issues. 

� Develop specific guidelines for licensing agencies and clinicians on how to refer 

drivers for specialized driving assessments. 

� Provide education and training to clinicians so that they fully understand existing 

laws, regulations, and policies related to reporting individuals who they think may 

be medically unfit to drive. 

� Provide incentives for physician participation in medical advisory boards. 

� Provide education and training to members of medical advisory boards on issues 

related to functional limitations and medical fitness to drive. 

� Develop resources through community collaboration to support the transition 

from driving. 

� Increase the number of qualified people who can provide driving assessments 

and rehabilitation services. This recommendation was motivated by the 

observation that current demand for these services far outstrips existing supply, 

and that this disparity will only grow worse unless action is taken. 

Research needs: 

The workshop identified specific areas in which research is needed. Chief among 

research needs is to develop better screening tools to identify which drivers should go 

through a full assessment and better assessment tools that are able to predict which 

drivers are likely to crash if they continue to drive. 

� Design and test screening and assessment tools against objective measures 

using large-scale epidemiological studies across multiple jurisdictions. 

� Translate research findings into specific, practical guidance for licensing 

agencies, clinicians, and other relevant organizations. 


� Along with focusing on whether research findings are statistically significant, it is 

important to consider whether they are clinical meaningful. For instance, just 

because a given screening tool identifies a subset of drivers with significantly 

higher risks of crashing, this increased risk may not be clinically important 

enough to take licensing action. 

� Evaluate research outcomes within the context of how applicable and defensible 

they would be at the individual driver level. 

� Continue work to determine effectiveness of interventions by expanding 

evaluation of programs and practices that are intended to promote older driver 

safety and mobility. 

Recommended Elements of Model Licensing Systems 

Currently, no state has a model system for driver licensing, although some states have 

elements of a model. The final breakout session built on findings from the earlier 

sessions and outlined elements of a model licensing systems. These elements were 

then prioritized by the full group, and thus, in some ways, are the major findings from 

this workshop. 

The model licensing system elements are listed below separately for policy and 

practice, in order of the number of votes (in parentheses). In this context, the Group 

believed all of the following recommendations were important. However, the numbers 

of votes does provide a measure of how the Group prioritized them. 

Policies 

� Driver assessment should not be age-determined, but triggered by decreasing 

functional ability, as measured objectively through screening (30) 

� Safety (crash prevention) should serve as the primary basis for driver screening 

and assessment (24) 

� Although it is not appropriate (or practical) to have age-triggered assessment, it 

is appropriate to have age-triggered driver screening, with screening only used to 

see if further testing should be done, not to determine license actions that can 

have much wider ramifications (22) 

� In-person driver license renewal should be required for drivers of all ages (21) 

� A medical advisory board with broad representation should be involved in both 

decisions on individual competency to drive and policy development relative to 

licensing (21) 

� Voluntary reporting of at-risk drivers to licensing authorities is important, as is 

immunity for those reporting (17) 


Best Practices 

� It is important to have multi-tiered systems encompassing both screening and 

assessment (27) 

� A model system requires valid driver screening tools (23) 

� High quality data systems to support licensing decisions (driver records and 

crash databases) should share information across states (21) 

� Validated road course tests for assessing driving performance are needed (16) 

� Education and training should be made available for licensing personnel, 

practitioners, and the public (16) 

� Agency responsibilities should be viewed along a continuum, with identification of 

at-risk drivers at one end and assistance in transitioning to alternative 

transportation options at the other end (11) 

� Validated driver simulation measures for assessing driving performance are 

needed (10) 

Summary 

Currently, no state has a model system for driver licensing, although some states have 

elements of a model. It is our hope that the workshop papers and the deliberative 

process used to come up with these findings and recommendations will move us a step 

closer to having model systems. Nevertheless, workshop participants recognized that 

there is a long way to go. 

The workshop participants identified a variety of best practices that could be 

implemented in licensing agencies now. These include creating strong, well-funded 

medical advisory boards and enacting laws that allow for voluntary reporting with civil 

immunity. It is not enough to just enact new laws; educating clinicians, license 

personnel, law enforcement, and the public on proper procedures for reporting 

potentially unsafe drivers is key. 

Licensing personnel at the counter can also play a key role in screening, but only if inperson 

renewal is required. Although better screening tools are needed, providing 

training on how to use existing tools is something that can be done now. Some licensing 

agencies are already making a difference with counter-level screening. 

Licensing agencies should have a role in assisting older adults’ transition from driving to 

other mobility options. At a minimum, when someone fails a driving test and is required 


to surrender his or her license on the spot, it is important that procedures are in place to 

get the person home, and it would be beneficial if the agency had a list of alternative 

transportation options in the community, so the person is not left at such a delicate time 

feeling that he or she is at the end of the road. (See “Getting Around: Alternatives for 

Seniors Who No Longer Drive,” available at www.aaafoundation.org/reports under the 

2007 listings). 

In addition, the Group strongly believed that more should be done to routinely identify 

and share best practices. Consequently, the Foundation has begun working on a project 

that will catalog best practices for driver license agencies. The project will result in a 

Website of best practices in North America; the Website will be released in early 2009 

and will be updated as license agencies move toward model systems of licensing. 

CONVERGENCE WITH PREVIOUS WORK 

There were many areas of convergence between the workshop outcomes and those of 

the licensing policy events previously mentioned. Findings from the 2007 TRB workshop 

highlighted the promise of multi-tiered systems supported by active medical advisory 

boards, and suggested that functional capacity screening may be useful as part of a 

comprehensive medical review but should not be relied on for categorical licensing 

decisions. Licensing agencies were advised to consider becoming more involved in 

helping at-risk drivers transition from driving to alternative transportation options, 

possibly in conjunction with other agencies. Other advice included basing driver 

licensing policies and practices on timely empirical evidence, and in the case of 

conflicting results, taking into consideration the mobility, independence, and social 

needs of older adults, as well as public perceptions of fair play, in licensing decisions. 

The 2006 Canadian Driving and Function Forum also highlighted the importance of 

multi-tiered systems, as well as the need for a continuum of assessment rather than just 

pass/fail and multiple settings for identifying those who may be impaired (e.g., licensing 

agencies, health care settings, public health agencies, families, community). Key issues 

focused on the need to: distinguish between screening and assessment; consider the 

setting and infrastructure requirements; establish validity and reliability, sensitivity, 

specificity, and predictive power; standardize administration within and across settings; 

and conduct structured observations during the license renewal process. Further 

research was recommended to address limitations such as the need for more evidencebased 

tools and the validation of existing tools. 

Finally, the 2006 AAMVA forum led to identification of a set of underlying core values to 

guide licensing policy for screening and assessment that included safety, fitness-based 

not age-based, sustainable, practical, flexible, evidence-based, acceptable to the public, 

and routinely re-evaluated. Among the conclusions from the forum were: age-based 

criteria are an inefficient and costly screening mechanism, fitness-based criteria will 

address the problems present among older drivers, medical conditions that affect driver 

fitness can occur at any age, driver cessation programs are necessary, wellness 


programs can extend driving, and everyone will stop driving one day underscoring the 

need to plan ahead. 

NEXT STEPS 

The North American Licensing Policies Workshop resulted in a number of widely agreed 

upon high priority recommendations for improving licensing policy and practice. These 

recommendations represent an important step in the process of developing model 

licensing systems. However, as with every strategic initiative, it takes concerted action 

and planning by individuals with a stake in the process to translate goals, objectives, or 

in the case of the workshop, recommendations, into effective outcomes. To this end, we 

propose that next steps should include the creation of several workgroups to develop 

implementation strategies (i.e., action steps, timetables, resources requirements, and 

responsible organizations and individuals) for the recommendations considered to be of 

high priority by workshop participants. The workshop provides a unique opportunity to 

do this, as many of the key stakeholder agencies and organizations were represented at 

the “table.” Specifically, we recommend the creation of the following workgroups, with 

the understanding that administrative and organizational support for the workgroups will 

be needed: 

1. A research sponsor workgroup composed of representatives from AAA Foundation 

for Traffic Safety, National Highway Traffic Safety Administration, Centers for Disease 

Control and Prevention, Insurance Institute for Highway Safety, National Institutes of 

Health, Administration on Aging, and other appropriate organizations to develop an 

implementation strategy for the consensus screening and assessment research 

recommendations (which would all essentially fit into one study). 

2. A practice workgroup composed of representatives from the American Occupational 

Therapy Association, American Medical Association, Association for Driver 

Rehabilitation Specialists, Beverly Foundation, Community Transportation Association 

of America, American Public Transportation Association, and other appropriate 

organizations to develop implementation strategies for consensus practice 

recommendations. 

3. A policy workgroup composed of representatives from the AAA Clubs, AARP, 

American Association of Motor Vehicle Administrators, Canadian Council of Motor 

Transport Administrators, Governors’ Highway Safety Association, and other 

appropriate organizations to develop implementation strategies for consensus policy 

recommendations. 

4. A group composed of interested researchers from the US, Canada, Australia, and 

other jurisdictions to synthesize current research studies relevant to older driver 

licensing, with special emphasis on initiatives outside of the US that may have practical 

applications to US licensing agencies. 


As initiatives are launched to implement these recommendations, it is important to 

continue to build on what has already been accomplished. For example, the 

“Physicians’ Guide to Assessing and Counseling Older Drivers” should serve as an 

important resource in developing standardized education and training materials for 

clinicians. It is also important to identify and foster collaboration with established groups 

that are already addressing some of these issues (e.g., AAMVA’s driver fitness 

committee, TRB’s Operator Education and Regulation Subcommittee). 


APPENDIX A 

NHTSA OVERVIEW OF OLDER DRIVER SAFETY: 

CURRENT AND UPCOMING PROJECTS 


NHTSA Older Driver Safety: 

Current Projects 

November 15, 2007 

The Offices of Behavioral Safety Research and Safety Programs are conducting the 

following older driver/occupant safety projects that address the strategy outlined in 

NHTSA’s Older Driver Traffic Safety Plan: 

Screening and Assessment 

Licensing 

Medical Providers 

Public Education and Program Promotion 

Other Activities 

Screening and Assessment 

Title: Maintaining Older Drivers’ Mobility: Evaluating and Rehabilitating Driving 

Skills, Smoothing the Transition from Driving 

Objective: Review the literature and solicit expert opinion regarding: 

• Validity of tests designed to evaluate older drivers; 

• Efficacy of remediation programs improve older drivers’ performance; 

• Value of programs that incorporate gradual transition from driving to help drivers 

to maintain their mobility. 

This project will highlight which tools/programs have evidence based support. 

Title: Taxonomy of Older Driver Behaviors and Crash Risk 

Objective: Describe relationships among functional changes, traffic conditions and older 

drivers’ errors. Tasks include: 

• Reviewing the literature and obtaining expert opinion regarding relationships 

between functional changes (sensation, cognition) and increased risky driving 

behaviors; 

• Developing a taxonomy that lists risky driving behaviors common in older drivers 

according to likely underlying functional changes and driving conditions under 

which these behaviors are most prevalent. 

Title: Building Capacity for Assessment and Rehabilitation of Older Drivers 

Objective: Eliminate barriers to establishing and operating assessment and 

rehabilitation programs. Tasks include: 

• Developing a strategy to encourage rehabilitation center administrators to 

establish driving programs 

• Pilot testing a program guide using the strategy. 

• Disseminating the program guide 


Licensing 

Title: Safety Outcomes for Older Drivers of Licensing Procedures 

Objective: Clarify the effect of licensing procedures on older drivers’ crash rates. 

• Identify 10 States with licensing policies and procedures specific to older drivers; 

• Compare older driver crash rates with those of States that lack such policies. 

Title: Enhancing Driver Fitness Programs 

Objective: Develop science-based guidelines for States’ use in making licensing 

decisions regarding drivers with medical conditions. Tasks include: 

• Reviewing medical licensing standards in states for vision, cognition, and 

physical function; 

• Developing recommendations for harmonizing practices across the States, based 

on safety data. 

Title: State Licensing Programs to Increase Reporting of Medically At-Risk Drivers 

Objective: Increase reporting of medically at-risk drivers to licensing authorities. 

Specifically, 

• The New Jersey Motor Vehicle Commission will train State judges and 

prosecutors to make referrals. 

• The Virginia Department of Motor Vehicles will train the Medical Advisory Board, 

the referral staff, and law enforcement across the commonwealth on making valid 

referrals to the DMV. 

A contractor will evaluate the projects. 

Medical Providers 

Title: Practical Guide for Physicians on Screening and Counseling Older Drivers 

Objective: Provide resources for physicians guiding older adults in driving decisions. 

Tasks include: 

• Developing a reference guide for physicians on screening and counseling older 

drivers; 

• Increasing awareness of and effective use of these medical guidelines through 

CME training seminars. 

Title: Pilot Study to Test Multiple Medication Usage and Driver Functioning 

Objective: Use medical databases to identify trends in exposure to potentially driver 

impairing (PDI) medications by seniors. Tasks include: 

• Pilot testing strategies to investigate how multiple medication use affects the 

ability to drive safely; 

• Updating state of the art knowledge about older drivers who are at risk from PDI 

medications. 

Title: Driving with a Visual Field Loss 

Objective: Compare driving behaviors in drivers with restricted and normal visual fields. 


Participants with restricted visual fields (

• Develop workshop curriculum – Work with the Pedestrian and Bicycle 

Information Center to develop materials to aid State and local efforts in 

implementing pedestrian senior safety efforts; 

• Establish and evaluate Senior Pedestrian Projects in three communities: 

o Hendersonville, NC; Madison, WI; San Francisco, CA. 

Title: Focus Groups with Older People on Transitioning From Driving 

Objective: Explore the themes and messages that help drivers decide to make the 

transition to the passenger seat. 

• Develop messages and materials that support this transition. 

Other Activities 

Title: Fitness to Drive in Early Stage Dementia 

Objective: explore the feasibility of using in-car technology to monitor driving 

performance of: 

• Older drivers recently diagnosed with dementia 

• Drivers of similar age with normal cognition 

In addition to determining whether in car devices are sufficiently sensitive to detect 

changes in driving performance in drivers with early dementia, this will provide 

information about: 

• Normal older adult driving; 

• Diving changes that can be expected to occur with the onset of dementia. 

Title: Develop and Test Prototype Seating Device for Short-Statured Older Adults 

Objective: Provide a safe, easy to use means for older drivers to raise their driver seat 

height so that they are better able to see the roadway. 

• Develop a device to raise driver’s seating position to improve their ability to see 

the roadway; 

• Evaluate device safety and usability. 


APPENDIX B 

AUTHOR BIOGRAPHICAL SKETCHES 


KEZIA AWADZI, PHD 

Dr. Awadzi is a Postdoctoral Fellow in the Department of Occupational Therapy, 

College of Public Health and Health Professions, University of Florida (UF). She 

received her B.S. in Home Science from the University of Ghana, Legon, Ghana (1993), 

her MA in Mass Communication with a concentration in Journalism from the University 

of Florida (1999), and her PhD in Health Services Research from the University of 

Florida (2006). Dr. Awadzi’s research interest primarily focuses on older driver safety 

issues. Her dissertation “Socio-ecological determinants of motor-vehicle injury among 

younger and older adults involved in a fatal crash in the United States” used the 2003 

Fatality Analysis Reporting System to identify risk and protective factors for older driver 

crash injuries. Subsequently Dr. Awadzi has authored an article, and co-authored 

numerous articles with the first author, Dr. Classen. One of these projects was awarded 

with UF’s Institute of Learning in Retirement Award for Graduate Aging Research in 

2007. 

DAVID B. CARR, MD 

Dr. Carr is an Associate Professor in the Department of Medicine and Neurology at 

Washington University at St. Louis. He is a board certified internist and geriatrician, and 

completed his fellowship training in geriatrics at Duke University in 1990. Dr. Carr 

accepted a position as Clinical Director in the Division of Geriatrics and Nutritional 

Science at Washington University in 1994. He has been a clinician in the Memory and 

Aging project in the Alzheimer's Disease Research Center for the past 14 years. He is 

the director of the geriatric fellowship program, which educates general internal 

medicine physicians for careers in geriatric medicine. Dr. Carr maintains an outpatient 

consultative practice in the Memory Diagnostic Center in the Department of Neurology, 

and is Medical Director of Parc Provence, a long-term care facility for dementia care in 

the greater St. Louis area. Dr. Carr is also an Associate Director of The Rehabilitation 

Institute of St. Louis. His research interests are in medical conditions that affect driving 

and especially, issues of assessing driving safety and cessation in the older drivers with 

dementia. 

SHERRILENE CLASSEN, PHD 

Dr. Classen is an Assistant Professor in the Department of Occupational Therapy, and 

Adjunct Professor in the Department of Epidemiology and Biostatistics, College of 

Public Health and Health Professions, University of Florida. She received her B.A. in 

Occupational Therapy from the University of the Orange Free State in Bloemfontein, 

Republic of South Africa (1984), her MPH with a concentration area in Epidemiology 

from the University of Florida (2004) and her PhD in Occupational Therapy from Nova 

Southeastern University, Fort Lauderdale, FL (2002). She completed a Post-Doctoral 

Fellowship at University of Florida in 2004. Her research interests mainly centered on 

older driver safety issues, specifically identifying the determinants of driver safety and 

reduction of crash-related injuries/fatalities among older drivers. She is interested in 

developing interventions to reduce crashes, injuries and fatalities, to facilitate driving 

safer and longer, and to promote independence in community mobility. As a recipient of 

the Centers for Disease Control and Prevention’s Career Development award (2004- 


2008), she had been researching the effects of medications and chronic conditions, the 

social network, environmental design and political environments on the driving 

performance of older adults. She instructs graduate students in the Occupational 

Therapy and Rehabilitation Science Doctoral Programs; has authored numerous peer 

reviewed articles and presentations on older driver safety issues; and is primary 

convener elect (2008-2010) for the Transportation and Aging Formal Interest Group of 

the Gerontological Society of America. 

BONNIE DOBBS, PHD 

Bonnie Dobbs is an Associate Professor and Director of Research, Division of the Care 

of the Elderly in the Department of Family Medicine at the University of Alberta, 

Edmonton, Alberta, Canada. She has a BA (Honors with First Class Standing) and a 

PhD in Gerontology, with specialization in Psychology, Human Ecology, and Medicine, 

from the University of Alberta. Her primary research interests include the effects of 

medical conditions on driving competence, procedures that improve identification of 

medically at-risk drivers, the consequences of driving cessation for medically impaired 

older drivers and their families, the role of support groups for individuals who have had 

to stop driving [and for their caregivers], and the role of alternate transportation in 

maintaining the mobility, independence, and safety of medically at-risk drivers. 

In 1998, she was awarded a contract from the U.S. National Highway 

Transportation and Safety Administration (NHTSA) and the Association for the 

Advancement of Automotive Medicine (AAAM) to provide an integrative review of the 

scientific research on medical conditions and driving, and to oversee the development 

of new consensus guidelines for physicians for medically-at-risk drivers. That review 

has been highly influential, with the American Medical Association using it as a scientific 

basis for developing The Physician’s Guide to Assessing and Counseling the Older 

Driver. She was involved in the development of the guide as an expert panel member. 

Dr. Dobbs is currently updating that review, and publishing a book on the subject matter 

due for release in 2008. 

Dr. Dobbs has been involved as an expert member on numerous national and 

international committees/working groups on the older driver/medically at-risk driver. She 

has published in the areas of medical conditions and driving, driver assessment 

procedures, and the consequences of having to stop driving. Dr. Dobbs also has 

provided expert testimony nationally and internationally on medical conditions and 

driving, and has presented locally, nationally, and internationally on the older driver and 

the medically at-risk driver. 

JAMIE DOW, MD 

Dr. Dow is the Medical Advisor on Road Safety at the Société de l'assurance 

automobile du Québec (SAAQ). A former emergency physician, he holds academic 

qualifications from the Royal Military College, Concordia University, University of 

Saskatchewan and Université Laval. 

Currently he is the chairman of the Medical Advisory Committee of the CCMTA 

and the Canadian medical representative on the AAMVA Driver Fitness Working Group. 

He was a member of the Scientific Editorial Board for the 7 th Edition of the Canadian 

Medical Association's medical guide and the chairman of the working group formed by 


the Quebec College of Physicians to produce the practice guidelines on driver fitness 

assessment published in April 2007. On-going projects include continuing medical 

education programmes on road safety, rewriting the Quebec regulations on the medical 

aspects of licensing and a comprehensive study of Quebec drivers and the relationship 

between severity of disease and accident risk. 

DAVID W. EBY, PHD 

David W. Eby is a Research Associate Professor and Head of the Social and Behavioral 

Analysis Division at the University of Michigan Transportation Research Institute 

(UMTRI) where he has been working since 1993. He holds a doctorate degree in 

experimental psychology from the University of California, Santa Barbara. He has also 

held a postdoctoral fellowship in the Department of Cognitive Sciences at the University 

of California, Irvine. While at UMTRI, Dr. Eby’s research has focused on reducing the 

number of deaths and injuries associated with motor-vehicle crashes by conducting 

behavioral research that improves the safety of automobile transportation. An important 

component of this work has been to improve the safety and mobility of older drivers. In a 

project sponsored by the Federal Highway Administration, he has investigated how invehicle 

navigation assistance systems might be useful for maintaining safe driving in the 

older population. In a project for General Motors and NHTSA, Dr. Eby led the 

development and validation of a self-screening instrument (Driving Decisions 

Workbook) intended to educate older drivers about their current abilities, what those 

abilities mean for safe driving, and what older people can do to continue driving safely. 

Since its development, the workbook has been converted into Japanese, edited for 

Australia by the Road Traffic Authority of New South Wales, and included on several 

older driver web pages, such as the American Association of Occupational Therapists 

site. In a recently completed project for NHTSA, Dr. Eby led the development and 

validation of a new web-based self-screening instrument called SAFER Driving: the 

Enhanced Driving Decisions Workbook. Dr. Eby is a co-convener for the Transportation 

and Aging Interest Group of Gerontological Society of America. Dr. Eby is the Founding 

Director of the Michigan Center for Advancing Safe Transportation throughout the 

Lifespan (M-CASTL), a University Transportation Center sponsored by the US 

Department of Transportation and focused on both young and older adult users of the 

transportation system. 

J. PETER KISSINGER, MS 

Mr. Kissinger has over 30 years of experience in transportation safety. He has been 

President and CEO of the AAA Foundation for Traffic Safety since May of 2002. The 

AAA Foundation is a not-for-profit affiliate of AAA and the AAA motor clubs that 

supports research and develops educational products to enhance traffic safety. Other 

relevant experience includes 10 years with the Civil Engineering Research Foundation 

where he managed “Innovation Centers” that evaluated new technologies for the public 

works and transportation community, and 8 years as the Managing Director of the 

National Transportation Safety Board (NTSB). Previously, he served as a 

Transportation Safety Specialist with NTSB, conducting evaluations of transportation 

safety programs, and an Operations Research Analyst with the US Coast Guard where 

he evaluated proposed Federal safety standards and managed a research and 


development program. He has an MS in Operations Research from George Washington 

University and a BS in Engineering from the US Coast Guard Academy. 

JIM LANGFORD, M.ED 

Jim Langford joined the Accident Research Centre as a full-time Senior Research 

Fellow in mid-2005, after five years as a part-time secondment from the Department of 

Infrastructure, Energy and Resources,(Tasmania). He is currently involved in a range of 

projects dealing mainly with older driver and speed issues and is also responsible for 

editing and contributing to the Australasian Road Safety Handbook. 

RICHARD A. MAROTTOLI, MD, MPH 

Dr. Marottoli is an Associate Professor of Medicine at the Yale University School of 

Medicine, an attending physician at the VA Connecticut Healthcare System, and 

Director of the Adler Geriatric Assessment Center at Yale-New Haven Hospital. He is a 

former chairperson of the Committee on the Safe Mobility of Older Persons of the 

National Research Council’s Transportation Research Board and a member of the 

Connecticut DMV Medical Advisory Board and the Connecticut DOT and DPH CODES 

project advisory group. 

THOMAS M. MEUSER, PHD 

Dr. Meuser, is a licensed Clinical Psychologist and currently an Associate Professor of 

Social Work and Psychology at the University of Missouri – St. Louis. He serves as 

Director of Gerontology, as an instructor for graduate courses in aging, and as a social 

science researcher. From 1999-2007, Dr. Meuser was a Research Associate Professor 

of Neurology at Washington University School of Medicine in St. Louis. His research 

interests include mobility in aging, medical fitness to drive, loss and grief in aging and 

dementia, and educational program development and evaluation. Dr. Meuser has 

received funding support from the Alzheimer’s Association, Automobile Association of 

America Foundation for Traffic Safety, National Institute on Aging, National Highway 

Traffic Safety Administration, and the Missouri Department of Transportation. He serves 

as a master trainer and consultant to the Older Drivers Project of the American Medical 

Association. His research has appeared in such journals as The Gerontologist, the 

International Journal of Gerontology, the Clinical Gerontologist, and OMEGA: The 

Journal of Death & Dying. 

LISA J. MOLNAR, MHSA 

Lisa Molnar is a Lead Research Associate with the Social and Behavioral Analysis 

Division of UMTRI where she has worked since 1986. She holds a B.A. in Sociology 

from Michigan State University and an M.H.S.A. in Public Health Policy and 

Administration from the University of Michigan School of Public Health. Her primary 

areas of interest are traffic safety and driver behavior. Ms. Molnar has worked on a 

variety of projects focusing on: older safety and mobility; adolescent driving behaviors; 

development and evaluation of traffic safety laws, policies, and programs; prevention of 

alcohol-impaired driving; and use and misuse of safety belts and child safety seats. Ms. 

Molnar has considerable experience in conducting literature reviews and moderating 

focus groups with older adults, especially in the areas of self screening of driving-related 


abilities, and driving reduction and cessation. Ms. Molnar has also explored occupant 

protection issues in focus groups with young, middle-age, and older drivers. She coauthored 

the Driving Decisions Workbook, a self-screening instrument for older drivers, 

and was the primary author on Promising Approaches to Enhancing Elderly Mobility, a 

guide that identifies promising programs and practices in the areas of screening and 

assessment, education and training, vehicle modifications and advanced technology, 

roadway design, and alternative transportation. She is currently updating that guide in a 

project sponsored by AARP. She is also the co-investigator of a project sponsored by 

the Alzheimer’s Association to compare multiple forms of assessment of early stage 

Alzheimer’s patients with actual driving performance. Ms. Molnar is the primary 

convener of the Transportation and Aging interest group of the Gerontological Society of 

America and a member of the American Society on Aging. Ms. Molnar is the Assistant 

Director of the Michigan Center for Advancing Safe Transportation throughout the 

Lifespan (M-CASTL). 

ELIN SCHOLD-DAVIS, OTR/L 

Ms. Schold-Davis has headed the American Occupational Therapy Association’s 

(AOTA) Older Driver Initiative since its launch in 2003. She is an occupational therapist 

specializing in adult rehabilitation and driving. For the past 15 years she has pursued 

opportunities for advancing occupational therapy's role in the Activity of Daily Living 

(ADL) of driving and community mobility. Current AOTA initiatives include projects 

supported by the National Highway Traffic Safety Administration (NHTSA) targeting 

therapist education and driving rehabilitation program expansion to meet the emerging 

needs of older drivers in their communities. Elin has authored articles and lectured 

nationally and internationally on the topics of both cognitive rehabilitation and driving. 

Elin is a certified driving rehabilitation specialist (CDRS), a member of the American 

Society on Aging’s DriveWell Speakers Bureau, and a CarFit Instructor. She represents 

AOTA on the National Older Driver Safety Advisory Council and TRB’s Committee 

ANB60 Safe Mobility of Older Persons. 

NINA M. SILVERSTEIN, PHD 

Dr. Silverstein is Professor of Gerontology at the University of Massachusetts Boston, 

College of Public and Community Service. She received her Ph.D. in 1980 from the 

Heller School at Brandeis University. Since 1984, she has worked closely with the 

Alzheimer’s Association on projects relating to the Association’s Helpline, its Safe 

Return Program, respite care, support groups for family caregivers, home safety 

adaptations, and environmental and behavioral issues in special care units for people 

with dementia. She was honored in 2007 by the Alzheimer’s Association Massachusetts 

Chapter as their Person of the Year. She is a Fellow of the Gerontological Society of 

America and serves on the executive committee of the Association for Gerontology in 

Higher Education. She has co-authored two books: Dementia and Wandering Behavior: 

Concern for the Lost Elder and Improving Hospital Care for Persons with Dementia 

(Springer Publishing: NY). Recent publications have appeared in The Gerontologist, 

Gerontology and Geriatrics Education, Geriatrics and Aging, Transportation Research 

Record, and the Annals of Emergency Medicine. She spent a sabbatical in Washington, 

DC for the ’04-05 academic year where she divided her time between the Department of 


Transportation and the Alzheimer’s Association Public Policy Division. She is currently a 

co-investigator with a team from the University of Michigan Transportation Research 

Institute that was awarded funding from the national Alzheimer’s Association for a 

project titled: Fitness to Drive in Early Stage Dementia: An Instrumented Vehicle Study. 

KIM SNOOK 

Ms. Snook, Director, Office of Driver Services for Iowa. Ms. Snook has worked for Iowa 

State Government for 28 years in all aspects of driver licensing. Ms. Snook is the 

current Chair of AAMVA (American Association of Motor Vehicle Administrators 

(AAMVA) Driver Fitness Working group and also a Region III board member for 

AAMVA's International Driver Examiner Certification program. Ms. Snook has worked 

on many projects concerning driver fitness and research programs nationally and within 

the State of Iowa. 

CARL A. SODERSTROM, MD, FACS 

In September 2005 Dr. Soderstrom was appointed Chief, Medical Advisory Board and 

Director, Driver Safety Research Program of the Maryland Motor Vehicle Administration. 

He leads the MAB in providing advice regarding medical fitness to drive based on 

current clinical practices and research. 

Dr. Soderstrom was a member of the surgery/traumatology faculty of the Shock 

Trauma Center of the University of Maryland School of Medicine for 25 years attaining 

the rank of Professor of Surgery. He was a Senior Researcher at university’s National 

Study Center (NSC) for Trauma and EMS. In addition to a wide variety of clinical areas, 

Dr. Soderstrom has conducted research on issues involving substance abuse and 

trauma, particularly as related to vehicular crashes. He has over 100 publications. 

Dr. Soderstrom served and continues to serve on local, regional, and national 

groups addressing injury prevention. Current appointments include: Transportation 

Research Board of the National Research Council - Alcohol, Other Drugs, & 

Transportation Committee; Association for the Advancement of Automotive Medicine 

(AAAM) - Board of Directors, Executive Committee and president-elect for the year 

2008. He is a member of the American Association of Motor Vehicle Administrators 

Driver Fitness Working Group which is a multi-year project to develop national driving 

fitness guidelines and policies. 

Dr. Soderstrom was a member of the Surgeon General’s Work Group on Drunk 

Driving (1988) and NHTSA’s Partners in Progress Work Group (1995). He has provided 

testimony on numerous injury prevention legislative initiatives. In 2003, he testified in 

the National Transportation Safety Board’s hearing on Medical Review of the Non- 

Commercial Driver. 

Dr. Soderstrom continues to teach at the Shock Trauma Center and to assist in 

NSC research projects. He is a Faculty Associate at the Johns Hopkins University 

Bloomberg School of Public Health Department of Health Policy & Management. 

LOREN STAPLIN, PHD 

Dr. Staplin is the founder and Managing Partner of the consulting firm TransAnalytics, 

LLC. He has also served as a Senior Research Scientist with the Texas Transportation 

Institute (2002-2003); Vice-President for Transportation Safety at the Scientex 


Corporation (1992-2000), and Senior Associate with Ketron, Inc. (1982-1992). Before 

joining Ketron, Dr. Staplin worked for three years at Lehigh University in Bethlehem, 

Pennsylvania, as an assistant professor in Experimental Psychology. He is a member of 

long standing of the Human Factors and Ergonomics Society; and is a founding 

member of the newly-formed (2002) Human Factors Resources advisory group to the 

National Committee on Uniform Traffic Control Devices. Dr. Staplin also is a member of 

the National Academy of Sciences' Transportation Research Board, and currently 

serves as Chair of the Committee on Operator Education and Regulation (ANB30). 


APPENDIX C 

WORKSHOP AGENDA 


NORTH AMERICAN LICENSE POLICIES WORKSHOP 

December 6-7, AAA Foundation for Traffic Safety 

607 14 th St., NW, Suite 201, Washington, DC 20005 

WORKSHOP AGENDA 

December 6, 2007 

Time Description Participant 

8:30 – 9:00 Hot Breakfast All 

9:00 – 9:10 Welcome Kissinger 

9:10 – 9:30 Opening Remarks 

Part 1: Identification of At-Risk Drivers 

Eby 

9:30 – 9:45 Roles and responsibilities of licensing 

agencies 

Snook 

9:45 – 10:00 Current knowledge on medical fitness-todrive: 

The role of the clinician 

Carr 

10:00 – 10:15 Alzheimer’s Disease and fitness to drive Silverstein 

10:15 - 10:30 Driver screening and assessment in the 21st 

century 

Staplin 

10:30 – 10:45 License renewal policy & reporting of 

medically unfit drivers 

Meuser 

10:45 – 11:45 *Breakout Session #1: Consensus guidelines 

All 

for screening and assessment 

11:45 – 12:15 Reporting out for session 1 Facilitators 

12:15 – 1:15 Lunch All 


for license renewal and physician reporting 

All 


Part 2: Interventions with High Risk Drivers 

2:45 – 3:00 Licensing agency options for interventions Soderstrom 

3:00 – 3:15 Remediation from the OT’s perspective Schold-Davis 

3:15 – 3:30 Remediation from the physician perspective Marottoli 


for intervention 

All 



December 7, 2007 

Time Description Participant 

8:30 – 9:00 Continental Breakfast All 

9:00 – 9:15 Overview of Day 1 Eby/Molnar 

Part 3: Elements of Model Systems 

9:15 – 9:30 Licensing authorities’ options for managing 

older driver safety – Practical advice from the 

TRB workshop 

9:30 – 9:45 Outcomes of the AAMVA/CCMTA Forum-- 

Challenging Myths and Opening Minds: 

Aging and the medically at-risk driver 

9:45 - 10:00 Outcomes of the Canadian Driving and 

Functions Forum 


for a model driver license system 

Langford 

Dow 

Dobbs 

11:00 – 12:00 Reporting out and discussion for session 4 Facilitators/All 

12:00 – 1:00 Lunch and continued discussion All 

1:00 – 1:15 Wrap up Eby/Kissinger 

*Breakout sessions will involve workshop participants meeting in small groups to discuss and 

reach consensus on the session topic. Discussions will be focused and led by a facilitator. 

All 


APPENDIX D 

RECOMMENDATIONS NOT CONSIDERED HIGH PRIORITY 

OR GENERALLY LACKING CONSENSUS 


RECOMMENDATIONS NOT CONSIDERED HIGH PRIORITY OR GENERALLY LACKING CONSENSUS 

In many cases, at least one group did not even assign a priority rating because the 

group felt that more research was needed before policy or practice guidelines could be 

developed. Such recommendations are marked with an asterisk (*). 

Breakout Session 1: Screening and assessment 

Policy recommendations 

� Consider enhanced vision testing and/or extending vision testing requirements to 

adults in midlife.* 

Practice guidelines 

� Require standardized reassessment intervals for drivers with dementia who have 

been deemed safe to drive.* 

� Adopt guidelines for feasible screening practices in licensing agencies including 

use of computer-based measures to promote standardization; automated 

measures to minimize staff time; careful integration of new measures to promote 

acceptance. 

� Develop multi-tier assessment processes for use in licensing agencies. 

Research needs 

� Develop national registry of older drivers who have undergone assessment for 

driving fitness to provide large sample for studying effects of various screening, 

assessment, and intervention strategies. 

� Develop a mid-level screening tool (e.g., more complex than self-screening but 

less so than formal assessment). 

Breakout Session 2: License Renewal and Physician Reporting 


� Foster national dialog on driver license renewal standards. 

� Require in-person renewal for potentially at-risk drivers (e.g., age based at 80+ or 

85+).* 

� Shorten and standardize renewal period for all drivers (e.g., every 4 years).* 

� Consider “incentive” approach to license renewal for individuals of all ages, inrenewal 

resulting in full-term license and other forms of renewal in abbreviated 

license.* 



� Develop standard forms for physician reporting across jurisdictions that go 

beyond simple visual acuity or visual field checks.* 


� Evaluate effectiveness of mandatory versus voluntary reporting laws and 

reporting forms for detecting and managing conditions affecting driving and 

ultimately for impacting traffic safety. 

� Evaluate effects of licensing renewal policies on actual driving performance and 

crash risk but also identification of intermediate outcomes that may demonstrate 

benefits (e.g., participation in rehabilitation, use of alternative transportation). 

Breakout Session 3: Interventions for At-Risk Drivers 


� Broaden societal perspective to view licensing policy within the larger framework 

of independent community mobility and foster society-wide dialog on thresholds 

of acceptable risk, roles and responsibilities of licensing agencies and clinicians, 

and mobility-quality of life issues. 


� Improve communication and coordination among professionals, federal agencies, 

and states. 

� Include individuals and families in goal and priority setting for meeting 

transportation needs.* 


� Determine whether combining interventions results in added benefit or just 

escalating lists and complexity. 

ADDITIONAL RECOMMENDATIONS IDENTIFIED BY A SINGLE GROUP 

Screening and assessment 

� Enhance alternative transportation, maintenance of mobility (policy) 

� Increase research funding (policy) 

Licensing renewal and physician reporting 

� All licensing agencies should have in-house medical component (policy) 

� Support re-initiation of data collection on state licensing projects (practice) 

� Develop guidelines for multi-disciplinary composition for MABs (practice) 

� Provide standardized resource materials/curriculum for MABs (practice) 

� Determine the barriers to and incentives for physician participation in MABs 

(research) 

� Determine pathways to identify and evaluate at-risk drivers (research) 


� Validate screening and assessment tools across multicultural communities 

(research) 

Interventions for at-risk drivers 

� Consider when drafting policy that driving is a privilege and mobility is a right 

(policy) 

� Encourage licensing agencies to collaborate with local agencies (practice) 

� Develop and evaluate tools to assist individuals and families in goal setting for 

meeting transportation needs (research) 

� Develop whether education/coalition model in Canada is replicable in US 

(research) 

� Explore how licensing agencies fit into broader issue of safe mobility (research) 

� Identify outcomes in addition to crashes (research) 

� Assess reliability and validity across road testers (research) 

� Validate licensing agency road test (research) 


PART II 

PAPERS COMMISSIONED FOR WORKSHOP 


ROLES AND RESPONSIBILITIES OF LICENSING AGENCIES 

Kim Snook 

Director, Office of Driver Services 

P.O. Box 9204 

Des Moines, IA 50021 

Kim.Snook@dot.iowa.gov 


Licensing agencies have three roles: Highway Safety, Customer Service, and 

Education. 

Highway Safety is the key to a licensing agency. The many aspects of highway 

safety include making sure customers are capable and competent to operate a motor 

vehicle – this includes any type of motor vehicle from a moped to a commercial semi. 

Licensing personnel try to determine a customer’s ability during a brief, face-to-face 

meeting. Not an easy accomplishment to establish a licensing decision during a renewal 

process. The lack of established criteria to use during the license process is apparent. 

The need for proven tests for screening and assessing drivers is lacking. Beginning at 

age 70, Iowa has a shorter renewal period and allows additional time to meet with the 

customer. Jurisdictions also need to communicate with law enforcement agencies. 

When a customer is stopped and cited for a traffic violation or has an accident, it is 

important that the customer’s driving record be documented with this information. An 

accident can lead to a suspension or reexamination of a person’s ability to operate a 

motor vehicle. Likewise, a moving violation which is severe enough will lead to the 

customer’s license being suspended or revoked for a period of time governed by rules 

and regulations. Some violations require classes or evaluations before the customer is 

able to become licensed again. 

Customer Service: Every customer has needs. It’s our job to identify customer needs 

and to satisfy them as appropriately and effectively as we can. For example, an 

amputee may need special equipment to safely operate a vehicle and may require more 

time to determine what is needed. An elderly customer is another example. This 

customer may only need to drive in their hometown to accomplish tasks such as doctor 

appointments, getting groceries, and going to religious functions. A restricted license 

allows this customer to remain independent and safe. Customers must be served by 

licensing personnel in a timely manner, yet special licensing takes time. At locations that 

service a large number of customers, safety is sometimes compromised due to the 

pressure to get people through in a timely manner. 

Education: Educating physicians, law enforcement personnel, and the general public is 

an effective way of maintaining highway safety. Programs and presentations are an 

excellent way to educate the public on topics such as younger and older driver issues. 

Law enforcement personnel can be trained to recognize problems such as dementia 

and physical conditions (e.g., hearing loss, loss of dexterity and vision problems), and 

thereby help in determining when to have a person’s driving reviewed. Many times 

jurisdictions can’t take action on a driver without having the accident report and referrals 

from law enforcement and other agencies. Physicians have knowledge of the 

capabilities of their patients; however, they’re not always educated about which 

functional impairments are associated with driving problems. Caregivers also need to be 

educated about driving laws and taught how to recognize dementia and other medical 

conditions that are associated with diminishing driving skills. 


CURRENT KNOWLEDGE ON MEDICAL FITNESS-TO-DRIVE: THE ROLE OF THE 

CLINICIAN 

David B. Carr, MD 

Associate Professor of Medicine and Neurology 

Clinical Director, Division of Geriatrics and Nutritional Science 

Associate Medical Director, Rehabilitation Institute of St. Louis 

Washington University School of Medicine 

4488 Forest Park Ave., Health Key Building, Suite 201, St. Louis, MO 63108 

dcarr@im.wustl.edu 


ABSTRACT 

This manuscript will focus on common and important medical conditions that: a) are of 

high prevalence in the older adult population; b) have a known direct effect on functional 

abilities that are key to operating an automobile; c) can be detected with relative ease or 

at low cost, yet may be missed by primary care physicians; d) have been linked to 

driving impairment (e.g. evidenced-based); and e) are amenable to available treatments 

and/or interventions to improve, maintain, or slow progression of the disease. The 

medical conditions discussed in this paper are: 

• Reduced vision (e.g. cataracts, glaucoma, macular degeneration) 

• Cognitive limitations (e.g. stroke, sleep apnea, medications) 

• Motor skill deficits (e.g. arthritis and muscle weakness). 

These diseases, although not all-inclusive, will be used as key examples of 

conditions that should be detected, assessed, and treated by primary care physicians. 

Drivers’ license agencies may request physician evaluations for older adults whose 

abilities to drive safely have been questioned. The information or specific information 

that is requested on these forms may be of assistance in diagnosing and managing 

medical illnesses. The definition and epidemiology of these specific diseases or 

conditions will be reviewed, along with the common symptoms of the disease, and the 

brief methods of physician office screening and/or detection. In addition, the key 

functional abilities that are necessary for driving that are affected by the condition will be 

discussed, along with the known evidence of impact on driving. Dementia, another 

common and key disease, is covered in the paper by Silverstein and will not be 

discussed in this paper. In addition, this review will not address illnesses that cause an 

impaired level of consciousness such as epilepsy, syncope, or the use of alcohol. 

Finally, the physician’s role in the licensing process will be reviewed. Medical review by 

driver licensing agencies (i.e. by requiring medical evaluations for high-risk drivers or 

input from Medical Advisory Boards) may serve dual roles of health promotion and 

enhancement of on-road safety. 

INTRODUCTION 

There are 36 million people over age 65 years in the United States representing 12 

percent of the population with almost 5 million people over age 85 years (US Census 

Bureau, 2005). Future estimates indicate that 21 percent of our population will be over 

age 65 by mid-century representing over 86 million older adults (US Census Bureau, 

2005). Currently, there are over 28 million licensed drivers age 65 years and older in the 

United States representing 15 percent of the driving population, and this percentage is 

expected to increase to 25 percent by the year 2030 (Insurance Information Institute, 

2007). Many of these current and future older adults will drive safely into late life. 

However, age-related chronic medical illnesses that progress in severity will impair the 

ability to drive for a substantial minority. If such illnesses are undetected, under-treated, 

or not amenable to stabilization or improvement, then this group of vulnerable older 

adults may be at-risk for a motor vehicle crash and/or driving cessation. 


The incidence and prevalence of chronic disease increases with advanced age. More 

than 1.7 million people die of a chronic disease each year and chronic disabling 

conditions affect more than one of every 10 citizens or about 25 million people (CDC, 

2005). In 2002 over 50 percent of older adults stated they had some type of chronic 

disabling illness, with 37 percent of these reported to be severe and 16 percent requiring 

some type of assistance (Administration on Aging, 2006). These numbers rise 

dramatically with advanced age with 30 percent of older adults over age 80 reporting the 

need for some type of assistance. However, not all chronic medical illnesses significantly 

impact driving. Dementia and visual impairment certainly have the potential to impair the 

operation of a motor vehicle, while hearing impairment (although not uncommon in late 

life) may be less of an issue. Two recent reviews of medical conditions have implicated 

numerous illnesses that place the patient and/or the public at risk (Dobbs, 2002; 

Charlton, Koppel, O'Hare, Andrea, Smith, Khodr, et al., 2004). Many of these illnesses 

are age-related and have a higher prevalence in late life. 

As part of the driver licensing system process in the United States, we not only need to 

assure qualifications to drive, but to prepare for the cadre of older adults that lose their 

license due to medical infirmities. Community-based interviews of older adults who have 

stopped driving indicate that medical conditions or health complaints were the most 

common reasons cited for driving cessation (Dellinger, Sehgal, Sleet, & Barrett-Connor, 

2001; Brayne, Dufouil, Ahmed, Dening, Chi, McGee, & Huppert, 2000). On average, 

older men can expect to live about six years and older women about 10 years without 

the ability to drive a car (Foley, Heimovitz, Guralnik, & Brock, 2002). Driving cessation 

can lead to decreased socialization or a reduction in out-of-home activities (Marottoli, de 

Leon, Glass, Williams, Cooney, & Berkman, 2000), and an increase in depressive 

symptoms (Ragland, Satariano, & MacLeod, 2005). There is recent data to suggest that 

driving cessation is associated with an increased risk of nursing home placement 

(Freeman, Gange, Munoz, & Wet, 2006). In addition, there is a significant societal cost 

for providing transportation services to older adults who no longer drive. Interventions 

that prevent loss of driving skills may therefore have substantial benefits to patients and 

society. Thus, any driver license system that interfaces with medically impaired older 

adults must also face the stark reality of assisting these vulnerable elders with the issue 

of driving retirement and mobility counseling. 

There are a myriad of common medical diseases that have the potential to impair driving 

in late life. It is beyond the scope of this paper to cover the numerous illnesses that have 

been comprehensively reviewed and/or studied in this area. This manuscript will focus 

on common examples of important medical conditions that: a) are of high prevalence in 

the older adult population; b) have a known direct effect on functional abilities that are 

key to operating an automobile; c) can be detected with relative ease and at low cost, 

yet may be undetected by the primary care physician; d) have been linked to driving 

impairment in evidence-based literature; and e) are amenable to available treatments 

and/or interventions to improve, maintain, or slow progression of the disease. 

The main objective of this review is to summarize information on common medical 

illnesses or conditions in late life that can be grouped into three categories based on 


their potential to impair key intrinsic factors or functional abilities needed for driving. They 

include; vision (e.g., cataracts, glaucoma, macular degeneration), cognition (e.g., stroke, 

sleep apnea, medications), and motor skills (e.g., arthritis and muscle weakness). These 

diseases will be used as examples of conditions that should be detected and treated by 

primary care physicians. The definition and epidemiology of each specific disease or 

condition will be reviewed, along with the common symptoms of the disease and the 

brief methods of physician office screening and/or detection. In addition, the key 

functional abilities that are necessary for driving that may be affected by the condition 

will be discussed along with the known evidence of impact on driving. Dementia is 

covered in a separate paper by Silverstein and will not be discussed in this paper. In 

addition, this review will not address illnesses that cause an impaired level of 

consciousness such as epilepsy, syncope, or the use of alcohol. 

Drivers’ license agencies may request physician evaluations, and the specific 

information that is requested on drivers licensing forms may be of assistance to guide 

diagnosis and treatment of the patient. In the second part of this manuscript we will 

explore the role of the physician in the license renewal process, the different aspects of 

referral laws among the states and how they may influence the decision to report a 

patient or medical condition, the role of the medical advisory board, and finally discuss 

key aspects of the licensing process that need further development and/or research. 

KEY MEDICAL CONDITIONS (SUMMARIZED IN TABLE 1) 

VISION 

Cataracts 

Cataracts can be defined as a clouding or opacity of the lens of the eye. An estimated 

20.5 million (17.2 percent) Americans older than 40 years have a cataract in one eye, 

and 6.1 million (5.1 percent) have pseudophakia/aphakia. The total number of persons 

who have a cataract is projected to rise to 30.1 million by 2020; and for those who are 

expected to have pseudophakia/aphakia, to 9.5 million (The Eye Diseases Prevalence 

Research Group, 2004). According to Dana, Tielsch, Enger, Joyce, Santoli, and Taylor 

(1990), cataracts have the highest rate of self-reported visual impairment and account 

for over 8 million physician office visits every year (Koch, 1985). They are typically 

classified according to their location in the lens such as nuclear, cortical, or 

subcapsular. 

Risk factors for cataracts include diabetes, smoking, alcohol, ultraviolet light, and some 

medications. There are secondary causes due to glaucoma, radiation, or trauma. 

Common symptoms include cloudy or blurry vision, faded colors, halo around lights, 

glare, poor night vision, double vision, or frequent changes in eyeglass prescription. 

Static visual acuity and standard contrast sensitivity testing can be used for detection of 

impaired vision due to cataracts. Screening for functional impairment attributed to vision 

is often done by questionnaire. Scores on the VF-14 (Steinberg, Tielsch, Schei, & Javitt, 

1997) have been correlated with impairment in daily activities prior to surgery and with 

improvement after cataract surgery (Friedman, Tielsch, Vitale, Bass, Schein, & 

Steinberg, 2002). Cataracts are often detected by history of classic symptoms or 


documenting impaired static visual acuity and graded by direct visual inspection, 

typically during a slit lamp exam in an eye clinic. 

From a functional standpoint, an impaired lens typically affects visual acuity, contrast 

sensitivity, and disability glare, the latter being attributed to retinal straylight (Mabtyjari & 

Tuppurainen, 1999). However, research has indicated that the effect on contrast 

sensitivity may be most predictive of driving impairment (Higgens & Wood, 2005). 

Cataracts have been associated with increased crash risk (Owsley, Stalvey, Wells, & 

Sloane, 1999) and cataract surgery has been noted to decrease that risk (Owsley, 

McGwin, Sloane, Wells, Stalvey, & Gauthreau, 2002). Although this could be due to 

improvement in visual acuity, in part this is probably mediated by improvements in 

contrast sensitivity (Owsley, Stalvey, Wells, Sloane, & McGwin, 2001). This is 

consistent with a closed course road test study which found that measurements of 

contrast sensitivity were the best predictor of improved performance after surgery 

(Wood & Carberry, 2006). In addition, this study noted improvements in sign 

recognition, ability to detect and avoid hazards, and overall performance. 

Recently, lens extraction has also been noted to improve straylight values that could 

reduce the disability that is associated with glare (Van Den Berg, Van Rijn, Michael, & 

Heine, 2007) and loss of color vision (Espindle, Crawford, Maxwell, Rajagopalan, 

Barnes, Harris, & Hileman, 2005). In addition, cataract surgery has been noted to be 

associated with improvement or increased frequency of daytime and night-time driving 

(Bassett, Noertjojo, Nirmalan, Courtright, & Anderson, 2005). Leinonen and Laatikainen 

(1999) found that those who delay cataract surgery have been noted to be at increased 

risk for losing driving privileges. On a positive note, a recent study documented that 

after cataract surgery, over 20 percent of older adults that had stopped driving returned 

to operating a motor vehicle (Monestam & Wochmeister, 1997). 

Macular Degeneration 

Macular degeneration (MD) can be defined as a deterioration of the retina, and 

specifically the macula, where there resides a high number of photoreceptors that are 

needed for sharp or high-resolution acuity. An estimated 1.75 million (1.5 percent) 

Americans older than 40 years have MD in either eye, and MD affects up to 80 percent 

of women over age 80 (The Eye Diseases Prevalence Research Group, 2004). The 

same study noted that the total number of persons who have macular degeneration is 

projected to rise to almost 3 million by 2020. Many experts refer to the condition as Age- 

Related Macular Degeneration (ARMD) since there is a higher prevalence with age. 

Ophthalmologists typically separate the types of ARMD into wet (exudative) or dry. 

Severity is typically rated as mild, intermediate, or severe. Although wet ARMD is less 

common, it has a poorer prognosis and is responsible for a higher percentage of the 

functional visual loss. 

Risk factors for macular degeneration include being white, female, and having a family 

history. Common symptoms for dry macular degeneration include the need for brighter 

light when reading, difficulty adapting in low lit environments, blurry print, a decrease in 

intensity of colors, trouble recognizing faces, haziness of overall vision, or a blind spot in 


center of visual fields. Wet ARMD may cause visual distortions such as straight lines 

appearing wavy, a decrease in central vision, or a central blurry spot (CNN, 2006). 

Hallucinations can also occur despite intact cognition, a condition referred to as Charles 

Bonnet syndrome. 

ARMD is associated with an increased rate of depression, impaired quality of life, and 

impaired function (Dong, Childs, Mangione, Bass, Bressler, Hawkins, Marsh, et al., 

2004). Specifically, ARMD has been associated with decreased mobility, impaired 

reading or watching TV, and difficulty recognizing faces (Hassan, Lovie-Kitchin, & 

Woods, 2002). Screening for impaired function can be done by visual questionnaires 

such as the National Eye Institute Vision Function Questionnaire-25 (DeCarlo, Faao, 

Wells, & Owsley, 2003) and detection in the office is suggested by an impaired 

performance on an Amsler grid. ARMD is detected and graded by direct visual 

inspection, typically during a slit lamp exam in an eye clinic. 

An impaired macula typically affects central visual acuity. Thus, the ability to detect cues 

in the driving environment could be impaired, such as reading traffic signs, construction 

zone information, or viewing traffic in the forward line of sight. A recent review by 

Fletcher and Schuchard (2006) found that visual functional abilities that were tested in 

patients with ARMD noted declines in contrast sensitivity, visual fields, color contrast 

sensitivity, flicker detection, and adaptation. Questionnaire data have indicated that 

older adults with macular degeneration who drive are less likely to drive at night, during 

the rain, in heavy traffic, or during rush hour (DeCarlo et al., 2003). 

Two small studies found that patients with macular degeneration had an increased 

crash risk while driving at night (Szlyk, Fishman, Severing, Alexander, & Viana, 1993; 

Syzlik, Pizzimenti, Fishman, Kelsch, Wetzel, Kagan, & Ho, 1995). In a larger study, 

macular degeneration was found to be associated with increased at-fault crash risk 

(Owsley, McGwin, & Ball, 1998). Photocoagulation or photodynamic therapy (laser 

therapy), can stabilize conditions in exudative cases. More recent use of antivascular 

endothelial growth factors actually improves vision, moving the treatment of this disease 

beyond stabilization (Smith, Joseph, & Grand, 2007). 

Glaucoma 

Glaucoma is a condition that destroys the optic nerve, often in the setting of ocular 

hypertension, and is relatively common in older adults. An estimated 2.2 million (1.9 

percent) Americans older than 40 years have glaucoma in one eye, and glaucoma 

affects up to 3 percent of the population over age 55 (Weston, Albadi, & White, 2000). 

The total number of persons with the disease is projected to rise to over 3 million by 

2020 (The Eye Diseases Prevalence Research Group, 2004). In 2005, the American 

Academy of Ophthalmology stated that glaucoma is one of the leading causes of visual 

blindness, yet almost 50 percent are unaware of their diagnosis. There are two main 

types of glaucoma; chronic Open-Angle Glaucoma (OAG) and acute narrow angle 

glaucoma which is an ocular emergency (i.e. at risk for sudden loss of vision). The 

former is the more common condition reflected in the numbers cited above and is the 

subject of this section. 


Risk factors for OAG are increased intraocular pressure, trauma to the eye, thinner 

corneas and steroid treatment. Not all patients with elevated intraocular pressure (e.g. 

21 mm Hg or more) lose visual fields or have nerve cupping, and these individuals may 

be labeled as glaucoma suspects. Additional risk factors include advanced age, black 

race, and family history of the disease. Most patients do not have symptoms (Horton, 

2001). Grierson (2000) notes that with more advanced disease, the patient may 

complain of loss of peripheral vision or “tunnel” vision. There may be frequent 

prescription changes for glasses, difficulty in adjusting to darkened rooms, blurred or 

foggy vision, rainbows around objects, or mild chronic headaches. 

Most family physicians can raise the index of suspicion for a disease by performing 

ophthalmoscopy. The optic disc findings that suggest glaucoma are an enlarged cupdisc 

ratio greater than .5, asymmetry of the ratio between the two eyes of .2 or more, or 

simply an asymmetric cup (Distelhorst & Hughes, 2003). Computer based perimetry can 

map out the visual fields and provide feedback on the extent of damage. There is a 

small minority of patients who do not have elevated pressure, but still have the optic 

nerve manifestations of glaucoma. Ophthalmologists detect or diagnose the disease 

when it causes classic optic disc cupping and typical visual field loss. 

Screening for the disease has limitations. Goldman Applanation Tonometry (GAT) is the 

gold standard for measuring pressure, but there is a portable unit (Perkins) that is not as 

restrictive in positioning the patient. Other screening options that are available, brief, 

and more portable, include the Tono-Pen and non-contact tonometers (NCT) that use 

collimated light beams with directed puffs of air to measure intraocular pressure (IOP). 

However, measuring IOP is not sensitive, since some patients with disease have normal 

pressures. More emphasis has been made on the optic disc examination and visual 

fields. Visual fields can be assessed by Goldman perimetry, Humphrey threshold visual 

field testing, short-wave automated perimetry (SWAP), the pattern electroretinogram 

(PERG) and Frequency doubling technology (FDT) (Nduaguba & Lee, 2006). Quigley 

(1998) notes that the FDT correlates well with Humphrey threshold visual-field testing in 

the clinic and does appear to have the ability to predict future visual-field loss (Mederos, 

Sample, & Wenreb, 2004) 

Visual functional impairment can be assessed by using the National Eye Institute Vision 

Function Eye Questionnaire (NEI-VFQ) (Mangione, Berry, Spritzer, Janz, & Klein, 1998) 

and a newly validated instrument-- The Glaucoma Symptom Scale (Lee, Gutierrez, 

Gordon, Wilson, Cioffi, Ritch, et al., 1998). In questionnaires given to patients with 

glaucoma, this group was noted to drive less than non-glaucoma patients at night, on 

freeways, and in unfamiliar areas (Adler, Bauer, Rottunda, & Kuskowski, 2005). 

Although visual fields have been correlated with impairment in driving, at least one 

simulator study noted that contrast sensitivity was actually a better predictor of driving 

performance (Szlyk, Taglia, Paliga, Edward, & Wilesky, 2002). When glaucoma patients 

are followed longitudinally in an eye clinic, most retain functional vision across their life 

span, but a significant number (~50%) will have driving ineligibility related to their vision 

(Szlyk, 2002). 


A recent study from Canada noted that patients in a glaucoma clinic in comparison to 

controls had an increased risk for motor vehicle crashes in the previous five years and 

also an increase in at-fault crashes (Haymes, LeBlance, Nicolela, Chiasson, & 

Chauhan, 2007). Of all the baseline visual measures that were used in this study, 

Useful Field of View® was most predictive for crashes, but visual field impairment and 

stereopsis were also associated with increased at-fault crash risk. While several other 

studies have shown increase in crash risk in patients with glaucoma (Hu, Trumble, 

Foley, & Eberhard, 1998; Owsley, McGwin, & Ball, 1998; Szlyk, Mahler, Seiple, Deepak, 

& Wilensky, 2005), others have not (McGwin, Mays, Joiner, DeCarlo, McNeal & Owsley, 

2004; McCloskey, Keopsell, Wolf, & Buchner, 1994). Two crash studies that noted 

increased risk, studied patients with moderate to severe disease who have an impaired 

visual field of less than 100 degrees total horizontal field (Szlyk et al., 2005) or 

impairment in the central 24 degrees radius field in the worse functioning eye (McGwin, 

Mays, & Joiner, 2004). 

Recent studies have indicated that lowering intraocular pressure decreases the rate of 

progression (Heijl, Leske, Bengtsson, Hyman, Bengtsson, & Hussein, 2002; Leske, Hejl, 

Hussein, Bengtsson, Hyman, & Komaroff, 2003).Treatment can be either medical (e.g., 

eye drops) or surgical with use of a laser. Eye drops either reduce intraocular pressure 

by decreasing aqueous production and/or increasing outflow. Beta-blockers are typically 

prescribed to decrease aqueous production (e.g., Betoptic or betaxolol), as are topical 

carbonic anhydrase inhibitors (e.g., Trusopt), or combination agents (e.g., Cosopt or 

dorzolamide and timolol maleate combination). Topical prostaglandin analogs (e.g., 

latanoprost or Xalatan) are the most common medications that are prescribed for this 

condition and decrease aqueous production. Alpha agonists can both increase aqueous 

outflow and decrease production and are at times used in combination or as 

monotherapy (e.g., Alphagan and brimonidine tartrate). 

COGNITION 

Cerebrovascular Accident 

A cerebrovascular accident (CVA), or stroke, occurs when the blood supply to the brain 

in a specific area is diminished or occluded. Strokes are often classified into 

ischemic/infarcts or hemorrhagic/bleeds. Stroke is the third leading cause of death in 

most industrialized countries, making up 10 percent of all deaths (Leske, Hejl, Hussein, 

Bengtsson, Hyman, & Komaroff, 2003). Each year in the U.S., about 500,000 people 

experience a first stroke attack and 200,000 experience a recurrent attack. Stroke most 

heavily impacts select groups such as African-Americans between the ages of 35 and 

65 (American Heart Association, 2004). While fatalities are decreasing, morbidity is 

increasing—stroke is the leading cause of serious disability in the U.S. In 1999, more 

than 1,100,000 American adults reported functional limitations resulting from stroke. 

From 50–70 percent of stroke survivors regain functional independence, but 15–30 

percent fails to regain independence, and 20 percent require institutional care at three 

months after onset (Thom, 2006). Research on the proportion of working age stroke 

survivors who return to work shows mixed findings, with rates from 7 to 84 percent in 20 

studies across a number of countries (Lock, Jordan, Bryan, & Maxim, 2005). In 2006, 


the American Stroke Association noted that Americans will pay about $57.9 billion in 

2006 for stroke-related medical costs and disability. 

Symptoms of stroke are myriad and can include visual symptoms (e.g. visual field loss, 

inability to recognize objects), motor impairment (e.g. weakness of the limbs, dysphagia 

or trouble swallowing), sensory loss (e.g. numbness or loss of sensation), cognitive (e.g. 

neglect or hemispatial inattention), and/or deficits in gait/balance. Risk factors include 

hypertension, heart disease, diabetes, smoking, excessive alcohol use, and possibly 

hypercholesterolemia. The functional deficits from stroke that are relevant to driving 

include muscle weakness or paralysis, cognitive deficits such as memory loss, 

executive dysfunction, hemispatial inattention or visual field cuts, aphasia, and/or 

sensory loss. 

Usually, the diagnosis is not difficult when symptoms and signs are obvious and 

especially, when they correlate with new findings from brain imaging studies. However, 

small infarcts can escape initial detection, especially when they are asymptomatic or the 

symptoms are subtle. Definitions of stroke are usually based on the Trial of Org 10172 

in Acute Stroke Treatment (TOAST) classification system, which has a high degree of 

inter-observer reliability (Adams, Bendixen, Kapplelle, Biller, Love, Gordon, & Marsh, 

1993). This stroke classification system provides for specific definitions of stroke and 

classifies the subtypes based on etiology. 

There have been many tools created to rate the severity of stroke and the degree of 

disability or functional impairment attributed to the disease. The National Institute of 

Health Stroke Scale (NIHSS) assesses neurological impairment and is an indicator of 

stroke severity (Brott, Adams, Olinger, Marler, Barsan, Biller, et al., 1989). This 13-item 

test produces scores ranging from 0 (no deficit) to 46 (severe deficit). The Rankin scale 

(Sulter, Steen, & De Keyser,1999) measures independence rather than performance of 

specific tasks. The Barthel Index (BI) (Mahoney & Barthel, 1965) measures the patient's 

performance in 10 activities of daily life. The items can be divided into a group that is 

related to self-care (feeding, grooming, bathing, dressing, bowel and bladder care, and 

toilet use) and a group related to mobility (ambulation, transfers, and stair climbing). The 

maximum score is 100 indicating that the patient is fully independent in physical 

functioning. The lowest score is 0, representing a totally dependent bedridden state. 

The Stroke Impact Scale (SIS) is a 59-item assessment that is divided into eight 

domains. The participant is asked to rate their perceived recovery on a scale of 0-100 

with 0 being no recovery and 100 being full recovery (Duncan, Lai, Bode, Perera & 

DeRosa, 2003). 

Legh-Smith, Wade, and Hewer, (1986) noted a significant number of community 

dwelling stroke patients continue driving (~42 percent). Yet, in one study the majority of 

stroke patients (87 percent) did not receive any type of formal driving evaluation, but 

simply resumed the operation of a motor vehicle (Fisk, Owsley, Vonne, & Pulley, 1997). 

The greater longevity after stroke suggests that health professionals will be faced with 

increasing numbers of patients who continue to drive. Crash studies and stroke have 

been few and results have not been consistent. One study did note an increase in crash 


isk in stroke patients when compared to controls (Koepsell, Wolf, & McCloskey,1994). 

However, Salzberg and Moffat (1998) in the state of Washington did not find an 

increase in risk. 

Of all of the areas in neurology, stroke (except for perhaps dementia) has probably 

been the most studied disease in regards to fitness-to-drive or in determining the ability 

to pass a road test by off-road assessments. 

Preliminary studies on fitness-to-drive in stroke patients note that those patients that fail 

road tests have worsening scores on measures of perception, cognition, and complex 

visual-perception/attention information (Engrum, Lambert, & Scott, 1990). One test, the 

Motor-Free-Visual Perception Test (Bouska & Kwaty, 1982) appeared to have promise 

in a pilot study (Mazer, Korner-Bitensky, & Sofer, 1998), but was not found by itself to 

be predictive of failure on a road test with a larger validation study (Korner-Bitensky, 

Mazer, Sofer, Gelina, Meyer, Morrison, et al., 2000). Lundzvist and colleagues (2000) 

found that tests requiring high-order cognitive functions such as mental control, working 

memory, and attention provided the best differentiation of driving skills in patients with 

CVA. Work in Europe has tested the Stroke Driver Screening Assessment that includes 

a dot cancellation test (visual selective attention), compass test (divided attention, 

visuospatial orientation, reasoning), and road sign recognition (mental speed, working 

memory, and executive function). Using this battery the investigators were able to 

correctly classify 80 percent (pass/fail) of stroke patients that were administered an onthe-road 

test (Lundberg, Caneman, Samuelsson, Hakamies-Blomqvist, & Almkvist, 

2003; Nouri & Lincoln, 1993). 

Treatment of stroke usually includes both aggressive management of risk factors and 

rehabilitation. The latter can occur in a variety of settings including inpatient 

rehabilitation, a skilled nursing center, or home. Patients may find themselves in more 

than one setting during their course of recovery. Cognitive rehabilitation has potential to 

improve those impaired domains that are crucial for driving. One promising study in this 

area was able to double the rate of patients returning to driving after stroke by utilizing 

driving simulation training (Akinwuntan, Feys, Pauwels, Baten, Arno, & Kiekens, 2005). 

This study suggests that some stroke patients that retire from driving may be able to 

operate a motor vehicle if only for the opportunity to receive remedial skills training. 

Medications 

Polypharmacy is often defined based on the number of medications that are routinely 

taken (e.g. five or more), but can also be defined simply as taking too many medications 

or unnecessary medications (Family Practice Notebook, 2007). Based on these 

definitions, polypharmacy is common in older adults. As many as 28 percent of older 

adults over age 65 will take five or more prescription medications (Mitchell, Kauffman, 

Kelly, & Rosenberg, 2005). Older adults represent 12 percent of the population in the 

U.S., yet consume over 30 percent of prescription drugs (Rathmore, Mehta, Boyko, & 

Schulman, 1998). Therefore, many older adults have multiple medical problems and are 

on numerous medications. As a group, they are at higher risk for adverse drug events, 

due to age-related changes in drug metabolism, taking more routine medications 

increasing the changes for drug-drug or drug-disease interactions, and the presence of 


co-morbidities. 

Pharmacokinetics, or how a drug is metabolized in the human body, changes with 

aging. The proportion of adipose tissue increases with aging so medications such as 

benzodiazepines (e.g. Valium, Xanax) will have a longer duration of action. Total body 

water decreases by 15 percent over age 80 years, so the volume of distribution for 

hydrophilic drugs such as alcohol or cimentidine is decreased resulting in higher drug 

concentrations. Elderly persons have decreased lean body mass. Since digoxin binds to 

muscle, toxicity can occur at lower doses. The concentrations of plasma proteins such 

as albumin may decline in older adults. This results in reduced bound form of many 

medications and greater free drug levels. Phase I (Cytochrome P450) oxidation does 

decline on average with aging, and doses of medications that are metabolized through 

this pathway should be reduced. Many medications are excreted by the kidney and will 

often need to be adjusted by estimating creatinine clearance by age and body weight, 

since kidney function declines with aging. 

Pharmacodynamics describes the reaction or response to the specific drug. End organ 

responsiveness to a drug at the receptor level may be altered with aging. Changes in 

receptor binding, a decrease in receptor number, or altered translation of a receptorinitiated 

cellular response into a biochemical reaction may be responsible. Findings in 

the literature include a decreased response to beta blockers; and an increased 

sensitivity to benzodiazepines, opiates or narcotics, warfarin, and anticholinergics. It 

should be noted that many of the medications in the latter group have been implicated 

in driving impairment. 

Certain drugs have a high likelihood of causing side effects in the geriatric population 

due to decreases in physiologic reserve in organs systems with aging or disease. There 

are published lists of medications that should be avoided in the older adult population 

along with drug-drug and drug-disease interactions (Fick, Cooper, Wade, Waller, 

Maclean, & Beers, 2003). According to Wilkinson and Moskowitz (2001) a significant 

number of community-dwelling elderly (up to 25 percent) are prescribed drugs from this 

list. Many of these agents cause anticholinergic side effects or sedation, and have been 

associated with increased crash risk. The list of drug-drug or drug-disease interactions 

continues to grow as new agents are released, and it remains a difficult problem to stay 

up-to-date for many physicians and pharmacists. Most hospitals and pharmacies utilize 

computerized drug interaction software and may identify potential problems before they 

occur. 

There are many common medication classes that have been studied and are either 

associated with increased crash risk or impaired driving skills when assessed by 

simulators or road tests. These include, but are not limited to, narcotics and barbituates 

benzodiazepines, antihistamines, antidepressants, antipsychotics, hypnotics, alcohol, 

antiepileptic agents, anti-emetic agents, and muscle relaxants. One study focused on 

older drivers noted that long-acting benzodiazepines have been associated with 

increased crash rates (Hemmelgarn, Suissa, Huang, Boivin, & Pinard, 1997). Another 

report suggests that there may be a significant number of older adults driving while 


intoxicated or under the influence of other medications (Higgins, Wright, & Wrenn, 1996; 

Johansson, Bryding, Dahl, Holmgren, & Viitanen, 1997). 

Wang (2003) noted that any drug that can depress the central nervous system is 

associated with impairment in operating a motor vehicle. A new way to classify 

medications has been developed and classifies medications as to whether or not they 

are Potentially Driver Impairing (PDI) Medications. As more PDI medications are 

prescribed and used, crash risk increases (Leroy & Morse, 2005). PDI effects may 

include: sleepiness, fatigue, or sedation; lightheadness, dizziness, or low blood 

pressure; blackouts or syncope; or impaired coordination. Medications can affect 

eyesight in numerous ways including blurred vision, impaired visual fields, and night 

time vision (Wang, 2006). Kerrigan noted that some drugs have been found to delay 

central processing speed, leading to using inappropriate force with the steering wheel, 

or braking too late. However, it should be noted that many medication and driving 

studies are simply correlational in nature, and results may suggest increased crash risk 

but not necessarily prove causation. Whether it is the medication itself, the condition for 

which it is prescribed, the presence of other co-morbidities, or any combination, is 

difficult to sort out. Yet, clinicians should be aware of the associations and attempt to 

use the safest class of medications based on the most recent evidence. 

Older adults may have numerous physicians and multiple pharmacies. The primary care 

physician should write down all drugs by generic name and eliminate all unnecessary 

medications. Clinical indications should be identified and documented for all drugs, and 

those medications without a therapeutic benefit should be stopped. The side effect 

profile of each drug should be known to the clinician. Safer medications should always 

be substituted and lists in the medical record should be updated at each visit. Before a 

new drug is started, the clinician should identify risk factors for adverse drug reactions 

including advanced age, liver or kidney disease, or multiple medications. The risk of 

medication errors increases dramatically with the number of medications taken by the 

patient. 

Compliance is another major issue with older adults. Drug regimens should be simple, 

utilize the same dosage schedule with other drugs, and be administered as part of a 

daily routine task such as eating a meal. Instructing relatives and caregivers on drug 

regimens and monitoring by home health nurses and pharmacists may reduce adverse 

drug events. Aids such as pillboxes and calendars may increase compliance. Reviewing 

a patients’ knowledge of why they take medications, in addition to education about 

adverse drug reactions is paramount. 

Sleep Apnea 

Sleep apnea can be referred to as a periodic cessation of breathing during sleep. It is 

commonly undiagnosed and often under treated. It has been suggested that the 

prevalence rate may be as high as diabetes, with 4 percent of men and 2 percent of 

women affected (Young, Palta, Dempsey, Skatrud, Weber, & Badr, 1993). It has been 

defined as cessation of breaths for at least 10-seconds in duration. This results in 

fragmentation of sleep, daytime sleepiness, and nighttime awakenings. Some patients 


have a reduction in their airflow or a hypopnea. The apnea-hypopnea index refers to the 

total number of episodes per hour during sleep. A value of 5 or greater is considered 

abnormal and is associated with impaired function. 

There are many correlates of disturbed sleep including high blood pressure and right 

sided congestive heart failure, and the disease is correlated with increase mortality. 

There are two types of sleep apnea that are often described and include obstructive, 

where there is resistance to airflow, and central, where there is a reduced or diminished 

drive to breathe. Snoring is correlated with obstructive sleep apnea and this occurs 

often during REM sleep when the pharyngeal muscles are relaxed and the upper airway 

collapses. Risk factors include obesity, large neck circumference, male sex, and 

acromegaly. The other risk factors may be history of hypothyroidism and/or sedative or 

alcohol use. 

Symptoms can be variable. They may include daytime sleepiness and snoring, but also 

there may be headache, memory loss, impaired concentration or coordination, 

irritability, depression, anxiety, sweating, dry mouth or drooling, and reflux. Detection 

may be reported by a bed partner who can provide information such as cessation, 

gasping, snoring, or breathing cessation during sleep (Olson, Moore, Morgenthaler, 

Gay, & Staats, 2003). Attempts have been made to predict a diagnosis of sleep apnea 

based on history or exam. These include questionnaires such as the Berlin 

Questionnaire (Netzer, Stoohs, Netzer, Clark, & Strohl, 1999), the Epworth sleepiness 

scale (Johns, 1991), or using neck circumference size. The gold standard for diagnosis 

is the overnight polysomnography. Based on an overnight sleep study, sleep clinicians 

will rate the presence and severity of the disease, usually in the mild, moderate, or 

severe category. 

Drowsy driving is a common cause for a motor vehicle crash, and some authorities 

believe that 100,000 crashes a year attributed to fatigue may be a conservative figure. 

Crash risk is related to the amount of sleep that was previously obtained (Garharino, 

Nohili, Beelke, De Carli, & Ferrillo, 2001). Sleep disorder crash risk may be confounded 

or enhanced by the medication use such as analgesic or antihistamine use (Howard, 

Desai, Grunstein, Hukins, Armstrong, Joffeet et al., 2004). Maycock (1996) studied the 

Epworth and correlated impaired levels with crash risk. Sleep apnea patients have been 

noted to have increased crash risk ranging from two-fold to seven-fold increase 

depending on the study (Teran-Santos, Jimenez-Gomez, & Cordero-Guevara, 1999), 

and these drivers are also at risk for more serious injury (Medical News Today, 2007). 

These findings have been attributed to drowsiness and lack of concentration. There are 

a myriad of additional crash studies and driving simulator studies that have found 

increased crash risk or impairment due to driver fatigue, and improvements in driver 

performance with treatment. These have been extensively reviewed elsewhere 

(Charlton, et al., 2004). Thankfully, George (2001) and other investigators have found 

that treatment reduces crash risk back to base-line levels. 

Initial interventions may include weight loss (as little as 10 percent loss may be helpful), 

exercise, and behavioral therapy. There are oral devices that can assist patients with 


mild sleep apnea. Continuous Positive Airway Pressure (CPAP) has been shown to 

improve cardiac function, reduce blood pressure, and improve quality of life (Mansfield, 

Gollogly, Kaye, Richardson, Bergin, & Naughton, 2004). Zozula and Rosen (2001) have 

documented that compliance rates are low. Up to 40 percent of patients with untreated 

severe sleep apnea may die over an 8-year period (He, Kryger, Zorick, Conway, & 

Roth, 1998). Surgical procedures may be of benefit and tracheostomy is performed in 

severe cases (Alvi & Lee, 2005). 

MOTOR FUNCTION 

Muscle Weakness/Arthritis 

It is probably accurate to state that musculoskeletal abnormalities (e.g. diseases that 

cause muscle weakness, physical frailty, or restricted joint range of motion) have been 

less studied in terms of driving outcomes. The different types of diseases that can affect 

musculoskeletal function are broad and include (but are not limited to); arthridities, 

amputation, spinal cord injury, trauma, surgery, or deconditioning and weakness. The 

prevalence of a common form of arthritis (osteoarthritis) will be discussed in this section 

and mobility issues in general that relate to driving impairment will also be reviewed. 

It is estimated that over 40 million individuals in the U.S. have some form of arthritis and 

over 7 million report limited activity (Arthritis Foundation, 2007). Osteoarthritis, in the 

category of degenerative joint diseases, is the most common form of arthritis in older 

adults and affects over 20 million people (WrongDiagnosis, 2007). Cartilage is typically 

lost in this condition causing bone on bone friction, deformities, pain, and restrictions in 

mobility. The joints that are usually affected are the large weight bearing joints such as 

the hips, knees, and lower back, although neck, hands, and feet are also commonly 

affected. Risk factors include family history, injury, obesity, and advanced age. 

The major symptoms are pain, swelling, and loss of joint mobility, restricted range of 

motion, and if severe, diminished activities of daily living. Clinicians can assess muscle 

strength and joint range of motion by physical examination, but can also use devices 

such as dynamometers and goniometers for more specific measurements. However, 

these are less likely to be used in clinical practice and more commonly present in 

rehabilitation centers. The diagnosis of osteoarthritis is suggested by an insidious 

history of pain and discomfort along with common physical exam findings in typical 

joints, and is confirmed by radiographic findings. 

Problems driving that have been reported by patients with musculoskeletal disorders 

include difficulties with seat belt and key use, adjusting mirrors and seats, in steering, in 

transferring in and out of the car, in driving in reverse, and in using the foot pedal 

(Hones, McCAnn & Lassere, 1991). There have been several efforts to correlate 

functional abilities such as range of motion and muscle function with driving. However, it 

should be noted that these studies have not just focused on degenerative joint disease, 

but on general groups of older adults. For instance, driving impairment has been 

correlated with the inability to reach above the shoulder (Hu & Hu, 1998). 


Older adults with physical disabilities or frailty may be at increased risk for a motor 

vehicle crash (Sims, McGwin, Allman, Ball, & Owlsey, 2000; Marottoli, Wagner, Cooney, 

& Tinetti, 1994) and are more vulnerable to injury (Kent, Funk, & Crandall, 2003). 

Walking less than one block a day, impaired left knee flexion, and the presence of foot 

abnormalities all correlated with an adverse driving event in one study (Marottoli, et al., 

1994). Another study noted that crash involved subjects were more likely to have more 

difficulty walking ¼ mile than controls (Sims, McGwin, Pulley, & Roseman, 2001). The 

authors also cite numerous references in the literature in their discussion section that 

have found an association of a history of falls with an increased risk for a motor vehicle 

crash. Diminished cervical range of motion and delayed rapid pace walk have also been 

recently correlated with increased crash risk (Ball, Roenker, Wadley, et al., 2006; 

Staplin, Lococo, Gish, & Decina, 2003). 

A diagnosis of arthritis and the use of NSAIDs were associated with increased at-fault 

crash risk in a recent study (McGwin, Sims, & Pulley, 2000). This finding was also noted 

in a large study in the state of Utah that examined medically impaired drivers, and found 

an increased crash risk for drivers with musculoskeletal disorders, but not for muscle or 

motor weakness (Vernon, Diller, Cook, Reading, Suruda, & Dean, 2002). Conversely, 

patients with a specific diagnosis of osteoarthritis in one study (Koepsell, 1994) were no 

more at-risk for a crash than controls. Also reassuring was a recent study by Henriksson 

noting no increase in crash risk of drivers with cars that had been adapted for their 

musculoskeletal restrictions. 

Although the crash literature is incomplete, musculoskeletal abnormalities have been 

associated with driving cessation. In one study of an exercise intervention, where 

current and former drivers were compared, the current drivers had a lower rate of joint 

deformities, fewer sedating medications, faster cognitive processing speed, stronger 

grip strength, better joint range of motion, higher aerobic power, and faster walking 

speed (Carr, Flood, Steger-May, Schechtman, & Binder, 2006). Thus, arthritis, muscle 

strength, and range of motion may be important determinants of maintaining driving. 

The finding that weaker grip strength was an independent predictor of being a former 

driver has been also previously described (Retchin, Cox, Fox, & Irwin, 1988), and 

indicates that motor weakness may place older adults at risk for driving retirement. 

Interventions for joint disorders may include the use drugs in several medication classes 

including acetaminophen, to non-steroidal anti-inflammatory agents (NSAIDSs), 

narcotics, injections, steroids, and surgery. There are a host of non-pharmacologic 

interventions that have met with various success in treating osteoarthritis and include 

exercise, weight loss, heat, cold, topical analgesics or anesthetics, TENS units, 

ultrasound, massage, and whirlpool. Many of these interventions are offered in pain 

clinics and/or rehabilitation centers. Early intervention of arthritic disorders has the 

potential to improve or maintain driving skills and decrease crash risk or driving 

cessation, although this still needs to be proven. 


CLINICIANS’ ROLE IN THE DRIVERS LICENSING PROCESS 

Clinicians such as physicians, nurse practitioners, and physician assistants are often 

called upon by the State Department of Motor Vehicles (DMV) for assistance in 

determining fitness to drive. In addition, clinicians, themselves, may consider referral of 

an impaired driver from their practice if concern is raised regarding driving safety. 

Interestingly, a recent report from the Organization of Economic Co-Operation and 

Development noted support for a more focused approach to license re-evaluation. This 

is based on the assumption that a majority of the risk is attributable to those with 

medical illnesses causing functional deficits that are more prevalent with aging. Thus, it 

is recommended that future efforts for evaluating older driver safety should target these 

at-risk older adults and not all older adults (OCED, 2001). 

However, in order to target drivers with medical or functional impairment there must be 

a mechanism, policy, or law in the state that allows for referrals from health 

professionals or law enforcement agents. Concerns in regards to confidentiality and 

lawsuits have been cited as barriers to physician reporting. Six states currently have 

mandatory reporting requirements, including California, Delaware, New Jersey, Nevada, 

Oregon, and Pennsylvania. In California, physicians are required to report any patient 

with a disorder characterized by lapse of consciousness. This law includes disorders 

such as seizure disorders and Alzheimer’s disease among other conditions. Minimal 

data have been collected on the effectiveness of mandatory physician reporting. 

CLINICIAN REFERRAL TO STATE AUTHORITIES 

All 50 states have regulations supporting physicians’ voluntary reporting of unsafe 

drivers, but a few actually mandate reporting certain medical conditions. In most states, 

physicians report driving safety concerns to the DMV. States with mandatory reporting 

typically use standardized forms for physicians to complete and submit; those with 

voluntary reporting laws have various means for gathering information on potentially 

unsafe drivers. Although these forms may require a visual examination, rarely will they 

recommend a screen for dementia or daytime sleepiness. 

Many physicians appear to be unaware of state reporting requirements, and they should 

request a copy of the medical standards for retaining drivers’ licenses from their state as 

well as reporting requirements. One invaluable source of this information is the 

Physician’s Guide to Assessing and Counseling the Older Driver from the American 

Medical Association (AMA), which details the reporting regulations and mechanisms for 

each state. Another good source is the Insurance Institute for Highway Safety. Both are 

available online at www.ama-assn.org/ama/pub/category/10791.html and 

www.iihs.org/laws/state_laws/older_drivers.html. 

In many states, physicians are generally protected from civil liability when reporting 

unsafe drivers if the report is made in good faith and without malice. One caveat: if a 

patient is involved in an crash and determined to be at fault, physicians can be held 

liable—even in states with voluntary reporting. The key for physicians to protect 

themselves from liability is to document all concerns, recommendations, and referrals to 

outside sources and keep them in the patient’s file. Although it has been upheld in case 


law that sharing a patient’s personal information is a violation of the privacy regulations 

of the Health Insurance Portability and Accountability Act (HIPAA), exemptions exist if 

the physician believes not sharing pertinent medical information could result in public 

harm. Physicians should review state laws and reporting requirements, and seek legal 

counsel when developing an approach or protocol for the office setting. 

When the patient continues to drive despite the objections of the physician and family 

members, the physician may be justified in writing a referral or letter to the state DMV. A 

breach of confidentiality in such circumstances is ethically appropriate when it is in the 

interest of public safety and the community. State officials often follow a physician’s 

recommendation to revoke a driver’s license, although the driver can usually appeal the 

decision. Some physicians believe that such action will have a negative impact on the 

doctor-patient relationship. Thus, a substantial barrier to referral may exist in states that 

do not provide anonymity for the physician. 

REPORTING AND EVALUATING IMPAIRED OLDER DRIVERS 

Interestingly, Pennsylvania requires health professionals to report any medical condition 

that may impair the ability to control or safely operate a motor vehicle. Apparently, the 

state receives over 10,000 reports a year and 72 percent of these individuals have 

impairments serious enough to merit temporary or permanent recall of their license. 

Some physicians have raised concerns about such mandatory reporting, stating it 

violates privacy, compromises their ability to counsel patients without immediate 

punitive action, and can negatively affects the doctor-patient relationship. Mandatory 

reporting has the potential to discourage patients from visiting the physician or 

disclosing their illness. This could result in under diagnosed or under treated older 

drivers. 

There are some data to indicate that patients may not inform their doctor of their 

relevant medical history (Taylor, Chadwick, & Johnson, 1995). Drivers may have a poor 

understanding of the rules and laws in their state and lack insight into their own driving 

abilities (Kelly, Warke, & Steele, 1999). Thus, others argue in favor of mandatory 

reporting. On the other hand, physicians may be reluctant to report unless they are 

required by law to do so. One study indicated that physicians practicing in mandatory 

reporting law states are more prone to report impaired drivers to the licensing agency 

(Cable, Reisner, Gerges, & Thirumavalavan, 2000). A study of 523 Saskatchewan 

physicians regarding medical fitness to drive found that the most physicians would 

report patients medically unfit to drive, but a majority also believed the patient-physician 

relationship could be adversely affected by reporting (Shawn, Marshall, & Gilbert, 1999). 

Odell (2005) noted in some countries such as Australia, all persons are protected from 

civil action, if in good faith, they notify the licensing authority that a driver has a 

condition that could affect his or her driving. 

Lack of immunity is still the case for about 18 states and this may be a barrier to 

reporting. Family members and relatives could also be an important source of clinical 

observations in regards to identifying at-risk drivers (Lloyd, Cormack, Blais, Messeri, 


MCCallum, Spicer, et al., 2001). Sadly, only 18 states offer immunity to reporting 

outside the health professional arena (FHWA, 1997), but many states do provide 

immunity to physicians for reporting (Lococo, 2003). In a recent survey sponsored by 

the National Highway Traffic Safety Administration by Lococco and Staplin (2004), state 

licensing representatives noted physician immunity from civil liability among the top five 

medical oversight components of importance. 

Christie noted driver license bureaus need a reliable and valid process for evaluating 

older adults’ driving competency. Some countries require a medical report from a 

physician for both new licenses and renewal. These reports require the physicians to 

describe the medical issues and any functional impairment that could adversely affect 

driving ability (King, Benbow, & Barret, 1992). In the United States, the majority of 

driving fitness evaluations through the state will require physician input. Thus, 

physicians play an important role in assessing driving fitness and have an important 

need for knowledge in this area (Kakaiya, Tisovec, & Fulkerson, 2000). 

Despite what some see as their pivotal position, some studies have indicated that many 

physicians know little about their state’s fitness to drive requirements and/or submit low 

quality medical reports. Even with structured forms, Marshall and Gilbert (1999) noted 

many physicians are unaware of what tests they should perform to determine license 

eligibility. One study documented that inter-rater reliability was low when different 

doctors filled out the same medical report on the same patient (Steir, Kitai, Wiener, & 

Kahan, 2003). In addition, some studies have indicated that older drivers referred for 

driving evaluations from law enforcement are more likely to fail or lose their license in 

comparison to those referred by health professionals. The high pass rates of drivers 

referred by physicians may reflect the problems physicians have in assessing driving 

safety during routine office evaluations (Johansson, et al., 1996). 

SUMMARY AND RECOMMENDATIONS 

In this paper, we have summarized several medical illnesses and/or conditions that are 

common in older adults. It should be noted that for many of these diseases, there are 

simple methods of detection or screening available to identify them. Appropriate and 

timely diagnosis and treatment may improve or delay a decline in health. Early 

diagnosis and treatment of these conditions has not only a potential health benefit, but 

could improve public safety and delay driving cessation in older adults. These 

conditions are often under diagnosed and under treated, which is unfortunate for our 

older drivers and roadway safety. 

The National Transportation Safety Board has noted in a recent report that the issues 

regarding medical oversight of noncommercial drivers are extremely complex and will 

require close cooperation between Federal, State, and private organizations to create 

effective systems that protect the public while being sensitive to the needs of individual 

drivers (NHTSA, 2006). Medical Advisory Boards can serve to inform health 

professionals of the need to screen and detect diseases that can impair driving in older 

adults. All states should have active medical boards, physicians should be 


compensated for their time to review cases, medical standards and published guidelines 

should be used for decision-making (NHTSA, 2005). The state forms that physicians are 

required to fill out when making a referral of an unsafe driver to the state DMV, should 

be reviewed and revised to include common conditions that might be amenable to 

treatment. 

It is currently not known if these illnesses are consistently detected or addressed when 

traffic safety issues have been raised and physician reports are requested. This remains 

an interesting area for future investigation. Focusing on a group of common illnesses 

and brief methods of detection that can be performed by health professionals or lay 

people, could serve to identify a cadre of drivers with newly diagnosed illnesses and lay 

the groundwork for potential treatment. Most states will require a physician statement or 

examination for unsafe driving. 

In summary, the following recommendations are made in regard to the role of the 

clinician in the license renewal or medical evaluation process when the question of 

driving safety has been raised; 

1) Provide primary care physicians with a framework or background of knowledge in 

those key medical illnesses that impact driving, along with education on brief 

screens for disease detection. 

2) Encourage physician participation in Medical Advisory Boards and support 

legislation that provides resources to the creation and authority to the Boards. 

3) Medical advisory boards should assist in the creation of standard or universal 

forms for physicians. 

4) The state medical fitness-to-drive forms that physicians fill out should consider 

including other functional abilities rather than being limited to simply checking 

visual acuity and/or fields. 

5) States should move toward standard physician reporting laws that provide civil 

immunity and anonymity. 

6) Further research is needed to determine which reporting laws (mandatory vs. 

voluntary) are most efficacious for older adults with significant medical illnesses, 

which physician evaluation forms maximize the detection and appropriate 

management of key diseases that have the potential to impact driving, and 

ultimately, measure the impact of these interventions on public safety. 

7) Licensing renewal centers need to address the increasing number of older adults 

who will lose their license due medical impairments, and consider a role in 

mobility counseling or at least referral to this type of service (e.g. identifying 

alternate methods of transportation) should be expanded. 


Table 1: Key Medication Conditions (see text for references) 

Disease Prevalence Primary Care Functional Treatment 

Screening Impairment 

Cataracts 20,000,000 Questionnaire Contrast IOL Implant 

over age 40 Visual Acuity Sensitivity 

years 

Glare 

Macular 1.75 million Questionnaire Central Vision Topicals 

Degeneration over age 40 Amsler Grid Contrast Laser 

years 

Sensitivity 

Glaucoma 2.2 million over Questionnaire Visual Fields Topicals 

age 40 years Ophthalmoscope 

Stroke 1, 100,000 with History 

Attention Treat Risk 

functional Examination Visuospatial Factors 

impairment Brain Imaging Skills 

Executive 

dysfunction 

Visual field 

cuts 

Aphasia 

Rehabilitation 

Polypharmacy 20% over age Medication Attention If possible, 

65 years Review 

Processing remove 

Speed 

Syncope 

Dizziness 

Sedation 

Fatigue 

offending agent 

Sleep Apnea ~3% of men Epworth Attention Weight Loss 

and women Sleepiness 

CPAP 

Scale 

Surgery 

Arthritis 40,000,000 in History 

Weakness Medications 

the U.S. Examination Limited Range Weight Loss 

of Motion Therapy 


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ALZHEIMER’S DISEASE AND FITNESS TO DRIVE 

Nina M. Silverstein, PhD 

Professor of Gerontology 

University of Massachusetts Boston 

100 Morrissey Blvd., Boston, MA 02125-3393 

nina.silverstein@umb.edu 


ABSTRACT 

Alzheimer’s disease, the most common form of dementia, affects over five million 

Americans, almost all age 65 years and older with about ½ million early onset, younger 

than age 65. Impairments in memory, attention, motor activities, perception, and 

judgment are hallmark features of dementia, placing cognitively impaired drivers at risk 

for crashes, becoming lost, and poor performance on a variety of critical driving tasks. 

Complicating the recognition of dementia is that few people with Alzheimer’s disease or 

related disorders have a diagnosis of the condition in their medical records. Thus, it is 

not sufficient to address the concerns related to dementia and driving only as they relate 

to persons who already have a diagnosis. Impairments in critical driving skills may be 

among the first indications of the disease for the individual and concerned family 

members. Studies have demonstrated that compared to the general driving population, 

drivers with dementia are at an increased risk for unsafe motor vehicle operation. 

Becoming lost in familiar areas is one of the most commonly reported concerns. In 

addition to geographic disorientation, other red flags for unsafe driving include incorrect 

turning, impaired signaling, decreased comprehension of traffic signs, and lane 

deviation. Thirty to 45 percent of persons with dementia continue to drive. Reports on 

the length of time that persons with dementia continue to drive vary from about three 

years following diagnosis to over five years. Best estimates are that about 50 percent of 

drivers with dementia continue to drive more than three years after the onset of 

symptoms. The concern is not simply that individuals with dementia should or should 

not drive, but that driving skills predictably worsen. There is a need for a shift toward a 

public health paradigm that shares the scope of responsibility among the health care 

system, the licensing authorities, and the community. The role of each stakeholder 

needs to be strengthened and connected. The perspective with regard to strengthening 

the licensing authority is offered in this paper. Specifically, recommendations are offered 

for enhancing medical advisory board and registry activities. 

INTRODUCTION 

He would drive very erratically…He would always make terrible right hand 

turns…He would run over fire hydrants and nearly run over children and clip 

trees. And his wife and children were concerned. We recommended that he not 

drive. He was smart and got an attorney and they fought it. And the judge put it 

on delay for a year. So he drove for another year and ended up killing his wife in 

an automobile accident. (Occupational Therapist Focus group, 2006 in Adler et 

al., 2007a) 

This paper provides an overview of dementia, specifically Alzheimer’s disease (AD), 

and the syndrome’s relationship to the maintenance of critical driving skills such as 

yielding, turning, speed maintenance, gap acceptance, and wayfinding. The progressive 

nature of AD presents challenges to the licensing authority, to the driver and family 

members, and to the community. Responsibility for addressing these challenges lies 

across all stakeholders. Strategies are presented for consideration by licensing 


authorities both in terms of the development of dementia-sensitive protocols and in 

terms of recommendations for strengthening medical advisory board activity. 

Census projections estimate that by 2050, greater than 20 percent of the population, or 

almost 90 million people will be at least 65 years old (U.S. Census Bureau, 2007). Most 

of these older adults will be lifelong drivers who rely on the independence and 

convenience of the private automobile. Loughran, Seabury, and Zakaras (2007) report 

that “there are relatively few older drivers who need to be legally prohibited from driving, 

so these drivers pose a relatively small risk to traffic safety overall” (p.3). While it is 

likely that only a minority of older drivers may require special management by licensing 

authorities, those considered at greatest risk for unsafe driving behaviors are individuals 

with dementia (Langford et al., 2007). In a study of older men, Foley, Masaki, Webster, 

and White (2000) estimate that by 2020, approximately 260,000 men in the United 

States age 75 years and older may be driving with dementia. Researchers in Canada 

estimate 100,000 drivers with dementia in Ontario by 2028 (Hopkins, Kilik, Day, Rows, 

& Tseng, 2004). 

Impairments in memory, attention, motor activities, perception, and judgment are 

hallmark features of dementia (Chapman et al., 2006), placing cognitively impaired 

drivers at risk for crashes, becoming lost, and poor performance on a variety of tasks 

(Adler & Silverstein, in press). Staplin, Lococo, Gish, and Decina, (2003) caution that by 

2025, more than 40 percent of all fatal crashes may be associated with age-related 

frailties, with visual and cognitive impairments as major contributing factors. 

ALZHEIMER’S DISEASE AND FITNESS TO DRIVE 

Alzheimer’s disease, the most common form of dementia, affects over five million 

Americans, almost all age 65 and older (Alzheimer’s Association, 2007). Future 

estimates range from 11.3 to 16 million, or more poignantly stated: 

Every 72 seconds, someone in America develops Alzheimer’s disease; given 

current treatment, by 2050, it will be every 33 seconds…(Alzheimer’s 

Association, 2007, p.1). 

Dementia is a syndrome that affects memory, judgment, and psychomotor abilities 

(Alzheimer’s Association, 2007). Persons with dementia often repeat questions, 

misplace items, and need assistance remembering appointments. They may also 

experience language problems, impaired motor function, shortened attention span, 

spatial and temporal disorientation, and loss of judgment and planning skills (Chapman 

et al., 2006; Knopman, Boeve, & Petersen, 2003; Lloyd et al., 2001), all of which limit 

the ability to drive safely. Most persons with dementia reside at home in the community 

(Alzheimer’s Association, 2007). About 20 percent live alone (Newhouse et al., 2001). 

Studies report that from 30 to 45 percent of persons with dementia continue to drive 

(Carr et al., 2006; Duchek et al., 2003; Foley et al., 2000; Lloyd et al., 2001). Research 

findings vary on the length of time that persons with dementia continue to drive from 


about three to four years following diagnosis (Lucas-Blaustein, Filipp, Dungan, & Tune, 

1988; Fox, Bowden, Bashford, & Smith, 1997) to over five years (Bédard, Molloy, & 

Lever, 1998). Carr (1997) reviewed the literature and concluded that about half of the 

drivers with dementia stop driving within three years of disease symptoms’ onset. 

In addition to fatalities, the gerontological perspective focuses on the impacts to quality 

of life, such as long term care required for serious crash-related injuries. Older adults 

who experience a serious injury from a crash may have difficulty returning to 

independent living. (Adler & Silverstein, in press; Dellinger & Stevens, 2006). Moreover, 

because the number of fatalities from crashes is currently measured as death within 30 

days, it is likely an underestimate of the actual number of serious crash-related injuries 

that result in deaths. 

EARLY ONSET 

Those persons with dementia who are younger than age 65 are considered early onset 

(Alzheimer’s Association, 2006).That number is estimated to range from 220,000 to 

640,000 Americans (Alzheimer’s Association, 2006). Persons with early onset can be at 

any stage of the disease progression; early, moderate, or late. Those in the early or 

moderate stages of the disease may be encountering difficulties in driving to and from 

the work place or to daily activities within their communities. These individuals may 

never come to the attention of health or social support services. They are even less 

visible to licensing authorities since functional assessments of critical driving skills are 

not routine. 

UNDIAGNOSED DEMENTIA 

Few people with Alzheimer’s disease or related disorders have a diagnosis of the 

condition in their medical records (Boise, Neal, & Kaye, 2004; Boustani, Callahan, 

Unverzagt, Austrom, Perkins, Fultz et al., 2005; Callahan, Hendrie, & Tierney, 1995; 

Ganguli, Rodriguez, Mulsant, Richards, Pandav, Bilt, et al., 2004). Small et al. (1997) 

note that “some primary care physicians, who are the port of entry for most patients with 

early-stage AD, remain uninformed and thus unable to diagnose, treat, and manage 

these patients effectively” (p.1). Given that, it is likely that impairments in critical driving 

skills will precede diagnosis. In fact, a recommendation to cease driving may be the first 

time a person is confronted with serious loss of function associated with the disease 

itself (O’Neill, 1997). Thus it is not sufficient to address the concerns related to dementia 

and driving only as they relate to persons who already have a diagnosis. 

CO-MORBIDITIES 

Dementia does not often occur in isolation from other chronic conditions, many of which 

impact critical driving skills in their own right. People with AD have, on average, at least 

three co-existing medical conditions. Hypertension, coronary artery disease, congestive 

heart failure, chronic obstructive pulmonary disease, osteoarthritis, stroke, diabetes, and 

cancer are the leading co-morbidities for adults with dementia age 65 years and older 

(Maslow, 2004). In view of the growing numbers of older drivers with dementia and comorbidities, 

the progressive nature of most cognitive disorders, and the expected 


decline in critical driving skills, the licensing authorities without question should be 

concerned about this group (Adler & Silverstein, in press). 

RECOGNITION OF IMPACTS ON CRITICAL DRIVING SKILLS 

The concern is not simply that individuals with dementia should or should not drive, but 

that driving skills predictably worsen (Adler et al., 1999). Studies have demonstrated 

that compared to the general driving population, drivers with dementia are at an 

increased risk for unsafe motor vehicle operation (Man-Son-Hing et al., 2007). 

Becoming lost in familiar areas is one of the most commonly reported concerns 

(Silverstein, Flaherty & Tobin, 2002; Uc et al., 2004). In addition to geographic 

disorientation, other red flags for unsafe driving include incorrect turning (Uc et al., 

2005), impaired signaling (Duchek et al., 2003), decreased comprehension of traffic 

signs (Carr et al., 1998), and lane deviation (Uc et al., 2005). Behaviors observed by 

family caregivers include uncertainty about the sequence for getting the car in motion: 

seatbelt, key, pedal, lights, wipers, gear, and gas (Alterra, 1999). Furthermore, drivers 

with dementia perform more poorly on road tests and simulator evaluations than drivers 

with normal cognition although studies have not yet consistently demonstrated higher 

crash rates (Man-Son-Hing et al., 2007). 

SELF REGULATION LIMITATIONS 

Some drivers with dementia may reduce their driving to avoid perceived high-risk 

situations (Adler, Rottunda, & Kuskowski, 1999a). They may drive fewer miles (Adler & 

Kuskowski, 2003; Stutts, 1998), less often, and at off-peak hours as well as limit their 

night and freeway driving (Adler et al., 1999a). It is unknown whether these decisions to 

modify driving are made by drivers themselves, at the urgings of family, or some 

combination of factors. They are not likely to be self-restricting in the way that older 

adults without cognitive impairments are known to self-regulate. Clearly, self-regulation 

is limited to the extent to which drivers are aware of their cognitive deficits. 

Moreover, drivers with dementia have been found to understate driving difficulties (Ball 

et al., 1998; Dubinsky et al., 1992) as well as continue to drive after crashes and 

becoming lost (Dubinsky et al., 1992; Tuokko et al., 1995). Of great concern is that 

some drivers with dementia rely on co-pilots to provide directions and other driving 

instructions (Shua-Haim & Gross, 1996). These co-pilots are likely among the current 

cohort of older adults that includes some non-driving spouses who rely on their 

husbands for mobility and may compensate for the driver’s declining skills by co-piloting 

(Adler et al., 2000). This practice should be discouraged. If the driver is not safe to drive 

alone, the driver should not drive. Failure to recognize and address declines in driving 

skills associated with dementia can have significant and hazardous consequences for 

the driver and others (Adler & Silverstein, in press). 

MOVING FORWARD 

NEED FOR DEMENTIA-SENSITIVE PROTOCOLS 

Although research provides insights into why driving is difficult for those with AD, it has 

yet to determine the level of cognitive impairment associated with an unacceptable 


driving risk. We do not yet know the appropriate time intervals for re-testing/license 

renewal of drivers with dementia. We also do not know enough about the other 

dementias and how their manifestations impact critical driving skills. Moreover, the 

specialized testing by an occupational therapist (OT)/ driver rehabilitation specialist is 

costly and not universally covered in full or at all through Medicare or private insurance. 

Other concerns may seem beyond the scope of the licensing authority but if they are not 

recognized and appropriate referrals are not made, there may be catastrophic 

consequences. For example, how does the person get home from the Department of 

Motor Vehicles (DMV) if a license is not renewed? While several DMVs already have 

addressed this concern, what happens the next day? Another concern is the turnaround 

time for notification after a report has been filed and also the method of 

notification. How are the mobility needs of an individual addressed during the review 

period? And if the notification is delayed weeks or months and only delivered by mail, 

will the driver with dementia acknowledge receipt of the notification and understand its 

implications? Drivers with dementia whose licenses have been suspended may not 

even be aware that they are driving without valid licenses. 

Finally, considering that drivers’ licenses are a standard and basic means of 

identification in the U.S., non-drivers and their families must be informed of the 

availability of identification cards that can be used for documentation. It should be 

noted, however, that because of the intentional similarity in appearance, some persons 

with dementia may consider such identification cards as valid licenses. 

PROMISING RESEARCH: IDENTIFICATION AND MONITORING OF COMPROMISED DRIVING 

BEHAVIORS 

Silverstein reported on Phase I of a study by Eby et al. (2006) on fitness to drive in early 

stage dementia (Adler et al., 2007a; Adler et al., 2007b). She shared several critical 

behaviors considered to be compromised in persons with dementia. These behaviors 

were identified by members of an expert panel as well as nine focus groups of drivers 

with dementia, family members, and occupational therapists/driver rehabilitation 

specialists (Adler et al., 2007a; Adler et al., 2007b). Sixteen experts met in Fall 2006 to 

identify strategic, tactical, and operational skills important to monitor in drivers with 

dementia. The experts represented the following disciplines: engineering, gerontology, 

neurology, neuropsychology, occupational therapy, psychology, public health, social 

work, and transportation. The desired outcome was to reach preliminary conclusions on 

the skills most commonly compromised in early stage dementia. The experts believed 

that poor judgment or impaired decision-making and impaired visuo-spatial abilities 

manifested across most driving maneuvers. The maneuvers identified by the experts 

included: wayfinding, observing, changing lanes, gap acceptance, passing, 

stopping/braking, yielding, responding to signals/signs, maintaining speed, backing up, 

signaling, maintaining lane position, following, seat belt use, and use of headlights. 

The focus group data clustered around seven themes: 1) pre-ignition, 2) basic vehicle 

maneuvers, 3) wayfinding, 4) insight and cognition, 5) attention and concentration, 6) 

decision-making, and 7) red flags. The following quotations illustrate those themes: 


Pre-Ignition 

If they’ve had a lot of trouble dealing with the secretary as far as making appointments. 

Those are usually the ones you’ll see struggle. Or you know, they’ll call repeatedly or 

they’ll not show up on time…if they can’t pass “the secretary test” then it’s probably 

going to be an issue (Occupational Therapist). 

Basic vehicle maneuvers 

Dad you’re in the turning lane. No, I’m not, this lane goes straight…so he whips over 

into the other lane of traffic. And we were fortunate there was no accident… And I was 

trying so hard to let him be independent (Family member). 

Wayfinding 

I’ve gotten confused as to where I am. In my younger years I’d say so what? But I think 

with Alzheimer’s I get scared. I’ll say [#@&]! I don’t know where I am. How did I get 

here? You don’t control the situation, fear creeps in which makes it worse (Driver). 

Insight and Cognition 

And I said what side of the road are we on? My side…The right side. It never clicked for 

him that he was driving down the wrong side of the road (Occupational Therapist). 

Attention and Concentration 

It’s like they have a record with skips in it. And part of the record plays right and then it 

skips here. It plays perfect, then it skips here (Occupational Therapist). 

Decision Making 

[If] you have almost had a couple of accidents you might as well say hey I better stop. 

That would be a hard thing to do (Driver). 

Red Flags 

If they can’t take that second step…and follow a two-step command (Occupational 

Therapist). 

The Eby et al. (2006) study will instrument the personal vehicles of people with 

dementia with a suite of sensors that include several cameras, a forward radar, a global 

position system, and vehicle control probes (e.g., turn signals, brake lamps, headlights, 

throttle). The engineers of the Eby et al. team have developed algorithms to convert the 

raw sensor data into the behaviors identified by the expert panel and described in the 

focus groups. The next phase of the study (2007-8) will involve instrumenting the 

vehicles of 24 persons with dementia and recording their naturalistic driving for one 

month. The driving behaviors derived from the instrumentation will then be compared to 

self- assessment, family assessment, and the assessment by the occupational 

therapist. This research should yield a greater understanding of the extent and 

manifestation of the impairments in critical driving skills exhibited in persons with early 

stage dementia. 


SUMMARY CONCLUSIONS AND RECOMMENDATIONS 

There is a need for a shift toward a public health paradigm that shares the scope of 

responsibility among the health care system, the licensing authorities, and the 

community. There is likely a hidden morbidity and underestimates of impact on traffic 

safety overall, given that key stakeholders in public safety do not readily recognize 

dementia. Hopkins et al. (2004) observed that “…the health care system was not 

designed and physicians are not trained to screen for individuals who may be a safety 

hazard on the road” (p.437). That concern is now being addressed, as promising steps 

are being taken in the United States to increase awareness by physicians, not only of 

screening but of the licensing and renewal requirements in their states (Wang et al., 

2003). Moreover, there is an increased understanding that allied health professionals 

can play a significant role in helping to screen and assess at-risk drivers. The American 

Occupational Therapy Association (AOTA) has taken a strong lead in community 

recognition of the importance of specialized driving assessment and monitoring of 

drivers with dementia. The task of addressing the challenge of at-risk drivers with 

dementia should not fall as the responsibility of any one stakeholder. The challenge is 

far too great. Figure 1 illustrates the shared responsibility: 

Figure 1: Stakeholders with a Role in Recognition of At-Risk Drivers 

At-Risk 

Driver 

Health Care Licensing 

Authorities 

Community 

Organizations/ 

Formal & 

Informal Support 

Networks 

Each stakeholder needs to be strengthened and connected so that the at-risk driver 

does not remain invisible until the occurrence of a catastrophic event. The following 

recommendations relate to strengthening one stakeholder, the licensing authorities. The 

recommendations are drawn from previous work by Lococo and Staplin (2005), 

Soderstrom (2007), and Adler and Silverstein (in press). An expert panel convened by 

the National Highway Traffic Safety Administration and facilitated by Lococo and Staplin 

(2005) generated 64 recommendations, of which at least seven have direct relevance to 

drivers with dementia (#1-#7). Age-based recommendations that were included among 


the 64 are intentionally omitted here. Age-based testing is not the solution for at least 

three reasons: 1) most older drivers are among the safest drivers on the road; 2) Early 

onset dementia is a growing challenge that affects persons younger than 65; and 3) It 

would not be cost-effective to institute population testing to identify 10-15 percent 

presumed to be at-risk. In addition, four more recommendations (#8-#11) suggested by 

Adler and Silverstein (in press) are added. Each of the recommendations has 

implications for research and practice in terms of policy, programmatic feasibility, 

intervention and implementation. 

RECOMMENDATIONS TO STRENGTHEN LICENSING AUTHORITIES 

1) Each jurisdiction should have a medical advisory board (MAB) staffed with 

physicians to provide advice to DMVs medical review department staff about 

licensees’ fitness to drive. 

2) The role of the MAB should include the review of individual cases for fitness to 

drive and the development of medical criteria/guidelines for licensing. 

3) Drivers with mild dementia who are deemed fit to retain driving privileges should 

be required to undergo periodic reexamination driving tests. 

4) The mission of the DMV should be expanded beyond the traditional role of 

ensuring public safety to supporting the continued safe mobility of drivers with 

medical conditions and functional impairments. 

5) The rules written for medical review of drivers should not be in statute, but should 

be in the Code of State Regulations, so that changes can be made quickly as 

new medical data become available. 

6) Continuing education for police officers in identifying potentially at-risk drivers 

with medical conditions and functional impairments, and procedures for referring 

drivers to the DMV for reevaluation, should be a priority activity for the DMVs and 

police departments. 

7) The opinions of driving-rehabilitation specialists are important in the 

determination of fitness to drive. Treating physicians should be educated about 

the role driving specialists play in assessing fitness to drive and providing 

rehabilitation and retraining. Mechanisms should be put into place for DMVs and 

treating physicians to refer drivers to these specialists. 

8) In-person renewal rather than mail or Internet re-licensing should be required for 

drivers considered at-risk. 

9) Increase the number of states in the U.S. that have laws that provide for 

physician immunity for reporting medically unfit drivers. 


10) Extend immunity for patient referral to DMVs and to allied health professionals 

(Soderstrom, 2007). 

11) Strengthen Medical Advisory Boards in the 35 states that have some level of 

medical advisory board activity and advocate for the establishment of such 

boards in states where they do not exist (e.g., strengthening would include 

training on dementia-related issues). 


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DRIVER SCREENING AND ASSESSMENT IN THE 21ST CENTURY 

Loren Staplin, PhD 

Managing Partner 

TransAnalytics, LLC 

1722 Sumneytown Pike, Box 328, Kulpsville, PA 19443 

lstaplin@transanalytics.com 


INTRODUCTION 

For individuals, personal mobility depends—for better or worse—on nothing so much as a 

valid driver’s license. Maintaining independent mobility is vital, simply to survive and 

certainly to thrive in contemporary society. At the same time, the private and commercial 

vehicles we drive are the cells in the lifeblood of our nation’s trans-portation arteries, and it 

is equally vital to keep these arteries flowing. This means reducing motor vehicle crashes, 

even as traffic volumes increase, highway capacity grows only incrementally or not at all, 

and operating conditions deteriorate. Lately, the consequence of deferred maintenance on 

our infrastructure has raised widespread concern. But even with collapsing bridges and 

other catastrophic failures, it is a virtual certainty that for decades to come, the reason for 

90-plus percent of crashes will be the same as it has been for the past 30 years: driver error 

(Treat, Tumbas, McDonald et al., 1979; Hendricks, Freedman, Zador, & Fell, 2001). 

There is an emerging appreciation that the overall health of the surface transportation 

system requires a system solution – namely, an evolution and harmonization of licensing 

policies, coupled with more “human-centered” principles of highway design and operations 

(see Staplin & Freund, 2005). Human-centered design rests upon the understanding that 

driving is, at its most essential level, an exceedingly complex information processing task. A 

premise of recent and ongoing updates to key engineering standards and guidelines 

(FHWA, 2001; FHWA, 2003; AASHTO, 2001) is that the risk of crash-causing driver errors 

can be mitigated by enhancements in the detectability, conspicuity, and comprehensibility of 

highway information elements, together with geometric changes that increase preview 

distances, aid gap selection, and eliminate violations of driver expectancy while easing the 

physical requirements for vehicle maneuvering and path maintenance. 

As a complementary strategy, to the extent that crash-causing errors reflect driver deficits in 

the competencies needed to safely control a motor vehicle and there are cost-effective, 

publicly-acceptable means to detect such losses, many would argue that it is past time for 

licensing authorities to proactively implement such procedures. But—without a dramatic 

increase in the availability of alternative transportation options that people actually want to 

use—whatever safety benefits may accrue to society from driver screening will be 

purchased at the cost of independent mobility for some number of, mostly older, individuals. 

Many would also ask, “Is it worth it?” 

The aging of America is accelerating. Isolated personal tragedies, certain to increase in the 

years ahead, can easily be magnified by media attention into a perception that “something 

needs to be done.” There is a growing need for research to inform policymaking as 

legislators grapple with this issue, and states begin to pilot test tools and technologies that 

offer the promise of identifying drivers at significantly higher risk of causing a crash. An 

overview of strengths, limitations, and the rationale for use of driver screening and 

assessment practices by licensing authorities in North America provides the framework to 

discuss what we can and should do next to enforce minimum standards for the ability of 

individuals to drive safely. 


IN SEARCH OF A ‘GOLD STANDARD’ FOR DRIVER QUALIFICATIONS 

ASSESSMENT 

Traditionally, a long-standing practice for re-licensure for the vast majority of States has 

been to renew full privileges for all residents, including seniors, who have clear driving 

records (not subject to administrative action) and who pay the required fees, without any 

further assessment of their qualifications other than a request for self-reporting of 

specified medical conditions on the renewal application. With the changing 

demographics of the driving population, such policies have seen a range of agesensitive 

exceptions: age-based requirements for vision testing, intervals for license 

renewal that can vary with driver age, and in-person versus mail-in renewal. 1 However, 

except for those who are subject to strict medical exclusion (e.g., for conditions resulting 

in loss of consciousness), the culmination of ‘due process’ and final arbiter of a person’s 

license status—including individuals claiming discrimination under the Americans with 

Disabilities Act 2 of 1990—is a DMV road test. This is the presumed ‘gold standard.’ 

A closer look suggests otherwise. One problem concerns the driving environments and 

traffic situations that individuals are (not) exposed to during a behind-the-wheel exam; 

benign testing conditions that do not confront a license applicant with the full range of 

everyday threats and hazards are not likely to reveal how capable he or she is to 

respond in risky situations. While there are practical as well as legal reasons why 

licensing agencies avoid high-risk situations during on-road tests, this nevertheless 

presents a challenge to the validity of their results. There is also evidence that 

individuals’ behavior behind the wheel during a driving exam may be flagrantly 

inconsistent with their behavior at other times—for example, immediately upon leaving 

the exam site, while they are being surreptitiously filmed by researchers in a following 

car (McKnight & McPherson, 1981). Finally, the philosophy that “seeing how someone 

drives today is the best way to predict how he or she will drive tomorrow” rests on the 

premise that critical aspects of vision, cognition, and physical function that the individual 

needs to drive safely are stable, i.e., not in decline. For a 25-year-old driver, this may be 

a reasonable assumption; but not necessarily for a 75-year-old. 

Not all road tests are equivalent. Certain states have expended considerable resources 

on exam development, examiner training, and improving the inter-examiner reliability of 

their test procedures. Still, if the axiom – that a licensing authority’s road test is the gold 

standard for determining fitness to drive – comes into question, its corollary also must 

be challenged, i.e., that the validity of a screening or assessment technique can be 

established by the extent to which it predicts road test outcomes. By this logic, 

validation using simulator outcomes is even more problematic. These are mediating 

variables, proxies for crash data. Are driving performance indicators irrelevant? Of 

course not. Crashes and/or violations on a driver’s record are widely accepted triggers 

for licensing actions, and they will remain so. A behind-the-wheel exam can afford a 

striking demonstration of failures in judgment or tactics that characterize an older 

1 http://www.iihs.org/laws/OlderDrivers.aspx 

2 see Subpart A – General, Section 36.101, Purpose 


person suffering from dementia. But our understanding of the ‘human factors’ that 

mediate driving errors tells us that neither driver performance as demonstrated during a 

typical DMV road test, nor a backward look at an individual’s driving record, are likely to 

be sufficient in themselves to identify normally-aging older drivers at increased risk of a 

motor vehicle crash. 

As most strongly associated with the work of Michon (1985), driving tasks must be 

negotiated at operational, tactical, and strategic levels. Drawing on a lifetime of 

experience, older persons are generally expert at safe driving strategies, planning their 

travel and making route choices to avoid the riskiest driving conditions and traffic 

situations. At the same time, analyses of the crash types in which older drivers are 

significantly overrepresented (Staplin & Lyles, 1991) have long established that these 

drivers experience difficulties at the tactical and operational levels—scanning the 

environment, detecting hazards, judging gaps, changing lanes and merging with other 

traffic, and maneuvering through turns. 

With the aging of our population, licensing authorities are looking to researchers for 

additional tools to help streamline and standardize the detection of medically at-risk 

older drivers. The nascent promise of recent work in this area is that such tools are 

pending, in the form of validated predictors of crash risk—indeed of crash causation— 

that can feasibly be applied in DMV field office settings. 

TO CRASH OR NOT TO CRASH? 

This is the question that has long confounded researchers who model driver behavior, 

relying as they have on surrogate (driver performance) measures for so many years. A 

major difficulty in predicting crash risk stems from the fact that such events occur 

according to a quasi-random process, where event probabilities constantly change with 

changing traffic and environmental conditions. When the state of the (driver-vehicleroadway) 

system at any given time varies randomly, the amount of variability in crash 

occurrence that can be explained by driver-centered components is relatively small 

compared to random and non-driver-centered factors (Peck, McBride, & Coppin, 1971). 

The conclusion of Stewart and Campbell (1972) is as pertinent today as it was 35 years 

ago: "The vast majority of all accidents occurring in a given period of time involve 

drivers having no accidents or violations in a previous period." 

One strategy to improve both the sensitivity (maximizing correct decisions that an 

individual is a high crash risk) and the specificity (minimizing incorrect decisions that an 

individual is a high crash risk) of screening practices is to focus on crash causation, not 

merely crash involvement, in the validation of those practices. The goal is to offer the 

strongest possible argument for (or against) the validity of a driver characteristic as a 

predictor variable. In the considerable literature on this subject a hierarchy may be 

discerned, connoting relatively weaker versus stronger evidence in this regard. 

The weakest studies are those that rely on self-reported crashes. McGwin, Owsley, and 

Ball (1998) found that 78 of 278 subjects’ self-reports (“Were you involved in at least 


one crash where the police were called to the scene?”) did not agree with State records; 

of these, 64 subjects, or roughly one-quarter of the sample, failed to report a crash that 

was recorded by the State. Although this is perhaps an inconvenient truth for 

researchers, there is no reason to believe that this is a unique or isolated finding. 

Among studies utilizing State (police reported) crash records, the weakest are those 

where crash involvement – any crash involvement – is the criterion. The quasi-random 

nature of motor vehicle crashes means that a substantial proportion of such events may 

simply reflect “being in the wrong place at the wrong time,” with no connotation of 

culpability. A step toward greater confidence in observed relationships between 

predictor variables and crash risk is to examine involvement in multiple crashes (cf. 

Staplin & Gish, 2005). Still better as a criterion is police-reported crashes where fault (or 

a surrogate such as “first/most harmful act”) is assigned by an investigating officer at the 

crash scene; this was the threshold for evidence cited in the results of the National 

Highway Traffic Safety Administration’s (NHTSA) Model Driver Screening and 

Evaluation Program: Guidelines for Motor Vehicle Administrators (Staplin & Lococo, 

2003). 

Most desirable as the criterion when evaluating the validity of a screening measure is 

police-reported, at-fault, exposure-adjusted crashes—provided that researchers have 

access to objective measures of driver exposure and do not rely on self-reports. 

Problems with self-reported mileage are discussed later. 

Across all types of crash records identified above, the validity of screening and 

assessment measures is best determined through examination of prospective crash 

data. In cross-sectional studies, it may only be possible to analyze predictor-criterion 

relationships using a ‘snapshot’ of previous years’ driving records. However, such 

evidence must be regarded as tentative until confirmed through longitudinal research 

that can relate the risk of future crashes to a candidate screening or assessment 

measure. This is especially important when attempting to identify high-risk individuals 

among a population where progressive changes (declines) in visual, cognitive, and 

physical status are more prevalent. 

THE DMV’S CHALLENGE: GETTING THE BEST SCIENCE AT THE 

BEST PRICE 

A useful convention is to distinguish procedures to evaluate driver qualifications that are 

administered by a DMV as part of their everyday licensing operations, versus 

procedures administered by physicians, occupational therapists, or other external or 

“offline” resources. The former, screening practices are subject to fairly rigid constraints 

in terms of the time, cost, and staff resources needed for test administration in a 

production environment, such as a Driver Licensing field office. Screens are designed to 

contrast, as efficiently as possible, license applicants who are medically fit to drive from 

those whose status is questionable, and who deserve closer scrutiny to make a fitnessto-drive 

determination. The latter, assessment activities are carried out by a DMV’s 

medical exam unit or Medical Advisory Board (MAB), or by various specialists in other 


institutions who devote considerably more time to in-depth, diagnostic procedures. 

Assessments are conducted to discern the reason for an apparent deficit; if and to what 

extent safe driving ability may be impaired; what restrictions, if any, may be appropriate; 

and, potentially, how to compensate or remediate. 

It is not a pejorative to say that licensing officials will tend to apply the best science they 

can afford. The practicalities of driver screening in a production setting are shaped by 

constraints on time, budgets, staff availability, staff expertise/training, hardware, and 

real estate; plus, there is a due process requirement that the agency apply substantially 

identical administrative criteria to all license applicants who are not already identified as 

medical review cases. 3 Screening procedures will always be open to criticism that an 

alternative approach can yield more reliable results and/or fewer misclassifications—but 

can it do so within a cost structure and time parameters that are compatible with 

existing operations? 

It is essential to keep in mind that driver screening is not designed to identify individuals 

who are unfit to drive, nor (solely) to justify any restrictive licensing action. It is designed 

to identify individuals who are the highest priority for the licensing authority to examine 

further, before renewing full driving privileges. It is the first or entry-level “tier” for 

assessing driver qualifications at multiple levels, with progressively more in-depth 

procedures applied to progressively fewer people, to achieve the best balance between 

driver/customer service and public safety. 

An instructive example of the operational constraints in a “first-tier” screening 

application is provided by the dictates of the Florida Department of Highway Safety and 

Motor Vehicles in cooperation with the Florida Department of Transportation’s ‘Safe 

Mobility for Life’ Program in the development of a Baseline Driver Screening System. 4,5 

Enhancement of Florida’s current static visual acuity test is to be accomplished using a 

countertop testing device, via substitution of a test slide incorporating contrast sensitivity 

as well as acuity stimuli, in a protocol that is completed in an average of 1 minute or 

less per driver. The introduction of cognitive screening measures is to be accomplished 

using the same computers now employed for road sign knowledge tests, in a protocol 

that is completed in 10 minutes or less per driver. 

In contrast, an assessment performed offline by a DMV or by an external resource such 

as a Certified Driving Rehabilitation Specialist (CDRS) may involve the use of a wide 

array of clinical tools, a closed course exam, and then on-road testing, that together 

requires hours of interaction with an individual applicant. Where external resources are 

required to complete a medical or neurological examination, optometric/ophthalmic 

examination, or driving evaluation it is commonly the responsibility of the license 

applicant to pay for these procedures, which can cost hundreds of dollars. Assessments 

3 

Source: John Joyce, Esq., Senior Research Associate, Driver Safety Research Office, Maryland Motor 

Vehicle Administration. 

4 

Source: Selma Sauls, Planner II Florida Department of Highway Safety Motor Vehicles/ DDL Director’s 

Staff, Florida GrandDriver Program. 

5 

Source: Gail Holley, Florida Department of Transportation, Safe Mobility for Life and Research Manager. 


for medical fitness to drive carried out by a State’s medical review unit or MAB may 

employ extensive (driving and medical history) reviews, interviews and examinations, 

often involving multiple contacts with an individual. All States bear certain administrative 

costs associated with medical review procedures; but assessment costs also can vary 

according to factors including a) whether the participating medical professionals are 

paid or serve voluntarily; b) the level of staff support provided by the DMV for case 

management; and c) the number and scope [i.e., are ‘home-area’ tests offered?] of 

behind-the-wheel examinations conducted by the licensing authority (Lococo & Staplin, 

2005). 

ARE CURRENT PRACTICES BEST PRACTICES? 

A comprehensive description of the practices for evaluating driver qualifications for new 

licensees, renewing drivers, and medical review cases that are utilized by Departments 

of Motor Vehicles in all 51 U.S. licensing jurisdictions was prepared in 2003, and is 

available on the website of the American Association of Motor Vehicle Administrators 

(AAMVA). 6 This resource covers the sections of each State’s Vehicle Code pertaining to 

the licensing of passenger vehicle drivers; forms that drivers complete for new licenses 

and license renewal in each jurisdiction that request self-disclosure of medical 

conditions; forms used by each licensing authority to request medical history from a 

driver’s physician; forms that law enforcement, physicians, and private citizens use to 

report drivers; procedures that counter staff, driver license examiners, and professionals 

conducting medical reviews use to measure functional abilities; and standards and 

guidelines each State uses when licensing drivers with specific medical conditions. 

This material is readily accessible via the Internet; and in any event is too expansive to 

meaningfully summarize in this paper. The following discussion will take a more narrow 

focus: reviewing the current state-of-the-knowledge regarding impairments – functional 

impairments, specifically – that increase older drivers’ crash risk, and the implications 

for improved driver screening and assessment practices. The emphasis on functional 

impairments—apart from excluding transient impairing states (e.g., DUI) from this 

discussion—makes a distinction with medical conditions per se as the focus of 

screening and assessment activities. 

This represents a true evolution of thinking in this area: the recognition that impaired 

driving results from loss of function—visual, mental, and/or physical—which may be 

attributed to age-related changes and/or to the presence of a medical illness(es). A 

diabetic patient may experience retinopathy, another peripheral neuropathy, and yet 

another's disease may be controlled such that s/he does not experience any symptoms 

that impair driving. One individual's mental confusion may be related to a cardiovascular 

condition, another's to mild dementia, and still others' to a side effect of a medication to 

control a generalized anxiety disorder. It is the type and degree of functional 

6 http://www.aamva.org/AAMVA/DocumentDisplay.aspx?id={4C38EEE9-5DC7-449C-A496- 

15757A99C3F6} 


impairment, not the medical diagnosis or condition per se, that should most directly 

influence the initial (first-tier) outcome for a license applicant. 7 

Until the last 15 years or so, the only viable candidates for functional screening were 

vision tests. Certainly, vision tests have a high level of face validity, given the 

dependency of most driving tasks on visual information. In addition, various aspects of 

sensory vision – e.g., acuity, contrast sensitivity, depth perception/ angular motion 

sensitivity, and visual field size/sensitivity – have been implicated via task analysis as 

important for the safe performance of maneuvers where drivers are exposed to the 

highest crash risk, in particular the safe negotiation of intersections (Staplin, Lococo, 

McKnight, McKnight, and Odenheimer, 1998). 

Relating sensory vision to crashes has been more difficult. As documented by Burg in 

the late 60’s (see Burg, 1967) and reiterated a quarter-century later by Shinar and 

Schieber (1991), static visual acuity – the vision screening test used by DMVs – 

correlates only weakly with crash involvement. Nor do any, more contemporary 

research findings dispute this. Yet this test is ubiquitous among licensing authorities, for 

a number of reasons. Static visual acuity can be measured quickly using relatively 

inexpensive test materials/devices. It has high face validity with respect to reading 

signs, seeing pavement markings and other roadway delineation elements, and 

detecting hazards in or near the roadway. Most acuity problems can be corrected, 

allowing drivers who show a deficit at the DMV to qualify for a license after proper 

refraction. And, the weak relationship with crashes may at least in part be attributed to 

the fact that current practices are generally effective in preventing people with the worst 

acuity from driving. In short, there is no reason for licensing authorities to move away 

from acuity testing—only to augment it. 

The measure of visual performance that has shown the greatest promise for use in 

driver screening is contrast sensitivity (CS). Where an acuity test measures the ability to 

resolve fine detail in a figure that contrasts sharply with its background—like the letters 

on a highway sign—a CS test measures the ability to discriminate a figure whose 

boundaries are not sharp edges, but which blur into the visual surround, and which 

appears only marginally brighter or darker than its background. Detecting the worn edge 

of a rural highway where the pavement is crumbling into the unpaved shoulder, viewed 

at dusk, is one example of a situation where good contrast sensitivity is required; 

another is detecting a pedestrian in dark clothing; or a curb, barrier, or road hazard on a 

city street without overhead lighting. 

Adding a contrast sensitivity screen to the standard vision test procedures used by 

licensing authorities has been advocated for some time (see Decina & Staplin, 1993). 

Compelling statistics have been reported showing significant and independent (of other 

7 Source: Pers. comm., 10/15/07, David B. Carr, M.D., Clinical Director, Division of Geriatrics and 

Nutritional Science, Washington University at St. Louis. Note: It is possible that the detection of 

functional impairment could be attributed to previously undetected or undertreated medical illness(es). 

Thus, it is important for older adults to be referred to their physicians or a subspecialist for an 

evaluation when they fail screening for license renewal or during referral for a driving evaluation. 


vision problems) associations between CS deficits (in one and in both eyes) and statereported, 

at-fault crash involvement (Owsley, Stalvey, Wells, Sloane, & McGwin, 2001). 

This and related work calls attention to CS deficits that are the result of cataracts and, 

encouragingly, to the improvement in visual function and in driving function that attend 

successful cataract surgery. 

Operationally, CS screening can be accomplished using a wall chart; a computer 

display; or a countertop vision tester. Scientifically-valid test results can be obtained 

using various types of test stimuli including letters, which must be read (Pelli, Robson, & 

Wilkins, 1988); sine wave gratings, for which an observer must correctly discern an 

orientation (see Evans & Ginsburg, 1985), and other (e.g., Landolt ring) stimuli. What is 

essential for CS testing is to have control over the spatial frequency of the critical detail 

in the test stimulus, and the brightness contrast between the stimulus and its 

background. In addition, vision scientists recommend a standard luminance (100 cd/m 2 ) 

in the test environment, for proper adaptation of the observer’s visual system when 

completing a CS measurement. In most cases it will be easier to meet this 

recommendation using a self-contained vision tester than a wall chart or computer 

display. Also, to use a wall chart or computer display, the driver must be positioned 2-3 

meters away (about 10 feet) so that the eye can accommodate to focus on the test 

stimuli as it would to focus on objects in the distance while driving. In a countertop 

vision tester, special optics (prisms) inside the device are used for this purpose. 

The remaining serious candidate for an enhanced vision testing protocol for driver 

licensing is to screen for visual (peripheral) field loss. Most commonly cited in this area 

is the work of Johnson and Keltner (1983), who found that older (age 60 and up) drivers 

in a volunteer sample in California with visual field loss in both eyes had retrospective 

rates of crashes and convictions that were over twice as high as age- and gendermatched 

drivers with no deficit. More recently, researchers (Rubin, Ng, Roche, Keyl, 

Freeman, & West, 2007) have reported that binocular field loss is significantly related to 

prospective crash involvement. But other researchers who examined prospective, statereported 

crash involvement in relation to clinical vision screening measures found that 

neither central nor peripheral visual field sensitivity was a significant independent 

predictor of crash involvement (Owsley, Ball, McGwin, Sloane, Roenker, White & 

Overley, 1998). 

One factor implicated in the discrepant findings in this area relates to testing 

methodology. Shinar and Schieber (1991) call attention to the “reliance on simplistic 

field screening rather than on diagnostic clinical tests” to explain the results of studies 

that have failed to find a significant relationship between visual field loss and crash 

rates. The so-called “confrontational” methods that they reference, implicitly, are what 

are practical to implement in a driver licensing office, though. The current state-of-theknowledge 

accordingly suggests that clinical visual perimetry can be a useful 

component of ‘downstream’ assessment techniques for selected, medically-referred 

drivers, but that ‘first-tier’ screening for visual field loss is not a top priority. 


While measures of visual function may assume primacy for driver screening, the most 

active area of research and development in recent years has focused on the impact of 

cognitive deficits. This includes both the incidence of Alzheimer’s and related dementias 

among older drivers, and the cognitive abilities that decline as a function of normal 

aging and that significantly predict (at-fault) crashes. 

It has been estimated that approximately 10 percent of community dwelling adults age 

65 and older probably have Alzheimer’s disease; more specifically this estimate may be 

broken down as follows: 65 to 74, 3 percent; 75 to 84, 19 percent; 85 and over, 47 

percent (Evans, Funkenstein, Albert, Scheer, Cook, Herbert, Hennekens, & Taylor, 

1989). While these authors acknowledged that their findings were “higher than 

previously reported,” and have been challenged by other researchers, an increase in 

prevalence with increasing age is undisputed, and—according to a 2006 report for the 

National Institute on Aging prepared by the U.S. Bureau of the Census—the 85-andover 

group is the fastest growing segment of the population. Detecting drivers with 

dementia is thus a growing concern. According to an authoritative recent review in this 

area (Molnar, Patel, Marshall, Man-Son-Hing, & Wilson, 2006), most jurisdictions 

recognize that some persons with mild dementia may be safe to continue driving, at 

least for a limited period. This same, systematic review sought to identify office-based 

tests that differentiate safe from unsafe drivers, using cutoff scores validated in a 

dementia population. Allowed evidence included crash data, simulator performance, 

and on-road assessments. Various methodological shortcomings—most prominently the 

failure to report cutoff scores—resulted in none of the reviewed test procedures being 

endorsed for ‘front-line’ applications, and a call for additional research to develop 

evidence-based guidelines for dementia screening for driver licensing applications. 

Notwithstanding the limitations noted by Molnar et al. (2006), two cognitive tests 

deserve further mention as potential office-based screens for dementia, according to the 

AMA’s Physician’s Guide to Assessing and Counseling Older Drivers (AMA, 2003). 

These tests are the clock drawing test (CDT), and the Trail-Making test, Part B (Trails 

B). To date, the CDT has shown respectable reliabilities (test-retest; +.70-.78) with 

Alzheimer’s patients. However, at least four different scoring protocols are in use for this 

paper-and-pencil test. There is evidence linking CDT results to pedal confusion, and to 

driver performance on a low-fidelity simulator (Freund, Colgrove, Petrakos, & McLeod, 

in press), but its relationship to crashes has yet to be demonstrated. The CDT did not 

meet the inclusion criteria for the Molnar et al. (2006) review. Trails B, on the other 

hand, has been validated as a significant predictor of at-fault crashes in prospective, 

case-control research (Staplin, Gish, & Wagner, 2003); however, the cutoffs developed 

from this research reflect the performance of a cross-section of older, communitydwelling 

residents presumed to be “normally aging,” i.e., these cutoffs do not 

necessarily apply to persons with dementia. 

In fact, it is for broad, population-level applications where research to validate measures 

of cognitive deficit as motor vehicle crash predictors has realized its greatest success in 

the past decade or so. Epidemiological studies with large (>1,000) samples that are 

representative of a State’s older (55 and older) driving population—at least in terms of 


their age distribution and prior crash and violation experience—have been conducted, 

where scores on a battery of functional status measures are analyzed in relation to 

future crash experience (based on State records) for one year, two years, and longer. 

The best known of such studies 8 , completed in Maryland under the sponsorship of 

NHTSA and the National Institute on Aging (NIA), in cooperation with the Maryland 

Motor Vehicle Administration (MVA), revealed four measures of cognitive ability as 

significant predictors of at-fault crashes. Based on peak valid odds ratios calculated in 

this research, these significant crash predictors are: 

• Visual closure. This ‘visuospatial’ ability enables a person to recognize a whole 

figure when only part is in view. By visualizing missing information, drivers may 

be able to anticipate and/or recognize hazards more efficiently. 

• Visual search, with divided attention. Efficiently scanning the environment for 

traffic control information and navigational cues, as well as vehicles, pedestrians, 

and other safety threats is critical for safe driving, especially at intersections. 

• Working memory. Drivers frequently must share cognitive resources between 

attending to an ongoing task (e.g., maintaining a safe following distance) while 

accessing/applying stored information (e.g., route following directions). 

• Visual information processing speed, with divided attention. This essential ability 

to concentrate cognitive resources on a central task, while processing peripheral 

stimuli at a ‘pre-attentive’ level sufficient to detect targets with high salience for 

the driving task, is also termed “useful field of view.” 

By no means does this suggest an exhaustive listing of cognitive screens that may be of 

potential value to licensing authorities. But there is substantial convergent evidence to 

bolster these as ‘core competencies’ in the area of cognition and driving. With respect to 

‘visual closure,’ researchers (Lesikar, Gallo, Rebok, & Keyl, 2002) have demonstrated 

significance for this visuospatial ability in a prospective study of brief neuropsychological 

measures to assess crash risk in older primary care patients. The test used to measure 

visual search, Trails B, has been singled out for its efficacy not only by the AMA, but in 

numerous other reports (cf. Stutts, Stewart, & Martel, 1998). The cued/delayed recall 

measure of working memory is an integral component of the Mini Mental Status Exam 

(MMSE), one of the most widely used neuropsychological instruments used in clinical 

driver assessments. And of course, the processing speed measure is richly represented 

in the technical literature reporting on the relationship between “useful field of view” and 

crash experience (cf. Clay, Wadley, Edwards, Roth, Roenker, & Ball, 2005). 

Still to be discussed are measures of physical function that significantly predict crash 

risk. With reference to the aforementioned ‘Maryland Pilot Older Driver Study,’ 

performance on the rapid pace walk and head-neck flexibility tests met the criterion for 

at-fault crashes (Staplin et al., 2003). The former measure is a composite of lower limb 

strength, balance, and coordination; it speaks to a driver’s ability to rapidly shift from the 

accelerator to the brake if conditions require an emergency response. The latter 

8 To access the summary technical report and raw data tables for the Maryland Pilot Older Driver Study, 

visit http://www.nhtsa.dot.gov/PEOPLE/injury/olddrive/modeldriver/volume_ii.htm 


measure helps gauge the driver’s ability to detect conflict vehicles during intersection 

negotiation, a lane change maneuver, or when backing. Because of space requirements 

and other demands of the test methodology for these measures, however, they may be 

better suited for ‘offline’ assessments than for in-office screening applications. 

ALTERNATIVE APPROACHES 

Alternatives to the detection of high-risk drivers via screening and assessment activities 

administered by the DMV principally include external reporting and self-reporting. The 

former is most often associated with physician reporting, and indeed, States rely heavily 

on physicians’ judgment about the extent to which a person with a given medical 

condition is incapacitated vis-à-vis safe driving. 

In 1999, the American Medical Association’s (AMA) Council on Ethical and Judicial 

Affairs developed recommendations to address physicians’ legal and ethical obligations 

with respect to reporting physical and mental conditions which may impair a patient’s 

ability to drive. As articulated by the AMA, the physician “must be able to identify and 

document physical or mental impairments that clearly relate to the ability to drive;” and, 

when a patient fails to self-regulate or the physician otherwise perceives a threat to 

public safety, the physician should notify his/her State’s Department of Motor Vehicles. 

This does not mean that there is uniformity in this area, either with respect to the 

medical standards across States, or their physician reporting practices. For example, in 

2003, physician reporting of individuals with driving-impairing conditions was mandatory 

only in six States; however, 30 States gave immunity from civil liability to physicians 

who voluntarily report. Similarly, in some States, the only guidance about disqualifying 

conditions (apart from vision impairments) that DMVs provided to physicians related to 

seizure disorders/loss of consciousness; but on the positive side, other jurisdictions 

(Utah, Maine, North Carolina) offered contrasting approaches that address multiple 

medical conditions, while recasting the problem of identifying impaired drivers in terms 

of “functional ability profiles” (Lococo & Staplin, 2005). Important recent developments 

include the publication of the Physician’s Guide to Assessing and Counseling Older 

Drivers by the AMA in cooperation with NHTSA. The Transportation Research Board 

(TRB) will launch a new Subcommittee on Driver Medical Review in 2008. But there 

remains a pressing need to recognize and promote best practices that are applied with 

some degree of uniformity from one State to another, in concert with the actions of a 

State MAB (or equivalent body) that both informs policy and conducts individual case 

reviews. 

Other external reporting sources include law enforcement, which also has received 

considerable attention from NHTSA in recent years, including the development of 

training programs to improve and standardize officers’ field observation techniques, and 

to increase the frequency of reporting of (functionally) impaired drivers. 9 Evaluations of 

these efforts are ongoing. Family, friends, and concerned citizens also may submit 

9 see http://www.lifesaversconference.org/webfiles2007/Judge.pdf 


eferrals to DMVs, which have procedures in place to verify the authenticity of the 

source and of the reported driving problems before contacting the subject driver. 

The opportunity for self-screening via voluntary disclosure of potentially impairing 

medical conditions is provided by forms that license renewal applicants submit in many 

jurisdictions, and by supplemental questions that may be posed to them by examiners. 

These vary considerably in the nature and level of detail in the items they include— 

diagnoses for specific diseases predominate, but lists of questions used by (Florida) 

license examiners also include more broadly-worded items, e.g., “Do you have any 

mental or physical disabilities that could effect your driving?” While no conclusive 

analyses on the subject could be located, it is fair to say that licensing authorities are 

not sanguine about the effectiveness of self-reports. 

An alternative approach that neither explicitly references medical conditions nor 

functional impairment has recently been advanced—screening renewing older drivers 

on the basis of their annual mileage reported to the licensing authority (Langford, 

Methorst, & Hakamies-Blomqvist, 2006). This work, citing analyses of survey data 

showing higher (self-reported) crash rates among older drivers with the lowest (selfreported) 

exposure, suggests this indicator as a trigger for individualized assessment by 

DMVs. However, a later report raises questions about the sampling methods in this 

research, and casts doubt on the reliability of data supporting a ‘low mileage bias’ 

(Staplin, Gish, and Joyce, in press). Specifically, the sample in the Langford et al. 

research was comprised of respondents at the final stage of a multi-year, multi-stage 

survey process; and with only about 10 percent of those initially queried ultimately 

contributing data to the analyses, potential selection biases in the analysis sample were 

unknown. More importantly, a pattern of misestimating for those who self-report an 

extremely low or extremely high number of miles driven is documented by Staplin et al. 

that inversely mirrors the curves reported by Langford et al., potentially eliminating the 

effect alleged in this article. There could also be concerns regarding due process, if 

(older) persons are singled out for more rigorous testing where there is no history of 

unsafe driving nor any directly observed or measured loss of function. Lastly, using low 

annual mileage as a trigger for special attention at license renewal could, ironically, 

penalize those who are most diligent at self-regulation, while rewarding those who are 

oblivious to (or who deny) their functional limitations. 

One other strategy that deserves comment before leaving this section is the periodic 

call for mandatory road testing for all drivers who exceed a given age. While the age 

threshold may differ, it should not be surprising when bills similar to Sen. Tom Hayden’s 

so-far-unsuccessful efforts in California surface in other States as well. This across-theboard 

strategy may be criticized, first, on its scientific merit as per a recent report from 

the RAND Corporation (Loughran, Seabury, & Zakaras, 2007). This report must be 

strongly qualified, due in part to its inability to segregate crash data for groups of drivers 

older than age 70; its premise that older and younger (adult) drivers encounter each 

other on the road at rates similar to their proportions in the overall population; and its 

assumption that the errors leading to multi-vehicle fatal crashes result from the same 

driver characteristics or deficits as errors leading to other types of crashes (e.g., single 


vehicle, run-off-road). These concerns aside, few working in the area today would 

disagree with the report’s conclusion that the benefits of imposing a blanket policy for 

retesting would be outweighed by its cost to DMVs and to older drivers themselves. 

Indeed, the RAND critique (unintentionally) reinforces the move toward “tiered” 

assessments by those jurisdictions that are pursuing innovative policies in this arena. 

NEXT STEPS: SUMMARY AND RECOMMENDATIONS 

In summary, the unambiguous measure of effectiveness for driver screening and 

assessment programs implemented by licensing authorities is crash reduction. To an 

overwhelming extent, crashes result from driver error. Older persons are ‘expert’ in 

terms of safe driving strategies, and commit errors primarily at the tactical and 

operational levels due at least in part to declines in specified visual, mental, or physical 

abilities. The principal goal of screening and assessment programs is to identify drivers 

at the highest risk of causing a crash. 

The validation of program elements is keyed to prospective crash experience. Driver 

performance measurements on the road and in simulators can also be valuable. Such 

measures help prioritize candidate driver screening procedures for validation in largescale 

epidemiological studies using (at fault) crash data, and for evaluations of the 

operational feasibility of new tools for use by DMVs. 

Demonstrating cause-effect relationships based upon driver characteristics is a 

challenge for researchers; there is a great deal of random (error) variance in crash 

events. But there is mounting evidence that specific declines in functional ability that are 

related to normal aging and the diseases that are more prevalent with aging are 

significant predictors of at-fault crash involvement. This evidence supports policy 

discussions that focus on 1) the validation of tools to detect high-risk drivers by DMVs; 

2) improvements in the external referral processes that bring medically at-risk drivers to 

the attention of licensing authorities; and 3) better education for older persons, their 

families, and health care providers about the impact of age-related changes on safe 

driving and about options for adaptation, remediation, or a transition to alternative 

transportation. 

The surge in older drivers, who as a group are more likely to experience serious 

functional impairments, is only one factor leading States to consider new screening and 

assessment practices. Additional goals include more uniform practices that are fairer in 

their application across different locations; plus, a desire to improve the efficiency of 

their medical review procedures. However, as noted above, there are many practical 

constraints in taking measures out of the laboratory and into the DMV. For jurisdictions 

considering new screening practices, several guidelines may be suggested: 

• Use computer-based measures, to promote standardization; 

• Measures should be automated, to minimize demands for staff time; 

• Carefully integrate new measures with existing office procedures, to promote 

acceptance by examiners. 


The next steps are to encourage States to take initiatives to design and pilot test 

innovative screening and assessment programs, then to evaluate and disseminate their 

results. This is a critical need, to progress from an essentially intuitive process—e.g., we 

need to measure vision because “you have to be able to see to drive”—to a data-driven 

process that yields increasingly sophisticated crash risk prediction tools. With parallel 

advances in the accuracy of techniques used by police to file crash reports 

(electronically, on-site), and with improved links between driver licensing, motor vehicle, 

and crash databases at the State level, the potential for continuing analyses to point to 

strategies that produce measurable safety gains will grow explosively. 

Key initiatives that are now in the national spotlight include pilot programs in California 

and Maryland. The ‘3-Tier’ program in California – whose population, it may be noted, 

exceeds that of many nations – includes a recall memory test, observations of physical 

functioning, and contrast sensitivity screening using a wall chart, at the ‘entry’ level. 

Renewing drivers that must take a written knowledge test are subject to these 

procedures; there is no suggestion of age discrimination. Drivers who do not meet the 

criteria at the first tier proceed to a “perceptual response test” (PRT). This is a 

computer-based test of visual information processing speed, validated as a crash 

predictor through prior testing performed by CA DMV. If a deficit is suggested at this 

second tier, a drive test may be required. Referrals by law enforcement, physicians, and 

others are also eligible for Tier 3, the drive test component, which can either be limited 

to familiar, well-practiced routes or have no such limitation. As of fall 2007, pilot tests of 

this innovative protocol have been implemented and evaluations of test performance, 

public acceptance, and operational feasibility are pending, in 2009. The results will lead 

to recommendations about whether and how an enhanced program should be 

implemented statewide. 10 

In Maryland, a pilot program is underway that has emerged as a national model for the 

assessment of medically-referred drivers. Centered on the activities of its MAB, the 

Maryland program has integrated “functional capacity testing” into its review process, 

augmenting driver history data, and physician reports and other subjective indicators 

with screening data common to all older examinees. The suite of functional status 

measures employed by the Maryland MAB includes all four cognitive crash predictors 

highlighted above, and one of the physical ability measures (rapid pace walk), plus 

contrast sensitivity testing. The addition of functional capacity screening to the medical 

review process has allowed the MAB to increase the proportion of cases with a clear 

recommendation for licensing action upon initial review while decreasing the number 

that must be re-reviewed before case disposition. 11 

It is too soon to suggest what safety benefits might result from these initiatives. Also, 

there is a healthy skepticism by investigators overseas (cf. White & O’Neill, 2000) that 

10 

Source: Leonard A. Marowitz, Coordinator, 3-Tier Pilot Program, Research and Development Branch, 

California Department of Motor Vehicles. 

11 

Source: Carl A. Soderstrom, M.D., Chief, Maryland Medical Advisory Board, Maryland Motor Vehicle 



any in-office screening tool will ultimately prove effective; or is in fact even necessary as 

an adjunct to physician reporting, other referral sources, and self-regulation by drivers 

with (age-related) functional deficits. Yet many U.S. licensing officials, as well as the 

examiners who make judgments every day that can trigger a medical review, are 

unequivocal about the need for better tools on the ‘front lines.’ In this context, the 

outcomes of pilot programs now underway and on the drawing boards assume even 

greater importance, to inform policy in this area. 

Finally, the enduring primacy of private vehicles to meet our personal mobility needs in 

North America provides licensing authorities with a unique opportunity to interact, on a 

periodic basis, with an overwhelming majority of individuals in our society. While major 

differences persist in States’ approaches to evaluating driver qualifications, this 

mandated interaction between State and Provencial governments and private citizens 

shares many common elements. And, a greater harmonization of practices in the U.S. 

may be anticipated with the eventual implementation of the ‘REAL ID’ Act of 2005. 12 

By adopting a core or baseline set of functional status indicators (in addition to visual 

acuity) as prerequisites for continuation of unrestricted driving privileges, a broad public 

health screening would be accomplished simultaneously. Since specific types of 

functional decline not only predict crash risk, but serve as markers for underlying 

medical problems, referrals to physicians, occupational therapists, eye care specialists, 

and other health care professionals would inevitably increase. Potential gains in 

highway safety would be augmented by the early detection of a number of diseases 

more prevalent among older persons. Treatment and remediation options would be 

utilized more often and more effectively, not only improving personal wellness, but also 

helping to limit long-term health care costs for society as a whole. 

12 For more information visit http://www.ncsl.org/realid 


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LICENSE RENEWAL POLICY & REPORTING OF MEDICALLY UNFIT DRIVERS: 

DESCRIPTIVE REVIEW & POLICY RECOMMENDATIONS 

Thomas M. Meuser, PhD 

Associate Professor of Social Work & Psychology 

Gerontology Program, School of Social Work 

University of Missouri - St. Louis 

One University Blvd, 406 SSB Tower, St. Louis, MO 63121 

meusert@umsl.edu 


ABSTRACT 

License renewal and reporting procedures are utilized by state governments to regulate 

the driving privilege, notably to identify individuals that may be unfit to drive due to 

medical and/or functional health conditions. Older drivers, while generally quite safe, 

face a higher risk of health changes that may impact on driving fitness. Some states 

target older drivers for special scrutiny, requiring in–person renewal at more frequent 

intervals. Other states do not distinguish drivers based on age at all. There are good 

reasons for both strategies, in fact. The general motoring public, however, has little 

knowledge of how age and health status may interact with driving ability and safety. 

When confronted with a medically impaired and potentially unfit driver, family members 

and health professionals are similarly at a loss about what do to. A national dialogue is 

needed; (1) to raise awareness about health and driver safety; and (2) to determine 

national standards for driver license renewal and reporting. 

INTRODUCTION 

Our system of certifying, licensing and regulating drivers in the United States (U.S.) is 

decentralized and necessarily imperfect. It is at once local and national, individual and 

group, based on evidence and opinion; and dichotomous in many other ways. Most 

regulation of the driving privilege is defined and managed on the state level, while 

individual travel knows no such boundaries. Drivers certified and licensed in one locale 

may travel as far and wide as they wish. 

Whether local or long distance, driving trips can be either safe or unsafe, depending on 

a host of interacting factors, ranging from individual function and skill behind the wheel, 

to the actions of other drivers, to weather and road conditions, to signage and lane 

markings, to the enforcement of speed limits, to the types and quality of vehicles, and 

the list goes on. National bodies, such as the U.S. Department of Transportation, the 

Transportation Research Board, the AAA, and others, set priorities for mobility and 

safety by studying the associated human, environmental and regulatory factors. As with 

our individual freedom to travel, the promotion of on-road safety knows no boundaries 

and is a universal value – we all hope that our travel from point A to point B will be safe. 

State governments set licensing standards in order to ensure a base level of driver 

knowledge and competence. Procedures for periodic license renewal further regulate 

the driving privilege, requiring licensed drivers to demonstrate ongoing intent and 

functional integrity to drive. Of course, license renewal can also be a means of revenue 

generation – something we all appreciate! 

In addition to renewal procedures, many states also regulate the driving privilege by 

allowing third party reports of potentially unfit drivers. The nature and validity of the 

report is reviewed by the State Department of Motor Vehicles (DMV), and medical 

evaluation and testing procedures may follow. Often, such reports are related to medical 

conditions that impact basic functions (i.e., vision, attention, motor speed, cognition, 


etc.) necessary for safe operation of a motor vehicle. Older adults (notably those over 

age 70) are particularly susceptible to such conditions. 

This paper is intended to provide a brief, descriptive survey of license renewal 

standards and reporting procedures as applied in the U.S. today. As we shall see, these 

standards and procedures vary widely, and do not always have a clear basis in 

evidence. Local custom and opinion may be the only determining factors. A model for 

reporting of unfit drivers is presented in detail, so as to explain the process and suggest 

targets for education, research and policy initiatives. 

One state, Missouri, will serve as a case example for detailed discussion. In Missouri, 

the driver licensing authority exists within the taxation body. The Drivers License Bureau 

is part of the Department of Revenue, and final driver licensing decisions are made by 

the Director of Revenue. Most other states have separate departments for driver 

licensing (i.e., Department of Motor Vehicles). For purposes of understanding, the 

acronym “DMV” will be used to refer to the Missouri structure and other states. 

On-road testing of Missouri drivers is provided by another branch of government, the 

Missouri State Highway Patrol (MSHP). MSHP Driver Examiners, non-officer employees 

with at least a 12 th grade education and specific training, utilize a standard test of 

vehicle operation for new, young drivers and others mandated for testing by the Director 

of Revenue, such as those reported as unfit due to medical and/or functional limitations. 

Test scores and written notes are submitted to the DMV in support of licensing 

determinations. A Medical Advisory Board (MAB), composed of specialist physicians, 

may be asked by DMV officials to provide input (i.e., by telephone or mail) on specific 

cases (see Lococo & Staplin, 2005, for a detailed review of MAB procedures in the 

U.S.). 

DESCRIPTIVE REVIEW 

MEDICAL FITNESS TO DRIVE Before discussing license renewal 

and reporting procedures, it is important to understand the underlying concept of 

medical fitness to drive (MFD). The “medically fit” driver is one with sufficient function in 

vision, alertness, cognition, joint range of motion, motor speed, etc., to manage the 

operational, tactical and strategic demands of driving an automobile (Anstey, Wood, 

Lord, & Walker, 2005; Wang & Carr, 2004; Wang, Kosinski, Schwartzberg, & Shanklin, 

2003; Michon, 1989). License renewal and reporting procedures exist, in part, to provide 

a means to recognize MFD concerns and act accordingly. 

While MFD is applicable to all age groups, it is particularly salient for older adults. As a 

group, older adults are at greater risk for health conditions that may impair driving ability 

and increase crash risk, especially after age 70 (Li, Braver, & Chen, 2003; Foley. 

Heimovitz, Guralnik, & Brock, 2002; Carr, 2000). Health conditions that detract 

meaningfully from these key abilities may increase crash risk, and thus require focused 

evaluation and intervention (Odenheimer, 2006; Dobbs & Carr, 2005). 


A range of health conditions have been linked with crash, licensing, and performancebased 

outcomes (Dobbs, 2005; Charlton, Koppel, O'Hare, Andrea, Smith, Khodr, 

Langford, Odell, & Fildes, 2004; Vernon, Diller, Cook, Reading, & Dean, 2001). Certain 

age-associated conditions, such as progressive dementia (e.g., Alzheimer’s disease), 

are of particular concern due to high prevalence in later life and strong evidence for 

unsafe driving beyond the mild stage (Duchek, Carr, Hunt, Roe, Xiong, Shah, & Morris, 

2003; Dubinsky, Stein, & Lyons, 2000). 

Just because someone is diagnosed with such a condition, however, does not 

automatically mean that driving fitness is compromised. Individual response to disease 

can vary greatly, making any blanket statements about disease status and driving 

fitness difficult to justify. For more information on MFD, see the detailed review by David 

B. Carr, MD, included in this volume. 

LICENSE RENEWAL PROCEDURES License renewal procedures 

can provide an opportunity for MFD-related concerns to be identified and managed. 

License renewal is periodic in most states, includes some form of vision assessment 

(typically a test of acuity), and may be accomplished by mail, electronic means and/or 

through in–person application. Some states utilize shortened renewal periods and 

require in–person renewal specifically for older adults. This gives license office staff an 

opportunity to observe and interact with such individuals, and identify those who may be 

unfit to drive due to medical and/or functional conditions. 

A number of up-to-date listings of state license renewal regulations for older adults are 

available on-line (see Table 1). 

Table 1: Resources Listing License Renewal Policies in U.S. 

AAA 

Governors Highway 

Safety Association 

Insurance Institute for 

Highway Safety 

Senior Licensing Laws (MS Word Document) 

http://www.aaapublicaffairs.com/Main/ 

Click on On the Road, Mature Drivers, to view & download. 

Mature Driver Laws 

http://www.ghsa.org/html/stateinfo/laws/olderdriver_laws.html 

US Driver Licensing Procedures for Older Drivers 

http://www.iihs.org/laws/olderdrivers.aspx 

Standard adult license renewal periods range primarily from 4 to 10 years, with 

shortened periods for younger and older drivers. There are some exceptions. In 

Arizona, for example, one’s license remains valid until age 65, at which time a 5-year 

renewal cycle is implemented. Most other states renew a license every 4-6 years. In 

Illinois, the standard renewal period is 4 years, but this drops to 2 years for those age 

81-86 years, and just 1 year for those age 87 years and older. Visual acuity and field 

testing is required at renewal in many states. A few more stringent states, such as 

Illinois, require on-road testing when a driver renews after turning age 75. 


Our example state, Missouri, utilizes a graduated system for teen drivers to gain needed 

experience, starting on the permit level at age 15 and allowing for full licensure starting 

at age 18. The standard full license cycle is six years. Drivers age 18-21 and those 70 

and older have an abbreviated cycle of 3 years. The Missouri Driver Guide (2006) 

provides a detailed description of the graduated system for young drivers, but says little 

about the shortened period for older drivers, except to note medical concerns. Drivers 

are warned that they may need a physician’s statement at the time of renewal under two 

circumstances: 

1. “You have had epileptic seizures, convulsions, or blackouts within the 6 months 

prior to your license application, or 

2. The driver examiner, licensing clerk, or other responsible person believes you 

may have some other medical condition that would make you an unsafe 

driver…” (Missouri Driver Guide, 2006, p. 17) 

To support the identification of such conditions, license office clerks are provided with a 

three-page guide entitled Evaluating Driver Impairments: A Guide for Field & Central 

Office Staff, a key table from which is reprinted below (see Table 2). License clerks are 

expected to report individuals that fail to meet these suggested standards. 

Table 2: Chart for Evaluating Driving Impairments 

ABILITY 

(what the applicant is able to do) 

Lower body strength, range of motion, mobility and 

coordination to use foot-operated vehicle controls. 

Upper body strength, range of motion, mobility and 

coordination to use hand-operated vehicle controls 

and to turn the head and body to the left, right and 

rear to observe for other traffic and pedestrians. 

To see other traffic, road conditions, pedestrians, 

traffic signs and signals. 

Cognitive skills (i.e., to think, understand, perceive 

and remember). 

STANDARD 

(what the applicant should be able to do) 

Person is able to walk to a license office counter 

unaided physically by another person or significant 

support device (i.e., walker, wheel chair. breathing 

apparatus or artificial limb). There is no loss (full or 

partial) of a leg or foot, No excessive shaking, 

tremor, weakness, rigidity or paralysis. 

Person is able to turn head and upper body to the 

left and right and has full use of the arms and 

hands. There is no loss (full or partial) of an arm. 

There is no loss of a hand or finger that interferes 

with proper grasping. No excessive shaking, 

tremor, weakness, rigidity or paralysis. 

Person is able to meet applicable vision 

requirements by passing a Department of 

Revenue vision screening or presenting evidence 

of similar testing by a vision specialist. 

Person exhibits cognitive skills. Responds to 

questions and instructions (i.e., is able to complete 

an application. knowledge test or vision 

screening). No obvious disorientation. 

To maintain normal consciousness and bodily Person exhibits normal consciousness and bodily 

control (i.e., no self-disclosed or obvious incident 


control. or segment of time involving altered 

consciousness. No loss of body control involving 

involuntary movements of the body characterized 

by muscle spasms or muscle rigidity, or loss of 

muscle tone or muscle movement). No obvious 

disorientation (i.e., responds to questions and 

instructions. Is able to complete an application, 

knowledge test or vision screening). 

To maintain a normal social, mental or emotional 

state of mind. 

Person does not exhibit an extremely hostile and/ 

or disruptive, aggressive behavior, or being out of 

control. No obvious disorientation. 

The author of this report is part of a research group currently evaluating how Missouri’s 

reporting procedures operate (Meuser et al., 2007; funded by the AAA Foundation for 

Traffic Safety). We have some interesting preliminary data on Missouri drivers reported 

as unfit by license office staff from 1999-2005. 

During this period, a total of 1,052 drivers aged 50 and older were reported as 

potentially unfit to drive by license office staff. These reports were based on direct, 

personal observation of the driver in the licensing facility. The majority of these 

individuals were 70 and older at the time of report (see Figure 1), and later were shown 

to have one or more health conditions related to driving fitness (see Figure 2). 

Figures 1 & 2: Age & Number of MFD-Related Medical Conditions of Drivers, 

Reported as Unfit by License Office Clerks in Missouri (1999-2005)* 

* Physician reports were available for a subset of cases (n = 410), and showed that most individuals 

observed as impaired by license office staff had at least one health condition related to driving fitness, 

and many had two or more such problems. Figure 2 is based on the Missouri Physician Statement (Form 

1528), which includes check boxes for six health categories: Cognitive Impairment, Psychiatric Condition, 

Disorders that Impair Consciousness, Musculoskeletal Conditions, Alcohol or Drug Abuse, Other 

Condition (physician must explain). 


A preliminary analysis of qualitative comments made by license clerks sheds light on 

how the standards in Table 2 are applied in practice. The first ability standard – lower 

body strength and mobility – received the most attention. An observed problem with 

ambulation was cited in more than half of these license office reports (62 percent), 

followed by mental confusion (20 percent), difficulty comprehending instructions (9 

percent), and slow reflexes and/or reaction time (9 percent). 

These data suggest that older adults with readily observable frailties (e.g., problems 

with ambulation, mental confusion) were most likely to be identified as potentially unfit to 

drive by license office clerks. Data from Physician Statements confirm these 

observations as valid, indicating that many of these reported drivers had legitimate 

medical conditions of concern. More than one third (40%) of drivers reported in 1999- 

2005 were subsequently listed as deceased when their files were reviewed in 

December, 2006. This high mortality rate came as a surprise to the research team, and 

indicates that many were near the end of both their driving and physical life 

expectancies when reported. 

Of those still living, just 18 (3%) passed the DMV review process and retained a valid 

license to drive; a fact that further validates the concerns of license office clerks. 

Together, these data indicate that license office staff can and do play an important role 

in identifying at-risk older drivers. 

PUBLISHED RESEARCH ON LICENSE RENEWAL The research data on 

license renewal policies are mixed and largely inconclusive (Molnar and Eby, 2005). 

Past studies suggest that vision testing at license renewal may reduce crash risk and 

societal costs (see Levy, Vermick, & Howard, 1995; Shipp, 1998). Levy and colleagues 

examined crash rates in a sample of drivers age 70 years and older across a number of 

states. Those residing in states with vision testing at license renewal had significantly 

lower fatal crash rates (when controlling for license renewal period), presumably 

because visually impaired individuals were effectively removed from the road. 

Combining a test of driver knowledge with vision testing did not lower crash risk, 

however. 

The most comprehensive study to date (Grabowski, Campbell, & Morrisey, 2004) 

examined all primary factors involved in license renewal: renewal period, in–person 

renewal, vision testing, and on-road testing. National data from the Fatality Analysis 

Reporting System from 1990-2000 was utilized, and organized around three age 

ranges: 65-74 years, 75-84 years, and 85 years and older. Shorter renewal period was 

not a significant predictor of crash risk for any age group. This is consistent with prior 

research examing Illinois’ age-based renewal system which found no benefit (Rock, 

1998). In fact, the only factor to predict lower accident risk was in–person renewal, but 

just for the oldest age group (85 and older), presumably because impairments are more 

readily observable among the oldest-old. 

Another recent study found no appreciable benefits to engaging in screening for health 

conditions at the time of license renewal (Viamonte, Ball, & Kilgore, 2006). The 

researchers compared screening (and, if necessary, intervening) with all drivers 


egardless of age, screening just for drivers age 75 and older, and no screening. They 

concluded that costs outweighed benefits, in part due to the modest quality of screening 

measures now available. 

REPORTING OF POTENTIALLY UNFIT DRIVERS Most states utilize 

voluntary procedures to address MFD concerns, whereby professionals of various types 

or family members may report concerns about individual drivers to the DMV (Morrisey & 

Grabowski, 2005). A handful of states, including California, Delaware, New Jersey, 

Oregon, and Pennsylvania, mandate that certain MFD-related health conditions (e.g., 

Alzheimer’s disease, epilepsy) must be reported to the DMV at the time of diagnosis so 

that ongoing driving fitness can be addressed (Wang et al., 2003). Licensed drivers, 

themselves, are also encouraged to take personal responsibility for MFD by selfreporting 

any concerns to the DMV and/or self-limiting their on-road exposure. In Illinois, 

for example, individual drivers must report “any medical or mental condition which could 

result in a loss of consciousness or any loss of ability to safely drive a vehicle” 

(CyberDriveIllinois, n.d.). 

It is safe to say that the identification of individuals as medically unfit to drive is a 

collaborative effort between citizens, professionals, and government officials. However, 

the final decision to revoke any individual’s license to drive resides solely with the state 

government. 

Reporting laws can be categorized under a number of basic headings, as shown in 

Figure 4 below. How the state behaves toward and protects the reporter is quite 

important. Is the reporter’s identity kept confidential from the potentially unfit driver or 

not? Is the reporter protected from legal prosecution that could result from making a 

report (e.g., for breach of patient confidentiality when a physician or other health 

professional is involved)? Does the law provide clear guidance to the reporter, listing 

specific conditions or symptoms of concern? How transparent and comprehensive is the 

system with regards to follow-up and driver-related evaluation? 


Figure 4: Components in State Reporting of Potentially Unfit Drivers 

The American Medical Association’s Older Drivers Project (AMA-ODP) summarized 

these components for all 50 states (Wang et al., 2003), and this summary is now being 

updated for re-publication in late 2008. One conclusion from this work is that few states 

are alike across these dimensions. The voluntary reporting law active in Missouri 

(House Bill 1536), for example, allows health professionals, law enforcement officers, 

family members, and others, to report potentially unsafe drivers for medical evaluation, 

retesting, and possible license revocation. The law grants anonymity to the reporter 

(i.e., the reporter’s identity is held in confidence from the reported driver) and civil 

immunity from prosecution for breach of confidentiality. A similar law in New York allows 

for reporting by these groups, but does not keep the reporter’s identity confidential, nor 

does it offer civil immunity protection. In which state is a physician or other professional 

more likely to feel “safe” in making a report? Unfortunately, little is known about how 

such provisions impact reporter behavior and the number or quality of reports received 

on the state level. This is an important area for research moving forward. 

When a report is made, the DMV may require medical evaluation and/or driving-related 

testing (written, vision, and/or on-road) to determine ongoing fitness and license 

eligibility. Should a physician identify an MFD-related concern, for example, he or she 

can report the affected driver to the DMV for evaluation and possible license revocation 

in most states (Meuser, Carr, Berg-Weger, Niewoehner, & Morris, 2006). A few states, 


such as Maryland, utilize detailed, age-specific evaluation protocols under such 

circumstances (see Staplin, Gish, & Wagner, 2003a; Staplin, Lococo, Gish & Decina, 

2003b), whereas others, such as Missouri, evaluate older drivers using standard driving 

tests applied at any age. The typical steps involved in state reporting are represented in 

Figure 5 below. 

Figure 5: State Reporting Process for Potentially Unfit Drivers 

At each point in the process, decisions are made by both state officials and reported 

drivers. Results of medical evaluation and testing may indicate a need for de-licensing 

for reasons of public safety. Regardless of these findings, however, drivers may choose 

to withdraw from the process at various points and move (voluntarily or involuntarily) 

into driving retirement. For some individuals and families, this choice may come as a 

welcome relief. For others, it may be viewed as an unjust intrusion and/or a violation of 

personal autonomy and rights. Often the latter cannot be avoided. 

The AAA Foundation for Traffic Safety is now funding the first comprehensive 

evaluation of state voluntary reporting law, linking individual crash and citation histories 

(important indicators of on-road safety) with medical and behavioral data from over 

5,000 drivers reported as unfit in Missouri from 1999-2005 (Meuser et al., 2007). These 

data are currently being organized and analyzed as of this writing, and hold much 

promise for the development of a model voluntary reporting process for all states. 

The data summarized earlier in this paper concerning license office staff reporting 

provide a glimpse of our larger findings. Those reported as unfit in Missouri tend to be 

very old, visibly impaired, with one or more medical conditions potentially affecting 

driving safety, with a positive crash history, and at high risk for death. Arguably, such 

individuals should not be licensed to drive an automobile. Very, very few retain a valid 

license to drive in the end. For this type of driver, at least, the voluntary reporting 

procedures in Missouri appear to work. 

There is an additional side to this story, however, which pertains to another important 

finding of a qualitative or “process” nature. It is the notion that the report to the DMV, 

itself, is just a small part of a larger set of related components and events. How a driver 

fitness problem is recognized, by whom, and under what conditions, are all critical 

factors in whether a report will eventually be filed or another intervention attempted. 

Educational initiatives, such as those initiated by the AMA’s Older Drivers Project, target 


these “upstream” components. Unless physicians, family members, and other potential 

reporters know what to look for and feel empowered to act, evidence of driver safety 

problems will go unnoticed and therefore unreported. Whether a reporting law exists or 

not becomes a moot point under such circumstances. 

A RECOGNITION-ACTION MODEL FOR DRIVER FITNESS INTERVENTION In the 

opinion of this author, a critical area for education, research and policy initiatives has to 

do with the recognition of driver fitness concerns in the community. While researchers 

are beginning to understand what to look for in terms of health and functional status, 

this information has been slow to make its way into public consciousness. We all have a 

stake in supporting safe driving, but few know what to do when confronted with 

evidence of a problem. Better education is one key. 

The author is part of an educational team that has provided over 50 workshops on this 

topic to health professionals and others over the past five years (see Meuser et al., 

2006; Wang & Carr, 2003). While a number of published guidelines on MFD exist, many 

health professionals lack training in how to apply these guidelines when evaluating 

patients (Marshall & Gilbert, 1999; Kelly, Warke, & Steele, 1999; King, Bendow & 

Barret, 1992); in when to refer for performance-based, on-road evaluation (Valcour, 

Masaki, & Blanchette, 2002); and in how to report to state authorities (Cable, Reisner, 

Gerges, & Thirumavalavan, 2000). From our workshops, we’ve learned that physicians, 

social workers, psychologists, occupational therapists, nurses, and a host of other 

professionals, are concerned about older driver safety and interested in learning how 

they can get involved. Until receiving notice of our workshop, however, they have not 

known where to turn for this training. 

An information gap exists between the driving safety research/policy communities (i.e., 

those that study the data and produce evidence-based guidelines), government 

regulators (i.e., those that set and enforce driver licensing regulations), and the wider 

community at large. We see this in our workshops with respect to state reporting 

(Meuser et al., 2006). Few of our Missouri trainees – less than 5 percent by informal 

count – report knowing anything about Missouri’s voluntary reporting law, despite it 

being active since 1999! 

One reason for this information gap is the complexity of the issue and the many different 

stakeholders involved. There is need for a model that captures the key elements of 

reporting so as to better target educational, research and policy-related interventions in 

the future. Figure 6 presents a first attempt at such a hypothetical model. 


Figure 6: A Recognition-Action Model of Driver Fitness Intervention 

In this model, the evaluative actor can be anyone, but law enforcement officials, health 

professionals and family members are the most common types (in Missouri at least; 

Meuser et al., 2007). The model considers one actor at a time, but many cases are 

likely to involve more than one actor in recognizing a problem and moving towards an 

eventual intervention. The actor(s) must possess an evaluative consciousness if 

anything is to happen, however. 

The evaluative consciousness involves three critical components: knowledge, efficacy 

(confidence), and responsibility. The knowledgeable actor has a clear understanding of 

how medical and functional conditions of aging may impact on driver safety, what to 

look for when assessing driver fitness on an individual, and requirements for DMV 

reporting. The confident actor feels comfortable with his/her knowledge and its “real 

world” application. Finally, the responsible actor has a legitimate sense of responsibility 

for addressing fitness to drive in his/her daily practice. 

The evaluative encounter can be any interaction where information about driving fitness 

is obtained (see green box), including observation and third party communication. If the 

actor were a police officer, for example, the encounter may be a traffic stop subsequent 

to a crash or other on-road incident. For a physician actor, the encounter could be a call 

from a concerned relative of a patient (“he’s not safe to drive because…). The 

evaluative encounter can involve direct observation, a report from someone else, a 

supposition based on obtained information, a clinical or expert judgment pursuant to an 

evaluative process, or merely a felt concern or hunch (“I’m concerned seeing all this 

damage to her car…”). 

To move to the next step of a fitness intervention, the actor must possess a sufficient 

evaluative consciousness to recognize red flags present in the encounter, weigh 


available evidence (“how much risk is there here?”), and choose an appropriate course 

of action. The fitness intervention can be as simple as a voiced concern (“I am 

concerned that you may no longer be safe to drive…”), or as serious as a formal report 

to the state DMV. The evaluative actor may choose something in between, possibly a 

counseling effort to determine what steps are best for an individual case. Such 

counseling might include talking with family members, identifying travel needs, referral 

to a driver rehabilitation specialist or additional driver training, evaluating alternative 

transportation strategies in the community, etc. (MacLean, Berg-Weger, Carr & Meuser, 

2007). 

Our workshops in Missouri and educational programs through the AMA’s Older Drivers 

Project, among other efforts, target most aspects of this model, but not necessarily with 

conscious intent or the best means of ensuring success. Building the efficacy and 

confidence of the evaluative actor is not a simple task, for example, and may involve 

practice-based learning and performance feedback. Such training is not possible in a 

typical lecture and discussion based educational format. Yet, if the actor lacks selfefficacy, 

will acquired knowledge be applied when an evaluative encounter takes place? 

It is also difficult to train someone to recognize and accept personal responsibility for 

action. 

What this hypothetical model does, however, is to make explicit the various components 

of fitness evaluation and how they may relate together. The identity of the evaluative 

actor will determine, in part, what components in the model may be particularly 

important targets for intervention. Police officers are likely to experience many 

evaluative encounters and they are certainly used to taking responsibility, but they are 

likely to lack knowledge and confidence with respect to the aging process and its impact 

on driver fitness. In contrast, physicians may know quite a bit about aging, but may not 

recognize when driving is a true concern, their responsibility to act, and then what steps 

to take. 

Just as this model can inform and challenge educators, it can also influence policy 

decisions and government allocations of resources. Missouri’s voluntary reporting law, 

for example, was implemented without resources for ongoing public education 

concerning the law and how to use it. No wonder so few of our workshop trainees tend 

to be aware of it! A statewide educational campaign could both be justified and tested 

via this model. 

SUMMARY & RECOMMENDATIONS 

Driver licensing and reporting procedures are determined on the state level, yet 

personal freedom to travel and expectations for on-road safety traverse state 

boundaries and apply to the US population as a whole. Our licensing system is at once 

local and national. 

Regardless of state of residence, however, we all have a stake in ensuring that licensed 

drivers meet basic standards of health and function. Certain medical and functional 


conditions are known to impair driver fitness. Many, such as Alzheimer’s disease, are 

associated with advancing age. Responsibility for addressing such conditions starts with 

the driver, and then extends on through the family to the level of the community and 

government. When individuals and those in their network (including their health 

providers) fail to act in response to a legitimate fitness concern, the government must 

act. 

Periodic license renewal is one means that states use to identify potentially unfit drivers 

due to medical and/or functional conditions. Advancing age may trigger an abbreviated 

license renewal period and a requirement for in–person application. License office staff 

may observe obviously frail or impaired individuals, and report them to state authorities 

for fitness-related evaluation. Screening of visual acuity (and other aspects of vision) 

provides another means of identifying potentially unfit drivers, but research is mixed on 

the safety benefits of such efforts. A requirement for in–person license renewal has 

been linked to improved safety for the oldest-old drivers. 

Another way that states learn about potentially unfit drivers is through formal reporting 

procedures. These are voluntary in most states, and allow physicians, police officers, 

family members, and others, to report drivers for evaluation and possible license 

revocation. A few states mandate that certain conditions, when diagnosed, must be 

reported. A recent position statement by the American Academy of Neurology (Bacon et 

al., 2007) argues that individual differences in disease presentation, and a relative lack 

of driving safety information for many health conditions, are sufficient reasons for 

reporting to remain voluntary – physicians (and others) need to make individual 

decisions in this complex area. A model for the reporting process is presented, 

suggesting areas whereby educational and policy-related interventions may enhance 

voluntary reporting in the future. 

ISSUES & RECOMMENDATIONS FOR DISCUSSION 

1) A disconnection exists between driver licensing standards and driver 

fitness/safety concerns, such that the former is defined on the state level, yet the 

latter is an equal priority of all citizens. It is time for a national dialogue on what 

constitutes medical and functional fitness to drive so that uniform standards may 

be developed and implemented in all states. 

2) While advancing age may be viewed as a risk factor for driver fitness concerns, 

age, by itself, is not a sufficient proxy for most health and functional changes that 

may impact on driver safety. On an individual level, a 90 year old with vision 

problems and arthritis can be more “fit to drive” than a 60 year old with similar 

health problems. Age is a weak predictor of function. Age-based regulations of 

the driving privilege require justification and supporting evidence to remain 

tenable. Where such evidence is lacking, a greater emphasis must be placed on 

the evaluation of individual function so as to avoid potential (and unnecessary) 

discrimination. 


3) In–person license renewal is a viable means to improve safety by identifying 

persons with serious (obvious) medical and/or functional conditions that may 

impact on driver fitness. This can be true for any age, but the data currently 

support its application just for the oldest-old. Data from Missouri suggests that 80 

years – just above average life expectancy – might be a reasonable age to 

require in–person driver license renewal, if at all. 

a. An alternative to requiring in–person renewal based on age is to 

“incentivize” this procedure for everyone, young and old alike. Those 

choosing to renew in–person would receive a full–term license, whereas 

those renewing by mail or on-line would receive an abbreviated term. This 

encourages in–person renewal without mandating it. With respect to 

medical conditions of aging, this system is likely to work best if the 

standard renewal period is short, say just 4 years. Older adults that would 

renew in–person could still be observed again at the license office in four 

years time. 

4) Certain states have adopted abbreviated renewal periods for older drivers, some 

even using a graduated system based on advancing age. Due to the differential 

impact of aging and disease on function, however, it is difficult to know where 

best to draw such lines. A standard, relatively short, renewal period for all drivers 

(say 4 years) might be the most equitable solution. 

5) Visual acuity testing at license renewal has strong face validity as a screening 

technique for driving fitness, even if the data in support of this activity is 

inconclusive. Changes in vision begin in midlife, and so it seems reasonable to 

apply a vision test requirement for most adults and not just those in the last 2-3 

decades of life. 

6) Reporting of potentially unfit drivers to state authorities is a multi-factorial 

process, involving characteristics of the reporter, how and when a driving 

problem is observed, and what opportunities for intervention are available. While 

all citizens are stakeholders in driver safety, general public awareness about 

fitness to drive in aging is very limited. Families are on the front lines of driving 

retirement decisions yet often don’t know where to turn for help. Too few 

physicians and other health professionals are trained, specifically, in this area. 

Opportunities for education exist on all levels to enhance reporting of potentially 

unfit drivers. A systematic, national model-driven effort is called for. 

b. License office staff members are an important target group for aging and 

driving fitness education. While such staff in Missouri are provided with 

written instructions on what to look for, many of their written reports 

suggest ageist bias and confusion about basic changes that occur with 

age (Meuser et al., 2007). It is one thing to have a written policy, and it is 

another to receive training in its appropriate application. As front line folks 

in the certification of driver fitness, license office staffers deserve to be at 

the front of the education line. 


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LICENSING AGENCY OPTIONS FOR INTERVENTIONS 

Carl A. Soderstrom, M.D., F.A.C.S. 

Chief, Medical Advisory Board 

Director, Driver Safety Research Program 

Maryland Motor Vehicle Administration 

Glen Burnie, MD 21062 

csoderstrom@mdot.state.md.us 


INTRODUCTION 

Some drivers age without the emergence of significant physiologic changes that affect 

their ability to drive safely. For those who do, rapidity of onset and severity of problem(s) 

can vary greatly. Hence, options for intervention should be considered on a case-bycase 

basis. This approach is endorsed by the American Medical Association’s 

Physician’s Guide to Assessing and Counseling Older Drivers (Wang et al., 2003) in 

which function, not age or condition, is the critical factor in determining fitness to drive 

and necessary interventions. 

POINTS OF INTERVENTION/INTERVENTIONS—NATIONALLY 

Lococo’s (2003) review systematically summarizes the interventions utilized by licensing 

agencies in the fifty United States and the District of Columbia. Some of the key findings 

pertinent to this discussion are highlighted below. 

The report mentions points of intervention for the 51 jurisdictions. All allow for an 

evaluation based on police reports and physician referral, and almost all as the result of 

reports from an occupational therapist, or concerns expressed by relatives and/or 

others. About half may require an evaluation for those involved in a fatal crash and over 

one-quarter for involvement in two or more crashes in a specified period of time. A few 

require evaluations based on age. Arkansas requires a physical examination for initial 

licensure, three jurisdictions require a physical examination for an initial license based 

on age (Louisiana, 60+; Maryland, 70+; District of Columbia, 70+ - and at renewal, and 

in Nevada those 70+ renewing by mail must submit a physician’s report. 

The following pertains to the approximately 60% of jurisdictions having medical advisory 

boards (MAB) for which complete information was available. As the result of review, all 

MABs can recommend suspension of driving privilege or driving restrictions. 

Remediation is an option in over half of the jurisdictions with complete MAB information, 

with periodic re-examination as an optional recommendation in most. 

The Summary of Medical Advisory Board Practices (Lococo, 2003) contains some 

information about inventions in the form of license restrictions for 16 jurisdictions. These 

include geographic restrictions in the form of mile range, daylight driving only, corrective 

visual equipment, adaptive equipment, and no highway/freeway driving. 

POINTS OF INTERVENTION/INTERVENTIONS—MARYLAND 

The Maryland Motor Vehicle’s medical advisory board was created in 1947. Since that 

time, the Maryland system of medical oversight for fitness to drive has matured to allow 

for a variety of interventions during the evaluation process. The following hypothetical 

case presentation is taken from a recent paper (Soderstrom & Joyce, 2007) describing 

that system which illustrates interventions. 


An elderly lady was referred to the MVA because she was driving 20 mph below the 

posted speed limit on a major highway during daylight in good weather. She was not 

aware she was causing problems with traffic flow and seemed a “little bit confused” and 

had trouble identifying her license in her handbag. The woman’s driving record revealed 

no past violations. (The officer did not cite her for driving below the speed limit and 

impeding traffic.) Based on this report, the MAB requested her to submit a physician’s 

report and a health questionnaire (HQ) and have functional capacity testing (FCT). In a 

study of Maryland drivers, Ball et al. (2006) demonstrated that such testing administered 

in an MVA setting could identify drivers at-risk of being involved in future crashes for 

which they were at fault. FCT screening has been used as standard practice in 

Maryland to evaluate drivers with cognitive concerns for about 7-8 years. 

The driver’s physician opined that the woman was fit to drive, noting history of a “ministroke” 

two years before the traffic incident and a score of 29 out of 30 on the MMSE. 

On the HQ the woman indicated “a change in her ability to remember things.” On her 

FCT, the client had a marginal score of 2 minutes 28 seconds on the Trails B element 

(cutoff >2:30) and a UFOV ® of 500 milliseconds (cut-off > 350 milliseconds). 

1 ST MAB REVIEW 

Based on review of the above materials the driver was requested to take an MVA 

course driving test. 

MVA COURSE DRIVING TEST 

For a person applying for a license, the test must be accomplished with no more than 

15 points being deducted for skills assessed. For the driver under medical review for 

cognitive concerns, the test is not “passed” by having less than 16 points deducted. The 

test is to assess safety for the driver and the examiner. If the driver achieves a score of 

over 16 points, and is not driving in a fashion that places the occupants, bystanders, 

and property in danger, the examiner is asked to complete the test. Hence, an 

inordinately high score combined with clinical, screening, and other elements provides 

the basis to recommend cessation of driving and/or referral to an occupational therapist 

(OT) for a comprehensive clinical and behind the wheel assessment. Allowing the driver 

to take the driving test a prescribed number of times before making such a 

recommendation is not standard of practice in Maryland. The driver had 11 pts 

deducted. Hence, she proceeded to an on the road driving test in unfamiliar 

surroundings. 

MVA ON THE ROAD TEST 

The driver poorly observed traffic, encroached into other lanes, and missed a turn. The 

test was terminated when she made an unsafe maneuver. At this point her driving 

privilege was suspended. 

2 ND MAB REVIEW 

An OT driving assessment was recommended. 


POSSIBLE OUTCOMES 

The OT may recommend retirement from driving, or additional training. A number of 

recommendations would follow this additional training, including driving cessation. 

Driving may be recommended with a number of restrictions including adaptive 

equipment (Examples: larger side mirrors, pedal extenders, etc.), no highway driving, 

and daylight driving only. A possible goal for this driver may be to have her qualify for a 

geographic restriction that would allow her to drive within her area to meet her activities 

of daily life. If she was granted such a license she could remain active and independent 

for an extended period of time. She would be road tested in her area on a periodic basis 

– usually every 6 months. 

This case illustrates the Maryland approach to maintaining “safe mobility for life” for as 

long as possible for the driver and other users of the road. 

REFERENCES 

Ball, K.K., Roeneker, 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? Journal of American Geriatric Society, 54, 77-84. 

Lococo, K.H. (2003). Summary of Medical Advisory Board Practices in the United 

States. Washington, DC: National Highway Traffic Safety Administration, June 

2003. 

Soderstrom, C.A., Joyce, J.J. (in press, 2007). Medical review of fitness to driver in 

older drivers: the Maryland experience. Traffic Injury Prevention. 

Wang, C.C., Kosinski, C.J., Schwartberg, J.G., et al. (2003). Physician’s Guide to 

Assessing and Counseling Older Drivers (Rep. No. DOT HS 809 647). 



REMEDIATION FROM THE OCCUPATIONAL THERAPIST’S PERSPECTIVE 

Elin Schold-Davis 

Coordinator, AOTA Older Driver Initiative 

American Occupational Therapy Association 

4720 Montgomery Lane 

Bethesda, MD 20824 

escholddavis@aota.org 


ABSTRACT 

The need for access to intervention services is increasing. As individuals and 

professionals use self-assessments and professional screening tools that associate 

impairments with driving risk, passenger safety intervention will be required to minimize 

the functional impact of these risk factors on driving safety. The intervention sought from 

driving rehabilitation specialists is expanding from evaluating for driving potential for 

persons with disabilities to an ever-increasing emphasis on addressing the question of 

“when a person should stop”. Decisions about driving are exceedingly complex. 

Therapists are typically committed to considering all options of remediation and 

adaptation/compensation before concluding that driving cessation is the necessary 

recommendation and the focus turns to alternative means for continued mobility and 

community involvement. The difficulty is determining when that point occurs. As 

researchers in aging continue to develop evidence clarifying the cut-points for decisions 

and compensation techniques, this information needs to be shared to ensure 

incorporation into occupational therapy professional development. There is also a need 

to increase the capacity for occupational therapy programs to provide evaluation and 

intervention services. Working at the level of the client, the occupational therapist can 

be the key link between research and practice of assessment and rehabilitation and the 

researchers and practitioners addressing alternative transportation issues. 

REMEDIATION FROM THE OCCUPATIONAL THERAPIST’S 

PERSPECTIVE 

With any client, occupational therapy intervention strategies consist of evaluation 

followed by remediation, compensation, education, or a combination of the three. The 

goal of the occupational therapist is to determine what remedial (restorative) 

intervention will allow the individual to perform their valued task. If the individual’s deficit 

cannot be remediated, the occupational therapist uses compensation strategies to teach 

the individual new methods, use adaptive equipment, or change the environment so that 

the individual can be successful. In driver rehabilitation, the fundamental objective has 

been to enable persons with cognitive, physical, or sensory deficits to learn or continue 

to drive safely in order to develop or maintain independent mobility. However, the clients 

referred to driving rehabilitation services has significantly changed within the last few 

years. Because of the momentous technological advances to automobiles and adaptive 

equipment (i.e., no effort steering, advanced warning systems, etc.), individuals with 

significant deficits have a greater potential for using devices to safely operate a motor 

vehicle. With the increased number of older adults with medical conditions, referrals 

from physicians and DMVs to driving specialists have risen with the expectation that the 

therapists will recommend remediation, compensation, or cessation appropriate for the 

older driver to ensure safe mobility. 

In occupational therapy, therapeutic intervention is a dynamic process. Evaluation and 

intervention strategies are used in tandem, as options are ruled out and compensation 

strategies are practiced. The driving environment poses risk that cannot be changed or 

even predicted. Unlike most settings, where the therapist can manipulate components, 


grade difficulty of the tasks, and manage time through practice, individuals drive in a 

public domain where a client’s miscalculation or developmental lapse can have 

consequences unlike any other therapeutic venue. Thus, the fundamental difficulty is 

determining which driver is appropriate for remediation or training, compensation or 

vehicle modification and which drivers should cease driving. The added complexity of 

considering the client’s driving environments (for example rural community versus urban 

traffic) adds to the complex formulation of an answer. 

TYPES OF INTERVENTION 

When considering driving, remediation is done with the clients who have the potential 

to develop or regain the requirements to be a safe driver through exercise, training, or 

corrective strategies such as programs in biofeedback to manage pain, correct vision 

through glasses, cognitive training, or vestibular training. Compensation is considered 

when remediation is not possible, but the individual can learn to compensate or develop 

new strategies. Compensation can be done with the individual, the vehicle, task 

demands (through restricted licensing), and to some degree the environment (advances 

in signage and intersection design). Examples include reduce exposure by eliminating 

night driving or change rules for route planning that eliminate left turns. Training may be 

offered to practice the recommended new strategies, address any bad habits, or offer 

new insights about methods of adaptation to driving. Adaptation for physical limitations 

may involve adaptive equipment added to the vehicle when the options for remediation 

of the impairment are exhausted. Prescription of adaptive equipment alters the demand 

of the driving activity, enabling residual strengths and abilities to perform the required 

driving tasks. Impaired lower limb sensation or amputation is easily compensated by the 

provision of hand controls of a design that can be safely managed by the driver. For the 

older driver, adjusted mirrors to avoid blind spots, extended foot pedals, or seat 

modifications may compensate for physical changes with aging. 

One of the most difficult issues is the problem of impaired cognition. Remediation is 

sometimes possible with individuals with brain injury, but with most dementias, 

remediation or return to higher levels of ability is not going to be possible. 

Compensation is often ineffective because of the impaired capacity for new learning. At 

this point education is the intervention that the occupational therapist uses with client 

and/or the client’s family. Frequently, the driving specialist is asked to use the on-road 

evaluation as an intervention strategy to demonstrate to the client and family members 

the risk of continued driving. These specialists recognize the profound difficulty families 

face imposing driving cessation restrictions and understand the need families have to 

believe it is the true and only option. The potential for this intervention to affect the 

awareness and behavior of persons with dementia likely depends on the progression of 

the disease. Because of the cognitive changes associated with dementias, the 

therapeutic benefit of intervention is most beneficial when it can be offered earlier in the 

progression of the disease. Once driving is no longer a safe option, the focus of 

intervention is again education but turns to the identification of appropriate 

transportation alternatives. Mobility choices must reflect knowledge and awareness of 

the impairments that resulted in driving cessation. The person with dementia cannot be 

expected to learn a bus route, and the person with paralysis may not be able to 


maneuver safely to access the city bus or cab. Intervention may offer families strategies 

to protect the person with dementia from access to their vehicle or techniques to 

respond to the incessant request for the keys. Persons suffering from debilitating 

conditions both physically and cognitively may need intervention to adapt techniques for 

transfer, restraint in the vehicle or strategies to address continence or anxiety that may 

pose a risk for the driver and passenger alike. 

REFERENCES 

American Occupational Therapy Association. (2002). Occupational therapy practice 

framework domain and process. American Journal of Occupational Therapy, 56, 

609-639. 

Stav, W.B., Hunt, L.A., & Arbesman, M. (2006). Driving and Community Mobility for 

Older Adults: Occupational Therapy Practice Guidelines. Bethesda, MD: 

American Occupational Therapy Association, Inc. 


REMEDIATION FROM THE PHYSICAN’S PERSPECTIVE 

Richard A. Marottoli, M.D., M.P.H. 

Associate Professor of Medicine 

Medical Director, The Dorothy Adler Geriatric Assessment Center 

20 York Street, TMP 15 

New Haven, CT 06504 

Richard.Marottoli@ynhh.org 


ABSTRACT 

The relative preponderance of evidence on identification of risk factors for crashes and 

driving cessation along with the relative paucity of data on intervention strategies has 

led to the terms intervention or remediation becoming synonymous with licensing 

decisions. This has further led to the negative perception of the whole assessment 

process and contributed to the reluctance of many physicians and drivers to be involved 

in it. The availability of more data on the availability and effectiveness of remediation 

strategies may help to change the perception (and the reality on which it is based), 

potentially leading to longer and safer driving careers. The difficulties attendant in 

conducting intervention studies are discussed, along with potential strategies for 

implementing their findings once available and helping to enhance clinician and driver 

participation in the process. 

INTRODUCTION 

The objectives of this chapter are to describe the concepts underlying why interventions 

are undertaken, the different types of remediation available, and the process of 

implementing a remediation strategy. Along the way, a number of barriers and roadblocks 

are described, including negative perceptions that limit clinician and patient 

involvement in the process, the relative paucity, until recently, of evidence on 

intervention effectiveness, and the factors that might enhance or encourage 

involvement in the assessment and intervention process. While new studies have 

provided encouraging results, there are still large gaps in our knowledge base regarding 

the real world effectiveness of remediation strategies, the effect of combining more than 

one intervention, and how to overcome barriers to participation in the process. 

Recommendations are provided at the end regarding how to practically implement 

existing knowledge and to gather new information to overcome existing barriers 

REMEDIATION FROM THE PHYSICAN’S PERSPECTIVE 

Much of the attention in the older driver safety literature has focused on licensing issues 

and identifying risk factors for crashes and driving cessation. This is understandable 

and reasonable because before one can remediate, one must know the appropriate 

factors on which to intervene. Also, although risk factor studies (typically cohort or case 

control designs) can be logistically complex depending on the choice of outcome and 

risk factors in question, intervention studies by their very nature are more time 

consuming and costly. However, there are unintended and untoward consequences of 

this weighting of the literature, creating a negative perception to the assessment and 

licensing process on the part of drivers, clinicians, and the public at large, superimposed 

on the reality of loss of licensure, driving privilege, and out-of-home mobility. At least in 

theory, the advent of more intervention studies will help to swing this pendulum back 

toward the positive side of the perception ledger and perhaps encourage more people 

to participate in the process. 


With this theoretical underpinning, we can approach the central questions of why and 

how to remediate from a practical, clinical perspective. The primary reason for why to 

pursue remediation is medical, or to improve health in general. Driving, for most 

clinicians and patients, would be a secondary benefit or added impetus for the clinician 

to prescribe, and the driver/patient to adhere to, the intervention in question. In some 

cases this added benefit to driving safety or prolonging driving might be sufficient to tip 

the risk/benefit equation in getting someone to pursue or adhere to an intervention, as a 

concrete example of how their quality of life might be improved. A possible tertiary 

benefit would be to public health as a whole. If indeed a large number of people with the 

condition or impairment in question were to undergo the intervention, then perhaps the 

health of the population as a whole (or safety in the case of driving outcomes) might 

benefit. In the latter case, small benefits to a given individual may translate to a large 

public health or safety benefit once extrapolated to the entire population, akin to 

conditions like hypertension where an average decrease of a few points in blood 

pressure can have a substantial benefit when applied to the health of the entire 

population. 

Central to this premise is the strength of association or linkage of each risk factor in 

question to driving safety and the demonstration of the effectiveness of interventions 

targeted to these risk factors in enhancing driving safety. While there is a considerable 

literature on risk factors for driving safety as discussed elsewhere in this volume, the 

effect of interventions for these risk factors on driving safety is often not known or not 

clear. This is one of the reasons for considering driving safety as a secondary (rather 

than primary) reason for undertaking an intervention as conceptualized above. 

However, there are a burgeoning number of studies that help to establish the 

effectiveness of interventions in enhancing driving safety (references below). 

Several potential remediation targets can be considered when addressing the 

effectiveness of interventions on driving safety, including medical conditions, functional 

impairments, and driving ability per se. 

Furthermore, conditions or functional impairments can be considered as single (where a 

single condition affects driving safety and the interventions themselves are relatively 

straight-forward and focused) or as multi-factorial (where the conditions or the 

interventions employed to treat them have multiple contributing components). 

An example of a single condition would be cataract, where a single visual disorder 

affects driving ability and where a relatively straight forward, successful, and 

inexpensive (in the universe of health care costs, at least) intervention can enhance and 

restore driving capability (Owsley, McGwin, Sloane, Wells, Stavley, & Gauthreaux, 

2002). 

An example of a multi-factorial condition would be stroke, which can have a variety of 

causes and types, myriad functional manifestations or sequellae, and varying degrees 

and rates of recovery. Correspondingly, interventions can be directed at the 

contributing factors to the stroke itself or its manifestations/sequellae. In addition, there 


is the whole process of retraining driving skills or adapting to residual deficits to 

determine if one can resume driving safely, the subject of much literature over the years 

and the foundation of many driving assessment and retraining programs based in 

rehabilitation facilities and performed by specially trained occupational therapists, as 

described in detail elsewhere in this volume. 

With regard to functional impairments, these are most often consolidated into sensory, 

cognitive, and physical impairments. For sensory impairment, the cataract example 

provided above illustrates the effectiveness of an intervention on the underlying 

condition (cataract), the functional impairment (vision loss), and driving prolongation and 

safety (resumption of driving and crash risk; Owsley, et al., 2002). With regard to 

cognition, one of the most widely studied measures is the useful field of view (UFOV), a 

measure of visual attention and information processing speed. Interventions that 

improve information processing speed have been shown to enhance daily activities and 

driving performance (Roenker, Cissel, Ball, Wadley, & Edwards, 2003; Ball, Edwards, & 

Ross 2007). With respect to physical ability, individuals with impairments in range of 

motion or speed of movement who underwent a physical conditioning program 

maintained driving performance relative to controls (Marottoli, Allore, et al. 2007; 

Marottoli, Van Ness, et al. 2007). 

Remediation of driving ability can be viewed in a straight forward manner - if you want to 

improve driving performance, it is more direct to focus on improving driving ability per se 

than on improving factors that might influence driving ability. However, results of studies 

in this area have been mixed. 

While classroom training programs have excellent face validity, the results of studies 

that have focused solely on classroom training have ranged from slightly negative to 

neutral to slightly positive (McKnight, Simone, & Weldman, 1982; Janke, 1984; Bédard, 

Isherwood, Moore, Gibbons, & Lindstrom, 2004; Nasvadi & Vavik, 2007). However, 

studies that combine classroom and on-road training have thus far demonstrated more 

consistently positive effects on driving performance and knowledge (Bédard, et al., 

2005; Marottoli, Allore, et al. 2007; Marottoli, Van Ness, et al. 2007). 

A parallel set of education studies have focused instead on awareness of limitations or 

capabilities, with the goal of modifying driving behavior or exposure based on this 

awareness (Eby, Molnar, Shope, Vivoda, & Fordyce, 2003; Owsley, Stavley & Phillips, 

2003). 

There are a number of caveats that must be considered when reviewing these findings. 

First, as mentioned at the outset, intervention studies are inherently time consuming 

and expensive. Therefore, they may have smaller sample sizes, making it difficult to do 

subgroup analysis by other relevant factors or to assess outcomes of real interest, like 

at-fault or injurious crashes. Many other factors may influence the outcome besides the 

primary elements of the intervention, including adherence to the intervention regimen, 

changes in participants’ health over the course of the study, and scheduling difficulties 

with otherwise active participants. Difficult choices may also need to be made regarding 


the threshold of impairment for participation in a study. If one chooses participants who 

are more impaired for a given factor, there is a greater likelihood of change in that factor 

and potential effect on the outcome of interest. However, there will be fewer potential 

participants with this higher level of impairment and the impairment may be so severe 

that interventions no longer work. 

When turning to the “how” aspect of remediation and driver safety, the focus becomes 

how to engage physicians in the process. Unfortunately, to date, in the relative absence 

of much information on interventions and their effectiveness, the most common area of 

physician involvement has been in the assessment and reporting arena, with often poor 

results. A number of studies have shown that physicians are often not aware of 

reporting requirements, and even when they are they tend to be reluctant to engage in 

the process (Drickamer & Marottoli,1993; Miller & Morley, 1993; Jang, et al., 2007). 

Among the reasons given for lack of involvement are concerns regarding the strength of 

association of conditions with driving risk, the ease or reliability of assessment, the fact 

that it may be time consuming (and not reimbursable), that it is not their job to do such 

assessments (but rather that of the licensing agency), and that the whole issue is too 

negative (negative effects on the doctor-patient relationship, negative effects on 

physicians’ business if word gets out that they are “taking people’s licenses away”, 

negative outcomes for patients in terms of mobility, and dislike of assuming a policing 

role). There are some positive aspects of involvement, however, including playing a role 

in protecting public health and safety and helping to ensure their own patient’s safety. It 

may turn out that new education initiatives (Wang, Kosinski, Schwartzberg & Shanklin, 

2003; Wang & Carr, 2004) and the advent of more intervention studies will help to swing 

the balance of this equation more to the positive side. 

There are a number of factors that may help to facilitate this change in perception and 

thereby physician involvement in the process. Among these are to make the process 

(be it assessment, reporting, or other intervention) as simple and transparent as 

possible, to make the rationale behind involvement understandable, and, ideally, to 

make the consequences of involvement as benign and beneficial as possible 

(Drickamer & Marottoli,1993; Marottoli, 2000a; Marottoli, 2000b). As alluded to above, 

unlike the current physician role in assessment and reporting, which is perceived as 

having many negative effects on patient well-being including loss of license, loss of 

driving, and decreased out-of-home mobility and activity, interventions have potential 

psychological and practical benefits in enhancing safety and prolonging safe driving and 

mobility. It will also be incumbent on future intervention studies to address these longer 

range outcomes as part of their demonstration of effectiveness. 


In summary, if we want to change physician attitudes and involvement in driving safety, 

we need to distill and disseminate new information on interventions, their effectiveness 

and their limitations. More effort needs to be made in demonstrating how these 

interventions will have a practical benefit to their patients, and make whatever system 


equests or requires their involvement to be as user-friendly and straight forward as 

possible. 

The availability of more information on the effectiveness of interventions should 

encourage more clinicians and drivers to participate in the assessment process. There 

are several potential ways to increase the likelihood of participation: 

• Publicize/disseminate information on known risk factors for crashes or driving 

cessation and potential assessment strategies; 

• Publicize/disseminate information on interventions for these risk factors, including 

the strengths and weakness of available evidence; 

• Where evidence is lacking, pursue research initiatives to gather data that will 

help answer outstanding questions; 

• Simplify roles as much as possible and clearly define the responsibilities of all 

parties involved; 

• Publicize reporting requirements/policies and the process by which reporting 

occurs; 

• Make things as transparent as possible to all involved by enumerating steps in 

the process and individual responsibilities; 

• Publicize information on available resources to assist with assessment or 

remediation in a given locality; 

• Address reimbursement issues for assessment and remediation; 

• Address potential barriers to reporting, including confidentiality and immunity 

from breach of confidentiality; 

• Publicize information on resources and resource people to facilitate transitions to 

driving limitations or cessation for people who choose or need to do so; 

• Publicize existing transportation options and develop new ones where needs are 

not currently being met; 

• Improve communication and coordination among different elements of the 

process; 

• Emphasize patient autonomy in the process and encourage individual and family 

involvement in setting goals and priorities for how best to meet transportation 

needs safely; 


• Encourage society-wide dialogue on thresholds of acceptable risk, roles and 

responsibilities, and the importance of meeting transportation needs to out-ofhome 

mobility and quality of life. 

These suggestions should serve as a starting point to moving forward. More information 

will be needed on a variety of issues, including whether combining interventions leads to 

synergistic benefits or just increases cost and complexity. Reaching consensus on the 

goals and priorities of all parties involved will help to define the agenda and determine 

which areas to prioritize. This will also likely vary from region to region, depending on 

geographical factors as well as existing resources. Again, having more positive 

outcomes to offer should facilitate all aspects of the process. 


REFERENCES 

Ball, K., Edwards, J.D., & Ross, L.A. (2007). The impact of speed of processing training 

on cognitive and everyday functions. Journal of Gerontology: SERIES B, 62B, 

19-31. 

Bédard, M., Isherwood, I., Moore, E., Gibbons, C., & Lindstrom, W. (2004). Evaluation 

of a re-training program for older drivers. Canadian Journal of Public Health, 95, 

295-298. 

Bédard, M., Porter, M., Marshall, S., Polgar, J., Weaver, B., Riendeau, J., & Hewitt, J. 

(2005). Efficacy of a driver training program. The Gerontologist, 45, 325. 

Drickamer, M.A. & Marottoli, R.A. (1993). Physician responsibility in driver assessment. 

American Journal of Medical Science, 306, 277-281. 

Eby, D.W., Molnar, L.J., Shope, J.T., Vivoda, J.M., & Fordyce, T.A. (2003). Improving 

older driver knowledge and self-awareness through self-assessment: The Driving 

Decisions Workbook. Journal of Safety Research, 34, 371-381. 

Jang, R.W., Man-Son-Hing, M., Molnar, F.J., Hogan, D.B., Marshall, S.C., Auger, J., 

Graham, I.D., Kurner-Bitensky, N., Tomlinson, G., Kowgier, M.E., & Naglie, G. 

(2007). Family physicians’ attitudes and practices regarding assessments of 

medical fitness to drive in older persons. Journal of General Internal Medicine, 

22, 531-543. 

Janke, M. (1984). The Mature Driver Improvement Program in California. Transportation 

Research Record, 1438, 77-83. 

Marottoli, R.A. (2000a). The physician’s role in the assessment of older drivers. 

American Family Physician, 61, 39-42. 

Marottoli, R.A. (2000b). New laws or better information and communication? Journal of 

the American Geriatrics Society, 48, 100-102. 

Marottoli, R.A., Allore, H., Araujo, K.L.B., Iannone, L.P., Acampora, D., Gottschalk, M., 

Charpentier, P., Kasl, S., & Peduzzi, P. (2007). A randomized trial of a physical 

conditioning program to enhance the driving performance of older persons. 

Journal of General Internal Medicine, 22, 590-597. 

Marottoli, R.A., Van Ness, P.H., Araujo, K.L.B., Iannone, L.P., Acampora, D., 

Charpentier, P., & Peduzzi, P. (2007). A randomized trial of an education 

program to enhance older driver performance. Journal of Gerontology: Medical 

Science, 62A, 113-119. 


McKnight, J., Simone, G., & Weldman, J. (1982). Elderly Driver Retraining. (Report DOT 

HS-806 336). Washington, DC: National Highway Traffic Safety Administration. 

Miller, D.J. & Morley, J.E. (1993). Attitudes of physicians toward elderly drivers and 

driving policy. Journal of the American Geriatrics Society, 41:722-724. 

Nasvadi, G.E. & Vavrik, J. (2007). Risk of older drivers after attending a mature driver 

education program. Accident Analysis & Prevention, 39, 1073-1079. 

Owsley, C., McGwin, G., Sloane, M., Wells, J., Stalvey, B.T., & Gauthreaux, S. (2002). 

Impact of cataract surgery on motor vehicle crash involvement by older adults. 


Owsley, C., Stalvey, B.T., & Phillips, J.M. (2003). The efficacy of an educational 

intervention in promoting self-regulation among high-risk older drivers. Accident 

Analysis & Prevention, 35, 393-400. 

Roenker, D.L., Cissell, G.M., Ball, K.K., Wadley, V.G., & Edwards, J.D. (2003). Speedof-processing 

and driving simulator training result in improved driving 

performance. Human Factors, 45, 218-233. 

Wang, C.C., Kosinski, C.J., Schwartzberg, J.G., & Shanklin, A.V. (2003). Physician’s 

Guide to Assessing and Counseling Older Drivers. Washington DC: National 


Wang, C.C. & Carr, D.B. (2004). Older driver safety: A report from the older drivers 

project. Journal of the American Geriatric Society, 52,143-149. 


MODEL STATE PROGRAMS ON LICENSING OLDER DRIVERS 

Sherrilene Classen, PhD. 1 and Kezia Awadzi, PhD. 2 

Assistant Professor 1 ; Post Doctoral Fellow 2 

Department of Occupational Therapy, College of Public Health and Health Professions, 

PO Box 100164, Gainesville, Florida, 32611-0164 

sclassen@phhp.ufl.edu 1 ; kawadzi@phhp.ufl.edu 2 


ABSTRACT 

This background paper was written to examine older driver licensing policies on a 

federal and state level. We identify what federal bodies have done, particularly the 

Federal Highway Administration (FHWA) and National Highway Traffic Administration 

(NHTSA), to promote safety practices for older adults. We provide a brief synopsis of 

state licensing practices and discuss four age-specific practices (e.g., accelerated 

license renewal) and three other practices (e.g., third party referrals). We describe the 

main activities of the five model states (California, Florida, Iowa, Maryland, and 

Michigan). Based on the lessons learned from the federal bodies’ involvement, the 

general state licensure policies, and the model state programs for licensing older 

drivers, we summarize the main findings as: older driver safety activities are not widely 

translated to implementation on the state level; efficacy of states licensing policies are 

not certain; model states have in addition to licensing policies, also community 

programs targeting the safety and continued mobility of older adults; a paucity of 

research exists on state policies; and that past research has mainly focused on crash 

datasets. In the light of these findings we discuss nine recommendations: advocate for 

policy making in the broad spectrum of transportation; more coordinated efforts in 

knowledge sharing; wider implementation of federal safety efforts; policies for in-person 

renewal for the 85+ group; research to examine in-person renewal and other practices 

by means of on-the-road test data; develop a registry of those who have received 

driving interventions; more prospective research; examine the role and efficacy of the 

community groups in older driver safety. 

INTRODUCTION 

Consistent with the growth in older persons is an increase in older drivers, and we 

expect that, by 2030, about 25 percent of all drivers in North America will be 65 years of 

age or older (Dellinger, 2003). Motor vehicle crashes are the leading cause of injuries 

and fatalities among older adults 65 to 74 years, and the second leading cause among 

those 75 years and older (CDC, 2005). Compared to younger individuals exposed to a 

crash of similar impact, those 65 years and older have a two-to fourfold higher rate of 

injury, hospitalization or death. For example, in 2004 the more than 28 million licensed 

drivers age 65 years of age or older in the U.S. experienced 191,000 non-fatal and 

6,512 fatal injuries which is, based on miles driven, substantially higher than most other 

age groups (National Highway Traffic Safety Administration, 2006). The underlying 

frailty, medical conditions, and medication use greatly contribute to the crash disparities 

and increased risks for injuries and fatalities (Langford & Koppel, 2006; McGwin, Sims, 

Pulley, & Roseman, 2000a). Beyond loss of function or life, injuries also contribute to 

health care and economic costs with the average cost of one non-fatal motor vehicle 

injury in the U.S. is over $60,000, while one fatal injury costs approximately $1,150,000 

(National Safety Council). 

These statistics, indicative of safety concerns for older drivers provided, the context for 

this background paper: i.e., to examine model state programs on licensing older drivers. 

Identifying the characteristics of model states, examining what policies these states 


have implemented, and understanding the broader context in which the state activities 

occur, will yield knowledge for making further safety recommendations. To examine the 

role of state policies we will first sketch the background by explaining what is happening 

on the federal level, i.e., examining the activities of the Department of Transportation, 

specifically the Federal Highway Administration (FHWA) and the National Highway 

Safety Administration (NHTSA), as those relate to older driver safety issues. Next, we 

will provide a brief synopsis of the main licensing policies across states; and finally 

discuss each of the five model states identified by the Government Accountability Office 

(GAO); i.e., California, Florida, Iowa, Maryland, and Michigan. We are not suggesting 

that these named ones are the only states with model licensing programs, but rather a 

literature search identified these states as ones with documented evidence on model 

licensing programs for older drivers. Finally, we conclude with a brief summary of the 

main points described in the background paper and provide a list of recommendations 

for further consideration. 

OLDER DRIVER SAFETY ACTIVITIES ON THE FEDERAL LEVEL 

INTRODUCTION 

The GAO conducted a survey among 51 state departments of transportation (DOT) in 

2007 to ascertain federal and state efforts in supporting older driver programs. The 

study evaluated the federal government’s efforts to promote practices to make roads 

safer for older drivers, and to examine the extent to which states have implemented 

those practices (GAO, 2007). Assuming that it is important to understand the role of the 

DOT in older driver safety initiatives, we provide a brief synopsis of the two main federal 

organizations—the Federal Highway Administration (FHWA) and the National Highway 

Safety Administration (NHTSA) -- and the activities occurring within each of these 

administrations. 

FEDERAL HIGHWAY ADMINISTRATION 

The FHWA has contributed to making roads safer for older drivers by recommending 

strategies to make roadways easier for older adults to use (Staplin, Lococo, Byington, & 

Harkey, 2001) and by providing funding for states to use for projects that address older 

driver safety. States have adopted the FHWA’s recommendations to varying degrees. 

For example, 24 states reported implementing 50 percent or more of the recommended 

guidelines, with most states implemented strategies specifically pertaining to roadway 

construction, operations, or maintenance. Table 1 presents the type of safety projects 

that have been adopted and the corresponding number of states which adopted these 

programs. This table shows that states do not a place high priority on older driver safety 

projects, but rather are focusing on those projects that benefit the majority of the road 

users. Although recent research has shown that these highway design guidelines, 

specifically intersection design, can be beneficial to older and younger adults (Classen 

et al., 2007; Lord, van Schalkwyk, Chrysler, & Staplin, 2007; Shechtman et al., 2007), 

more research is warranted to extend these findings to larger groups in different 

geographic regions, and efforts are needed to translate this research into policies. 


Table 1: Types of FHWA Safety Projects in which States Report Investing Resources 

Type of safety project Number of states investing to a great or 

very great extent 

Roadside hazard elimination or mitigation projects 36 

Road intersection safety projects 36 

Safety projects at railway/highway intersections 35 

Roadway departure projects 35 

Older driver safety projects 2 

Source: GAO (2007). 

Thus, early research suggests that implementing the design guidelines support 

improved (safer) driving performance among older, and in some cases, younger adults 

alike. No implicit connection is currently apparent between state licensing policies and 

states who implemented safer environmental design guidelines. However, we 

recommend that state licensing bodies collaborate with state DOTs to further test and 

implement the design guidelines as a moral responsibility to make driving environments 

safer for all road users. 

NATIONAL HIGHWAY TRAFFIC ADMINISTRATION (NHTSA) 

More than half of state licensing agencies have implemented assessment practices to 

support licensing requirements for older drivers. To make roads safer for older drivers 

NHTSA is sponsoring research to develop and assist states in implementing more 

comprehensive driver fitness assessment practices, as well as developing mechanisms 

to assist licensing agencies and other stakeholders to better identify medically at-risk 

individuals. Initiatives by NHTSA and its partner organizations include: 

• Model Driver Screening and Evaluation program, supported by the American 

Association of Motor Vehicle Administrators (AAMVA) and the National Institute on 

Aging (NIA), to provide a framework for driver referral, screening, assessment, 

counseling, and licensing. 

• Physicians Guide to Assessing and Counseling Older Drivers, developed by the 

American Medical Association (AMA), to assist physicians in judging a patient’s 

fitness to drive. 

• A Highway Countermeasure Guide for State Highway Safety Officials, developed 

with the Governors Highway Safety Association describing communication, 

outreach, licensing and law enforcement initiatives to improve older driver safety. 

• NHTSA web-site providing information for the driver, caregiver, licensing 

administrator, and other stakeholders to help ensure older drivers being safe. 

• Current work with the AAMVA and the American Association of Neurologists (AAN) 

to develop neurological guidelines related to the assessment of drivers with cognitive 

impairment. 


LICENSING POLICIES ON THE STATE LEVEL 

STATE APPROACHES TOWARD THE REGULATION OF OLDER DRIVER LICENSE RENEWALS 

States have different approaches toward the regulation of older driver license renewals 

in the U.S. Some states have one or more license renewal policy specific to older 

drivers. Renewal policies are classified as accelerated license renewals (16 states), 

mandatory vision screening (10 states), in-person renewal (5 states) and mandatory 

road tests (2 states). Other practices include accepting third party referrals regarding 

concerns about drivers of any age (50 states); relying on a medical advisory board to 

make recommendations for those with medical or other limitations that may impair their 

driving (35 states and the District of Columbia); and states requiring physicians to report 

conditions that may impair driving (9 states). Although it is beyond the scope of this 

paper to discuss every state’s licensing policy, we are providing a summary in Table 2-4 

to list older driver licensing requirements in effect in certain states as it pertains to vision, 

accelerated and in-person renewal. 

Table 2: States with Vision Testing Requirements for Older Drivers 

State Vision test and 

age 

requirement 

Additional requirements 

Arizona 65 and over None 

District of 70 and over At age 70, or nearest renewal date thereafter, a vision test is required and a 

Columbia 

reaction test may be required. Applicant must provide a statement from a 

practicing physician certifying the applicant to be physically and mentally 

competent to drive. At 75 years, or nearest renewal date thereafter, and on each 

subsequent renewal date, the applicant may be required to also complete the 

written and road tests. 

Florida 80 and over Renewal applicants 80 and older must pass a vision test administered at any 

driver’s license office or if applying for an extension by mail must pass a vision 

test administered by a licensed physician or optometrist. 

Georgia 64 and over None 

Maine 40 and over Vision test required at first renewal after driver reaches age 40 and at every 

second renewal until age 62; thereafter, at every renewal. 

Maryland 40 and over Vision test required at every renewal from age 40. 

Oregon 50 and over None 

South 

Carolina 

65 and over None 

Utah 65 and over None 

Virginia 80 and over None 


Table 3: States with Accelerated Renewal Cycles for Older Drivers 

State Standard renewal cycle Accelerated renewal for older drivers with 

relevant ages 

Arizona Expires at age 65 5 years (65 and over) 

Colorado 10 years 5 years (61 and over) 

Georgia 5 or 10 years (driver option) 5 years (60 and over) 

Hawaii 6 years 2 years (72 and over) 

Idaho 4 years or 8 years (age 21-62) 4 years (63 and over) 


Illinois 4 years 2 years (81 to 86); 1 year (87 and over) 

Indiana 4 years 3 years (75 and older) 

Iowa 5 years 2 years (70 and older) 

Kansas 6 years 4 years (65 and older) 

Maine 6 years 4 years (65 and older) 

Missouri 6 years 3 years (70 and older) 

Montana 8 years 4 years (75 and older) 

New Mexico 4 years or 8 years (driver option) 4 years (for drivers who would turn 75 in last half of 

an 8-year cycle) 

North Carolina 8 years 5 years (54 and older) 

Rhode Island 5 years 2 years (70 and older) 

South Carolina 10 years 5 years (65 and older) 


Table 4: States Requiring In-Person Renewals 

State Age for in-person 

renewals 

Additional requirements 

Alaska 69 and over Mail renewal not available to people 69 and older and to people whose 

prior renewal was by mail. 

Arizona 70 and over It cannot be renewed by mail. 

California 70 and over At age 70, mail renewal is prohibited. No more than two sequential mail 

renewals are permitted, regardless of age. 

Colorado 61 and over Mail or electronic renewal not available to people 61 and older and to 

people whose prior renewal was electronic or by mail. 

Louisiana 70 and over Mail renewal not available to people 70 and older and to people whose 

prior renewal was by mail. 


RESEARCH ON STATE LICENSING POLICIES TO REDUCE INJURIES AND FATALITIES AMONG OLDER 

DRIVERS 

Only a few studies have measured the association between older driver license renewal 

laws and decreases in injury and fatalities. Although prior studies showed a positive 

relationship between license renewal policies and prevention of injuries and fatalities 

(Levy, 1995; Levy, Vernick, & Howard, 1995), Grabrowski and researchers used a more 

rigorous approach in that they controlled for a variety of potential confounders in their 

analyses, including state laws (e.g., primary and secondary seatbelt laws), speed limits, 

illegal alcohol use (0.08 BAC), state employment rates, personal income per capita, and 

administrative license suspension rates (Grabowski, Campbell, & Morrisey, 2004; 

Grabowski & Morrisey, 2001). Thus, in two follow-up studies, using the 1985-2000 and 

the 1990-2000 database from the Fatality Analysis Reporting System (FARS), they 

quantified state motor vehicle laws affecting the injuries and fatalities of older driver 

groups (65-74, 75-84, and 85+).They found, in both studies, that only in-person renewal 

policies were significantly associated with a decrease (16.3 percent in the 2004 study) 

in fatalities for drivers 85 years and older. To interpret the meaning of this finding, we 


are the suggesting the following background information. Principally, there were few 

changes in laws over the duration of the study period. Although it looks and sounds like 

a longitudinal study, there were only before-after type comparisons of the impact of 

vision testing, in-person renewal, or road tests in—at most—three states. For example, 

a grand total of three states required road tests at any point during either study one 

state changed its road testing policy between 1985 and 2000, and zero states changed 

road testing policy between 1990 and 2000. Vision testing and in-person renewals were 

more prevalent, but there were virtually no changes in these laws within any given state 

over the period studied. Thus, the only variable in which there was any activity across 

states over the period of the study was the renewal period. That is, this study tells us 

lots about the fatality rates of seniors in states that do or do not happen to have certain 

policies, but really doesn’t tell us much of anything about the impact of changes in 

requirements for in-person renewal, vision testing, or road testing. Certainly more 

research needs to be done before any strong conclusion can be drawn. 

MODEL STATE PROGRAMS 

The six initial model states, as identified by the U.S. GAO, are: California, Florida, Iowa, 

Maryland, Michigan and Oregon. A model state is considered a state that has followed 

federal initiatives, or implemented plans, programs or policies, to the extent of improving 

the driving safety of older adults. The GAO specifically selected these states based 

upon recommendations from transportation experts of the National Cooperative 

Highway Research Program (NCHRP). Essentially these states were deemed 

“progressive in their efforts to improve older driver safety” (GAO, p. 47). However, upon 

conducting case studies in each of these states, the GAO found that although Oregon 

previously had an At-Risk Driver Public Education Consortium, it was disbanded in 

2003. Oregon, however maintains a vision testing requirement for drivers 50 years and 

older. So, with the exclusion of Oregon, each of the other five states are next discussed 

in terms of an overview, licensing policies, older driver related activities, and a 

summary. 

CALIFORNIA (CA) 

Overview 

In CA, there were 22,927,300 licensed drivers in 2005, of which 12 percent were 65 

years and older. Based on 2005 data, CA had 4,329 fatalities (NHTSA, 2006) and a 

death rate of 1.31 per 100 million vehicle miles traveled (VMT) (national death rate = 

1.45 per 100 million VMT) (COTS, 2007). 

Licensing policies 

CA has both accelerated (every five years) and in-person licensure renewal policies for 

residents age 70 years and older, and requires a visual acuity test before renewal. CA is 

also piloting a three-tiered driver assessment program consisting of the following tiers 

(Hennessy & Janke, 2005): 

(1) First tier: Non-driving assessment including screening tests to detect drivers who 

may have a condition that impairs their driving ability (vision tests, cognitive screen 

and observation by the Department of Motor Vehicles [DMV]) personnel; 


(2) Second tier: Non-driving assessment including complex test to identify persons 

with driving related physical or cognitive impairments (DMV knowledge test and 

computer test for perceptual response time); 

(3) Third tier: Assessment of driver fitness using an on-the-road test for drivers who 

demonstrate limitations in the first two tiers described above. 

As set forth in CA Vehicle Code section 1659.9, a pilot study will be conducted, from 

2007 to 2011, in targeted DMV offices to examine subjects undergoing in-person 

renewal. The main objectives of this study are to examine the: (1) costs associated with 

each tier of assessment; (2) willingness of participants to pay a fee for the assessment 

of driver fitness; (3) percentage of drivers who are assessed to have a limitation, but 

who, upon completion of the assessment, are able to retain their driving privileges; (4) 

utilization of certified driving rehabilitation specialist; and (5) results relative to crash 

rates and retention of driving privileges. 

Older driver-related activities 

CA’s strategic plan led to the establishment of the OCTS Task Force that develops 

educational programs and conducts research aimed at increasing older driver safety 

(OATS, 2002). Under the auspices of the CA Highway Patrol (CHP), the Older 

Californian Traffic Safety (OCTS) Task Force’s mission is to reduce motor vehicle 

collisions and pedestrian deaths and injuries among older Californians; and to increase 

seniors' alternate transportation options (CHP, 2007; OATS, 2002). The OCTS Task 

Force works with numerous stakeholders (e.g., law enforcement, aging services, other 

professionals) to implement strategies for improving traffic safety among older adults 

and to address senior mobility issues. CA also formalized the provision of education for 

older drivers by licensing providers of mature drivers’ courses and mandating insurance 

discounts for older drivers who complete the course. CA Vehicle Code section 1675 

requires the Director of the DMV to establish standards and criteria for voluntary 

classroom driver courses designed to address the changing needs of drivers 55 years 

of age and older. 

Summary: Why California is considered a model state 

The OCTS Task Force in CA is actively involved, with the support of numerous 

stakeholders, in presenting educational programs and conducting research aimed at 

increasing older driver safety. Main activities in the state include the three-tiered license 

system that emphasizes driver wellness at all ages; driving education incorporating 

standards for mature driver courses; and insurance discounts for course completion as 

part of the vehicle code. Table 5.a. summarizes the main OCTS functions, membership, 

and resources. 

Table 5.a. Older driver safety coordination groups’ organizations and functions 

California 

Coordinating 

group 

Organization and function Membership Resources 

Older Californian • Established in 2003 under the 43 members that Senior Driver web-site 

Traffic Safety California Highway Patrol. 

represent (CDMV, 2007) on older 

(OCTS) Task • Supported by grants from California • State 

driver license 

Force 

Office of Traffic Safety. 

agencies information, a senior 

• Consists of 8 work groups—(1) • Federal driver self-assessment 


aging services, (2) health services, 

(3) law enforcement, (4) licensing, 

(5) mobility, (6) policy/legislation, (7) 

public information, (8) transportation 

safety of interested stakeholders 

who develop and promote 

implementation of action items 

through the government agency or 

non-governmental organization that 

they represent. 

• Work groups provide progress 

reports at quarterly OCTS Task Force 

meetings. 

Source: GA0 (2007). 

agencies 

• Higher 

education 

institutions 

• Medical 

professional 

organizations 

and 

• Senior 

advocacy groups 

and service 

providers. 

quiz, links to alternative 

transportation resources, 

and health-related 

information. 

FLORIDA (FL) 

Overview 

In 2006, there were 15,491,878 licensed drivers in FL of which 17.4 percent were 65 

years and older. Based on 2006 data, Florida had 256,500 reported traffic crashes with 

214,914 injuries and 3,365 fatalities (FLDHSMV, 2007). The death rate was 1.65 per 

100 million VMT, which was above the national average for 2006 (1.42 per 100 million 

VMT) (FLDHSMV, 2007). Between 2005 and 2006, there was a 4.1 percent (3,518 to 

3,374) decrease in motor vehicle fatalities (NHTSA, 2007). 


FL has a vision test requirement for drivers 80 years and older that can be administered 

by DMV personnel (FLDHSMV), as well as mandatory reporting for physicians if they 

suspect that medical or functional conditions may impair the individual’s driving 

performance (FLDHSMV). 


To better understand the age-related effects on the driving ability of senior adults, the 

Florida At Risk Driver Advisory Counsel (FADC) was, with administrative support from 

the FL Department of Highway Safety and Motor Vehicles (DHSMV), formally 

established under state legislation in 2003. Collectively the FADC and DHSMV 

conducted a study to ascertain the effect of aging on driving abilities and presented the 

findings to the legislature in Feb. 2004. Forthcoming was agenda setting, including to 

find the best screening tools, develop model programs, and provide education for older 

adults and their stakeholders. One such educational program, the FL GrandDriver 

Program, provides web-based information for older adults and their stakeholders on 

age-related changes that may influence driving performance. Information includes 

resources on driver refresher courses, contact information for health professionals, and 

links to alternative transportation options (Florida GrandDriver, 2007). Table 5.b. 

summarizes the FADC’s main function, membership, and resources. 

Summary: Why FL is considered a model state 

FL is regarded as a model state because the state requires a vision test for drivers 80 

years and older, mandatory reporting, the activities of The FL At Risk Council, and the 


educational information provided by The FL GrandDriver Program. Collectively these 

programs hold the promise to reduce crashes and crash related injuries and/or fatalities, 

create awareness of older adult mobility issues, provide resources for screening and 

assessment courses, and provide alternative transportation resources. 

Table 5.b. Older driver safety coordination groups’ organizations and functions 

Florida 

Coordinating 

group 


FL-At-Risk • Established by state statute in 2003 33 members that FL GrandDriver 

Driver Council and administratively supported by represent 

Resources on older 

(FADC) 

DHSMV. 

• State agencies driver screening, 

• Chairperson elected by council • State legislators assessment, 

members. 

• FADC members rank issues and 

establish action items in four areas: (1) 

prevention, early recognition, and 

education of at-risk drivers, (2) 

assessments, (3) remediation, 

rehabilitation, and adaptation— 

• Higher education 

institutions 

• Medical 

professional 

organizations 

• Senior advocacy 

groups and service 

educational 

resources on effects 

of aging on driving, 

and alternative 

transportation, and 

resources for family 

and caregivers. 

community and environment, (4) 

alternatives and accommodations for 

transportation. 

• Stakeholders implement action items 

through the government agency or 

nongovernmental organization that 

they represent. 

providers. 


IOWA (IA) 

Overview 

As of June 2007, there were 2,157,800 licensed drivers in IA, of which 23.4 percent 

were 60 years and older (IADOT, 2007d). In 2000 (latest available data), drivers 65 and 

older represented 16.5 percent of all licensed drivers, and 9.3 percent of all crashes 

(IADOT, 2000). In 2000, there were 64,361 traffic crashes, 36,031 injuries, and 445 

fatalities. The death rate per 100 million VMT was 1.49 (national death rate for 2000 = 

1.52) (IADOT). Between 2005 and 2006, there was a 2.4 percent (450 to 439) decrease 

in motor vehicle fatalities (NHTSA, 2007). 


IA has an accelerated renewal policy for drivers 70 years and older and requires these 

drivers to renew their licenses every two years by passing a vision test (IADOT, 2007e). 


In 1999, the Iowa DOT adopted a Comprehensive Highway Safety Plan to promote 

older driver safety. This plan has lead to forming the IA Older Driver Target Area Team, 

a small group of member agencies that operate through informal partnerships to provide 

consulting services to IA DOT. The main function is to coordinate older driver 

transportation-related activities (GAO, 2007). Table 5.c. summarizes the older driver 

safety coordination groups’ organization, functions, membership and resources. Their 


web-site, embedded in the IA DOT’s domain, provides the following safety and 

educational information: 

Driving retirement: This resource contains information on how older drivers and families 

can plan for driving retirement and make informed decisions about alternative 

transportation. User-friendly tables are provided to summarize area specific alternative 

transportation, available family members or friends who may be able to assist with 

driving, activities and time of day that require transportation, and contact information for 

area agencies on aging (IADOT, 2007b). 

Driving with diminished skills: This document educates older adults on how normative or 

diagnostic related aging may negatively impact driving skills, and offers ways for driving 

safer and longer. Caregivers of those with dementia or Alzheimer’s Disease are 

educated on symptoms that may negatively influence safe driving, and on taking steps 

to manage the influence of such diseases on driving safety (IADOT, 2007c). 

Driver’s license renewal in IA: Older adults are educated on license renewal policies in 

IA with the objective of making the process less stressful for older drivers. This 

education includes an explanation of the age-related policies (vision test and 

accelerated renewal) and suggestions on how to prepare for renewing the driver’s 

license (IADOT, 2007a). 

Older driver and risk: This document provides statistical crash facts for older adults, and 

information on how older drivers, and their stakeholders can make informed decisions 

on stopping driving (IADOT, 2007f). 

A practical guide for seniors workbook: comprised of 50 multiple choice questions (and 

answers) on road knowledge, a test on matching road signs, and quick tips on driving 

safety (IADOT, 2000). 

Summary: Why IA is considered a model state 

The age-related policies for older drivers, the activities of the IA Older Driver Target 

Area Team, and the IA Department of Transportation’s educational resources position 

IA as one of the model states. 

Table 5.c. Older driver safety coordination groups’ organizations and functions 

Iowa 

Coordinating 

group 


IA Older Driver • Established in 1999 to (1) coordinate 25 members • IA Office of 

Target Area public education and outreach, (2) representing 

Driver Services 

Team 

promote research and analysis efforts, • State agencies • IA Dept of 

(3) provide guidance for policy and • FHWA 

Transportation 

legislative considerations, and (4) • Higher education –website. 

promote implementation of low cost institutions, and 

engineering safety improvements. • Senior advocacy 

• Team is currently reorganizing under groups and service 

the IA Traffic Safety Alliance to assist providers. 



in implementing the IA comprehensive 

Highway Safety Plan. 

MARYLAND (MD) 

Overview 

In 2004 MD had 3,820,114 licensed drivers of which 13 percent were 65 and older. In 

2005, there were 102,624 traffic crashes, 55,303 injuries and 614 fatalities, and a death 

rate of 1.08 per 100 million VMT (national death rate for 2005 = 1.46; MDOT, 2006). 

However, between 2005 and 2006, there was a 6.0 percent (614 to 651) increase in 

motor vehicle fatalities (NHTSA, 2007). 


The state of MD requires driver license renewals every five years as well as a vision test 

upon renewal for drivers 40 years and older. Drivers who renew by mail must provide a 

completed vision test by an ophthalmologist or optometrist, while those who renew inperson, 

are required to complete a vision test at the DMV (2004). 


The coordinating group for older drivers is the MD Research Consortium. Table 5.d. 

presents the older driver safety coordination group, organization, membership, and 

resources. In 2006, MD, with the State Highway Administration as the lead agency, 

began the MD Strategic Highway Safety Plan (SHSP). This project was based on 

recommendations of the Safe, Accountable, Flexible, and Efficient Transportation Equity 

Act: A Legacy for Users (SAFETEA-LU, 2005). A five-year statewide safety plan was 

developed within a framework for reducing injuries and fatalities on all public roads. 

Priorities for the SHSP were identified with 320 stakeholders from areas of enforcement, 

education, engineering, and emergency medical services. One area of emphasis 

pertained specifically to enhancing the safety of older drivers by developing: (1) 

effective methods to identify at risk older drivers; (2) enhanced training for EMS 

personnel on the proper assessment and triage of older persons at crash scenes, and 

(3) incorporating the FHWA Older Driver and Pedestrian Guidelines into the MD design 

guidelines (MDOT, 2006). 

In 2006, the Older Driver Safety Program, in cooperation with Johns Hopkins University, 

concentrated on expanding and refining the Seniors on the Move (Mature Operators 

Vehicular Education) training program. This program is composed of four educational 

and training modules for older drivers. The utility was tested by the MD Highway Safety 

Office (MHSO) and a pre and post test survey examined its impact on the knowledge, 

beliefs, self-efficacy, intention and behavior of older drivers (MHSO, 2006). Future 

strategies are: to publish the Seniors on the Move evaluation study; implement a handson 

in-vehicle assessment for the curriculum; conduct 20 Seniors on the Move programs 

in MD counties; compile and distribute a media contact list for senior news publications; 

and evaluate the effectiveness of the 2007 Older Driver Safety campaigns. 


Summary: Why MD is considered a model state 

MD activities include having accelerated license renewal, vision test requirements for 

license renewals of drivers 40 and older, the efforts of the MD Research Consortium, 

and having the MD Strategic Highway Safety Plan. Furthermore, MD developed specific 

older driver priorities to reduce motor vehicle related crashes and injuries and has plans 

to test and evaluate the Seniors on the Move educational program. 

Table 5.d. Older driver safety coordination group, organization, membership and resources 

Maryland 

Coordinating 

group 


MD Research • Developed in 1996 under the Motor About 250 members MD Dept of 

Consortium Vehicle Administration. 

representing 

Transportation 

• Established working groups in four- • Sate agencies –website. 

areas—(1) identification and assessment, • Federal agencies 

(2) remediation and counseling, (3) • Higher education 

mobility option, (4) public information and institutions 

education. 

• Senior advocacy 

• Currently operates as ad hoc group to groups and service 

promote collaboration among interested providers 

stakeholders. 

• Private 

• Quarterly meetings feature expert businesses, and 

presentations on older driver issues. interested individuals. 


MICHIGAN (MI) 

Overview 

In 2004, MI had 1,044,354 licensed drivers 65 and older; a 30 percent increase in 10 

years and representing 14.5 percent of the driving population (MDOT, 2007b). Based on 

2004 data, Michigan had 373,028 reported traffic crashes, 99,680 injuries, and 1,159 

fatalities (MDOT, 2006), and a death rate of 1.14 per 100 million VMT, which was below 

the national death rate of 1.44 per 100 million VMT in 2004 (MDOT, 2006). Between 

2005 and 2006, there was a 3.9 percent (1,129 to 1,085) decrease in motor vehicle 

fatalities (NHTSA, 2007). 


MI has no requirements for older drivers specifically. Although drivers can renew 

licenses every four years at an on-site branch, mail renewal, with special 

considerations, is also an option (MDOT, 2007a). Drivers with changes in medical or 

vision conditions since the previous renewal are required to have in-person renewals. 

Under Chapter 21 of the Automobile and Home Insurance Code of MI, automobile 

insurers are permitted to offer discounts to insured drivers 50 and older who have taken 

at least 8 hours of a certified traffic crash prevention course that also addresses the 

effects of aging on driving behavior. 


In 1998, the American Association of State Highway and Transportation Officials 

(AAASHTO) approved its Strategic Highway Plan, developed by the AASHTO Standing 

Committee for Highway Traffic safety with the assistance of the FHWA, NHTSA and the 


Transportation Research Board Committee (TRB) on Transportation Safety 

Management. The plan includes 22 key areas that affected highway safety. In the same 

year the Southeast Michigan Council of Governments (SEMCOG), convened a 

statewide, interdisciplinary Elderly Mobility & Safety Task Force. This task force created 

a “Final Plan of Action, Elderly Mobility and Safety – The Michigan Approach”, also 

called the MI Senior Mobility Action Plan (MSMAP). This plan contains essential 

guidelines for state agencies to promote older adult mobility and safety issues (MDOT, 

2006). The objectives of MSMAP are: reduce number and crash severity for older 

drivers and pedestrians; improve the effectiveness of alternative transportation; help 

older adults maintain safe mobility as long as possible; help older adults plan in 

advance for driving retirement (MI Department of Transportation, 2006b). Each of these 

objectives translate into specific goals in six areas, including: (1) planning/ 

administration, by identifying a task force that can help older adults plan for driving 

retirement; (2) research, by having reliable older driver mobility data; (3) education and 

awareness, by improving safer older adult driving and understanding better the 

relationship between mobility and health; (4) engineering countermeasures, by 

enhancing roadways and the driving environment; (5) alternative transportation, by 

improving older adults’ awareness, use, and availability of alternative transportation; 

and (6) licensing goals, by supporting the development of effective screening tools, 

providing information to the legal community, linking organization and resources, and 

distributing educational material on older adult mobility options. 

In 2002 the Michigan safety effort was reorganized, with the creation of the Governor’s 

Traffic Safety Advisory Commission (GTSAC). Although the membership stayed the 

same of the task force, their name was changed to “Senior Mobility Workgroup” 

reflecting the advisory role to the GTSAC. Table 5.e presents information on this group, 

its organization and function, as well as membership and resources. Main activities 

organized by the task force included the 2004 National Conference on Elderly Mobility. 

At this conference best practices were identified and shared. Forthcoming from this 

conference and as part of the MDOT’s State Long Range Transportation Plan, 

specifically the 2005 Highway Safety Program, highways were enhanced according to 

the FHWA guidelines. This included design, construction, and placement of signs, 

pavement markings, guard rails, traffic signals, and other safety improvements on the 

state trunk line system (MDOT, 2007, p.1). 

Summary: Why MI is considered a model state 

MI has an accelerated driver license program in which licenses are renewed, for all age 

groups, every four years; and an in-person renewal for those drivers who are 

experiencing changes in medical or vision conditions since the previous renewal. 

Additionally, an incentive system is in place (automobile insurers offering discounts) to 

insured drivers 50 and older who participated in a traffic crash prevention course. The 

MI Senior Mobility Action Plan has specific tasks to help prevent crash-related injuries 

and deaths, to help older adults to maintain safe mobility for as long as possible, to 

provide alternative transportation options and driving retirement strategies. 


Table 5.e. Older driver safety coordinating group, organization, membership and resources 

Michigan 

Coordinating 

group 


MI Senior • Established in 1998 to conduct an elderly 23 members MI Dept of 

Mobility Work mobility and safety assessment and develop a that represent Transportation 

Group 

statewide plan of action designed to guide state • FHWA –website. 

policy. 

• State 

• Used U.S. DOT and state funds to develop its agencies 

plan, Elderly Mobility & Safety—The MI 

• Local 

Approach (1999) which outlines 

agencies, and 

recommendations in the areas of (1) traffic • Senior 

engineering, (2) alternative transportation, (3) advocacy 

housing and land use, (4) health and medicine, groups and 

(5) licensing, and (6) education and awareness. service 

• Senior Mobility Work Group has continued to 

update this plan—that forms the basis for 

strategy defined in the MI’s SHSP to address 

older drivers’ mobility and safety—in an advisory 

capacity to the Governor’s Traffic Safety 

Advisory Commission. 

providers. 



Based on the lessons learned from the federal bodies’ involvement, the general state 

licensure policies, and the model state programs for licensing older drivers we have 

found that: (1) older driver safety activities are occurring on the federal level, but those 

are not widely and consistently translated to implementation at the state level; (2) states 

do have licensing policies, but the efficacy of such policies are not certain; (3) model 

states have, in addition to licensure policies, also community programs targeting the 

safety and continued mobility of older adults; (4) a paucity of research exists in 

determining the effectiveness of state policies; and (5) the research studies that are 

available use crash datasets which may not be sensitive to capturing effectiveness of 

driver safety policies. 

Thus we are making the following nine recommendations: 

1) Clearly, licensing policy for older drivers, as a way to address and promote safe 

driving, must be viewed in the broader spectrum of independent community 

mobility. Thus, if policies are going to target older adults who can no longer drive, 

solutions, such as counseling and provision of alternative transportation options 

must go hand-in-hand with such policies. 

2) Coordinated efforts for knowledge sharing by the federal bodies (FHWA and 

NHTSA), and by the five model states, may help all other states to prepare for 

the increasing demand of safe mobility across the lifespan. 


3) More states may want to consider implementing the FHWA guidelines for 

enhanced intersection design. Although more research is needed, early findings 

suggest that the FHWA intersection design guidelines are benefiting the driving 

performance (increased safety and reduction in driving errors) of older (and 

younger) adults while performing behind the wheel tests (Classen et al., 2007; 

Lord et al., 2007; Shechtman et al, 2007). 

4) In-person licensure renewal has shown to reduce injuries and fatalities among 

drivers 85 years of age and older. Thus in personal renewal for the oldest old 

group, also considered a medically at risk group, may be considered as a policy 

recommendation. 

5) Other forms of licensure renewal: i.e., accelerated license renewals, mandatory 

vision screening and mandatory road tests, are not predictive of a reduction in 

injuries or fatalities. However, the real benefit of such renewal procedures has 

not been studied in on-the-road tests. This is an important consideration, 

especially given the very small percentage of older drivers that actually crash. 

6) Likewise, other forms of license renewal practices, such as referrals from third 

parties, from medical advisory boards, or from physicians reporting those who 

are medically or functionally at-risk to drive, have not shown to be predictive of 

reduced injuries or fatalities among older drivers. The benefits of these renewal 

practices on safety of older drivers, not significant in crash data, must be 

determined in other ways (e.g., following recommendations for safer driving, or 

participating in rehabilitation or remediation, or success rate in using other forms 

of transportation). 

7) Most findings are based on analyses of crash databases. We suggest developing 

a registry of those drivers, 65 years of age or older, who have been referred to 

driving rehabilitations specialist, or who have been re-tested in on-the-road tests 

conducted by state DMV. This registry will require a collaborative effort among 

national (or state) stakeholders, such as the American Occupational Therapy 

Association (AOTA), AAN, DOT and state DMVs. By way of this registry, one 

may capture and examine characteristics and outcomes of drivers who 

underwent driving evaluations in states with vision, in person, or accelerated 

renewals. Study their patterns of returning to driving (or not) may yield a better 

estimate of the effectiveness of age-based state policies. 

8) Prospective research and funding for such research are warranted to test the 

above recommendations across larger groups in different geographic regions, 

and to facilitate the translation of effective strategies into policies. 

9) The benefits of the work done by community groups (volunteers, advocates) in 

promoting older driver safety, evident in each of the five model states, have not 

yet been determined. Efficacy needs to be validated empirically and translated 


accordingly for wider dissemination, implementation, and formulation of wider 

range policies. 


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CHP (2007). Older Californian Traffic Safety Task Force (OCTS). Retrieved September 

20, 2007, from http://www.chp.ca.gov/community/html/octs.html. 

Classen, S., Shechtman, O., Stephens, B., Davis, E., Justiss, M., Bendixen, R., et al. 

(2007). The impact of roadway intersection design on driving performance of 

young and senior adults. Traffic Injury Prevention, 8, 69-77. 

COTS. (2007). Office of Traffic Safety, 2006 annual report. Sacramento, CA: California 

Office of Traffic Safety. 

Dellinger, A. M. (2003). Population Trends, Risk and Assessment. Paper presented at 

the International Older Driver Consensus Conference, Arlington, VA. 

FLDHSMV. Motorist Services - Drivers Age 80 & Older - Vision Requirements. 

Retrieved September 29, 2007, from 

http://www.hsmv.state.fl.us/ddl/vision/index.html 

FLDHSMV. (2007). Traffic crash statistics report 2006: A compilation of motor vehicle 

crash data from the Florida crash records database. Retrieved September 26, 

2007, from http://www.hsmv.state.fl.us/hsmvdocs/CS2006.pdf 

Florida GrandDriver. (2007). Retrieved September 24, 2007, from 

http://www.floridagranddriver.com/index.cfm 

GAO. (2007). Older driver safety: Knowledge sharing should help states prepare for 

increase in older driver population. 

Grabowski, D. C., Campbell, C. M., & Morrisey, M. A. (2004). Elderly licensure laws and 

motor vehicle fatalities. Journal of the American Medical Association, 291(23), 

2840-2846. 

Grabowski, D. C., & Morrisey, M. A. (2001). The effect of state regulations on motor 

vehicle fatalities for younger and older drivers: a review and analysis. The 

Milbank Quarterly, 79(4), 517-545. 

Hennessy, D. F., & Janke, M. K. (2005). Clearing a road to driving fitness by better 

assessing driving wellness: California's prospective three-tier driving-centered 

assessment system. Sacramento, CA: Office of Traffic Safety. 


IADOT. (2000). 2000 Iowa crash facts: A summary of motor vehicle crash statistics on 

Iowa roadways. Retrieved October 3, 2007, from 

http://www.iamvd.com/ods/facts00/crashfacts.pdf 

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from http://www.iamvd.com/ods/senior.pdf 

IADOT. (2007a). Driver's license renewal in Iowa. Retrieved October 3, 2007, from 

http://www.iamvd.com/ods/dlrenewal.pdf 

IADOT. (2007b). Driving retirement: Planning and making it work. Retrieved October 2, 

2004, from http://www.iamvd.com/ods/drivingretirement.pdf 

IADOT. (2007c). Driving with diminished skills: Driving with normal aging changes and 

driving with dementia or Alzheimer's' disease. Retrieved October 2, 2004, from 

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2007, from http://www.iamvd.com/ods/renewal.htm 

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http://www.iamvd.com/ods/olderdrivers.pdf 

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license renewal policies and fatal crashes involving drivers 70 years and older. 

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Lord, D., van Schalkwyk, I., Chrysler, S., & Staplin, L. (2007). A strategy to reduce older 

driver injuries at intersections using more accommodating roundabout design 

practices. Accident Analysis & Prevention, 39, 427-432. 

Maryland Motor Vehicle Administration. (2004). Driver licensing information. Retrieved 

September 20, 2007, 2007, from 

http://www.marylandmva.com/DriverServ/Apply/renewinfo.htm 


McGwin, G., Sims, R., Pulley, L., & Roseman, J. (2000a). Relations among chronic 

medical conditions, medications, and automobile crashes in the elderly: A 

population-based case-control study. American Journal of Epidemiology, 152(5), 

424-431. 

MHSO. (2006). State of Maryland FFY 2006 Annual Report. Retrieved September 19, 

2007, from 

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pdf 

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from 

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18_7.pdf 

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http://www.michigan.gov/sos/0,1607,7-127-1627_8667_9048---,00.html 

MDOT. (2007b). State Long Range Transportation Plan 2005-2030. Retrieved 

September 20, 2007, from 

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06_166942_7.pdf 

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population., from http://www-nrd.nhtsa.dot.go-v/pdf/nrd- 

30/ncsa/TSF2004/809910.pdf 

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2007, from http://www.nsc.org/lrs/statinfo/estcost.htm 

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Injured for 2006. 1-149. 

OATS. (2002). Traffic Safety Among Older Adults: Recommendations for California. 

San Diego, CA: Center for Injury Prevention, Policy and Practice. 

Shechtman, O., Classen, S., Stephens, B., Bendixen, R., Belchior, P., Sandhu, B., et al. 

(2007). The impact of intersection design on simulated driving performance of 

young and senior adults. Traffic Injury Prevention, 8, 78-86. 

Staplin, L., Lococo, K., Byington, S., & Harkey, D. (2001). Guidelines and 

Recommendations to Accommodate Older Drivers and Pedestrians. Washington, 

DC: U.S. Department of Transportation, Federal Highway Administration. 


Staplin, L., Lococo, K., Byington, S., & Harkey, D. (2001). Highway Design Handbook 

for Older Drivers and Pedestrians. Unpublished manuscript. 

State of California. California Vehicle Code section 1659.9. 

State of California. California Vehicle Code section 1675, Chapter 129. 


‘LICENSING AUTHORITIES’ OPTIONS FOR MANAGING OLDER DRIVER SAFETY – 

PRACTICAL ADVICE FROM THE RESEARCHERS’: 

REPORT FROM THE TRB WORKSHOP, 21 JANUARY 2007, WASHINGTON D.C. 

Jim Langford, M.Ed 

Senior Research Fellow 

Monash University Accident Research Centre 

Building 70 

Victoria, 3800, Australia 

jim.langford@muarc.monash.edu.au 


Over the past few decades there has been a substantial expansion of knowledge in 

regard to the assessment and management of older driver safety. This increase in 

knowledge, however, has not always been translated into practice. Specifically, in the 

context of driver licensing, many jurisdictions both in the U.S. and elsewhere have failed 

to introduce new procedures and policies consistent with the research findings. 

A TRB Human Factors Workshop, “Licensing authorities’ options for managing older 

driver safety – practical advice from the researchers” was held in Washington D.C. on 

the 21 st of January, 2007. As is implicit in the Workshop title, the main aim was to 

present a ‘state of the art’ message from researchers, pointing to the best way forward 

for licensing authorities in assessing and managing older driver safety. 

The following presentations were made at the Workshop: 

• Licensing authorities’ view of their information needs (Lori Cohen and Kim Snook, 

American Association of Motor Vehicle Administrators and Iowa Department of 

Transportation) 

• What are the implications of older drivers’ high per-mile crash involvement to 

licensing authorities? (John Eberhard, Consultant) 

• The role of reduced fitness to drive in explaining older driver crashes. (Shawn 

Marshall, University of Ottawa, Canada) 

• The role of self-regulation in countering ‘normal ageing’. (Lisa Molnar, University of 

Michigan Transportation Research Institute) 

• Do current licensing procedures identify older drivers who are ‘unfit to drive’? (Kit 

Mitchell, Consultant) 

• The validity of off-road ‘screening’ tests in assessing fitness to drive. (Jim 

Langford, Monash University Accident Research Centre) 

• The validity of individual assessments of fitness to drive as conducted by 

occupational therapists. (Carol Wheatley, Workforce and Technology Center, 

Maryland) 

• Translating functional capacity research into medical review: the Maryland model. 

(Carl Soderstrom, Maryland Department of Transportation) 

• Where to from here? (Brian Fildes, Monash University Accident Research Centre). 

After the Workshop, an appointed Panel prepared a communiqué presenting the weight 

of judgment in regard to five key questions, based on the presentations and subsequent 

discussion from the floor. The Panel consisted of: 

Jim Langford, Monash University Accident Research Centre 

Keli Braitman, Insurance Institute for Highway Safety 

Jude Charlton, Monash University Accident Research Centre 

John Eberhard, Consultant 

Desmond O’Neill, Trinity College, Republic of Ireland 

Loren Staplin, TransAnalytics 

Jane Stutts, University of North Carolina Highway Safety Research Center 


This brief report is restricted to a presentation of the Panel’s summary messages in 

regard to five key questions. 

1. DO OLDER DRIVERS HAVE A HEIGHTENED CRASH RISK, AS A RESULT OF MEDICAL 

CONDITIONS AND SUBSEQUENT DETERIORATION IN DRIVING-RELATED ABILITIES? 

Older drivers as a group are not at heightened crash risk solely because of functional 

decline, whether the result of normal ageing or of disease/pathology. When compared 

to younger drivers with similar driving exposure, older drivers are as safe as drivers 

from other age groups. While a minority of older drivers may justify further assessment, 

screening for specific medical conditions cannot be relied upon for categorical licensing 

decisions. Recent research suggests that functional capacity screening may be useful 

as one component of a comprehensive medical review process to determine medical 

fitness to drive in individual drivers; however, the validity of this approach remains to be 

established 

2. WHICH GROUPS OF OLDER DRIVERS REQUIRE SPECIAL MANAGEMENT BY LICENSING 

AUTHORITIES? 

A minority of older drivers justify further identification and assessment, with early 

research suggesting that low annual driving distances may be a possible indicator for 

this group. Identification of those requiring special assessment may also be hinged off a 

series of medical conditions acting as ‘red flags’. Particularly, older drivers with cognitive 

decline need early identification and intervention, including regular monitoring by 

licensing authorities. 

3. HOW CAN LICENSING AUTHORITIES BEST IDENTIFY THOSE OLDER DRIVERS WHO NEED 

SPECIAL MANAGEMENT? ARE THERE ANY ASSESSMENT OPTIONS WHICH HAVE 

ACCEPTABLE PREDICTIVE POWERS TO IDENTIFY AT-RISK OLDER DRIVERS? 

Assessment of all older drivers reaching a threshold age is not an efficient means to 

identify those who are unfit to drive. Off-road tests of functional performance are 

ineffective when applied to all older drivers on a simple pass/fail basis. The assessment 

strategy holding most promise for licensing authorities involves multi-tiered assessment, 

preferably only of those already giving indications of being at risk. The development of 

active DMV medical boards is likely to support this process, as well as encouragement 

of academic development of driving assessment as a part of routine training of 

physicians dealing with older people. 

4. HOW CAN LICENSING AUTHORITIES BEST DEAL WITH POTENTIALLY UNFIT OLDER 

DRIVERS? 

A minority of older drivers need to cease driving as a result of their heightened crash 

risk. At least for these drivers, licensing authorities need to consider involvement in 

accessing alternative transport options, perhaps in conjunction with other appropriate 

agencies. The driving of others, particularly those with only a small increase in crash 


isk, may be prolonged with acceptable safety through a more strategic use of 

rehabilitation, as well as of licensing restrictions that are tailored to an individual’s 

functional capacities, limitations and specific mobility needs. 

5. WHAT POLICIES SHOULD LICENSING AUTHORITIES FOLLOW WHEN THE RESEARCH 

STUDIES DISAGREE AS TO WHAT IS EFFECTIVE? 

To keep abreast of new developments, licensing authorities and researchers need to 

continue to work closely to ensure that older driver licensing policies and practices are 

guided by the latest empirical evidence. It is recommended that when there are 

conflicting results, other issues – including older people’s mobility, independence and 

social needs and public perceptions of fair play– should also weigh in as critical 

considerations. 


OUTCOMES OF THE AAMVA/CCMTA FORUM--CHALLENGING MYTHS AND 

OPENING MINDS: AGING AND THE MEDICALLY AT-RISK DRIVER 

Jamie Dow, MD 

Chairman, Medical Advisory Committee of the CCMTA 

Medical Advisor on Road Safety, Société de l'assurance automobile du Québec 

Canadian Medical Representative, AAMVA Driver Fitness Working Group 

Jamie.Dow@saaq.gouv.qc.ca 


SUMMARY 

The American Association of Motor Vehicle Administrators (AAMVA), in conjunction with 

the Canadian Council of Motor Transport Administrators (CCMTA), developed a forum 

entitled Challenging Myths and Opening Minds: Aging and the Medically At-Risk Driver 

to bring together licensing administrators, medical professionals, researchers and nongovernmental 

groups representing the aged. 

The purpose of the workshop was to review the issue of aging and medically at-risk 

drivers from many different perspectives. The first two days of the event were primarily 

focused on general North American issues as well as examining challenges related to 

the United States, while the last day focused on Canada. 

In fact, Canada Day acted as the cumulative point for the workshop as it incorporated a 

series of discussion groups that included many of the US participants. The discussion 

groups sought to identify the important concepts that had been presented during the 

previous two days of activities and to relate them to the practical problems associated 

with driver licensing. 

General agreement was reached on a number of concepts that were felt to be important 

and these concepts were then incorporated into a list of core values. Safety has to be 

the primary concern in any programme dealing with driver licensing and age should not, 

in itself, be a determining factor in licensing decisions. Practical, comprehensive 

medical standards should alleviate any requirement for age-based standards. Medical 

standards must be evidenced-based, practical, flexible and acceptable to the public. 

Standards should be re-evaluated at frequent intervals. 

Following the Workshop the CCMTA Aging Driver Strategy has been revised through an 

extensive consultative process and a final draft of the revised document will be 

presented to the CCMTA Board in December 2007. 

The AAMVA Driver Fitness Working Group project is currently undergoing a review of 

its mandate. 


OUTCOMES OF THE CANADIAN DRIVING AND FUNCTIONS FORUM 

Bonnie M. Dobbs, PhD 

Associate Professor and Director of Research, Division of Care of the Elderly, 

Department of Family Medicine 

Adjunct Professor of Psychology, Department of Psychology 

University of Alberta, 

205 College Plaza, Edmonton, Alberta, Canada T6G 2C8 

bdobbs@ualberta.ca 


INTRODUCTION 

Driving is a complex task which usually takes place in a complex environment. As such, 

it requires cognitive, sensory, and motor skills. Understanding the functional abilities 

necessary for driving is of increasing interest to licensing agencies, policy makers, and 

researchers. A review of the literature indicates that, historically, a number of different 

approaches have been used to identify which functional abilities are needed for driving. 

In general, those approaches can be categorized as follows: the task analysis 

approach, the hierarchical model approach, and the functional approach. 

An overview of the models, along with a comprehensive discussion of the strengths and 

limitations of those models, is beyond the scope of the current paper. Briefly, the task 

analysis approach, although ecologically valid, is, from an applied, evaluation 

perspective, simply not feasible given the large number of tasks involved. Criticisms of 

the hierarchical approach include the conceptualization of the components as 

individually distinct and failure to take into account the changing demands of the driving 

environment or driver characteristics (experience, motivation, etc.), characteristics 

known to be influential for on-road performance. 

More recently, researchers have focused on a functional model of abilities needed for 

driving. Several researchers (Eby et al. 1998; Robinson et al. 1999; Richard, 2002) 

identify visual perception, cognitive factors, and psychomotor skills as factors critical to 

the driving task. Building on previous approaches, Dobbs (2006) proposed that affect, 

along with sensory, motor, and cognitive abilities, be included in a functional approach 

to driving, an inclusion endorsed by participants at the Canadian Driving and Functions 

Forum (OSMV & Traffic Injury Research Fund, 2006). However, research following the 

forum indicated that affect was very disparate from the other three functional abilities, 

and, as such, is best conceptualized as a construct relevant to some medical conditions 

(e.g., psychopathology and developmental delays) rather than a functional ability per se. 

That decision was endorsed as being valid through the peer-review process following 

the forum. 

FUNCTIONAL ABILITIES AND DRIVING: MOTOR, SENSORY, AND 

COGNITIVE 

A number of abilities within each of the three functional ability categories were identified 

during break-out sessions at the Forum. Those abilities, per functional ability category, 

are listed below. 

MOTOR 

Skills or abilities within this domain include coordination, dexterity, psychomotor speed, 

simple reaction time, range of motion of extremities, and trunk and neck 

mobility/flexibility. 1 


SENSORY (HEARING/VISUAL) 

Hearing and vision were the two primary sensory abilities identified. Specific visual 

abilities identified as relevant to the driving task included: acuity (static and dynamic), 

contrast sensitivity, disability glare, and visual fields. 1 Measures of visual information 

processing, defined as the processing of visual information beyond the perceptual level, 

are reflective of higher order cognitive processing, and are more accurately captured 

under the cognitive domain. 

COGNITIVE 

Cognitive abilities identified as being relevant to the driving task included attention 

(divided, selective, sustained), memory (short-term or passive memory, working 

memory [the active component of short-term memory], and long-term memory), 

perception, choice/complex reaction time, tracking, visuospatial abilities, and 

visuospatial processing. 1 Mental status, although not an ability per se, along with tests 

of other cognitive abilities (e.g., language, intelligence), also were identified within the 

cognitive domain due to their frequent inclusion in cognitive batteries used in driving 

related research. 

SYNTHESIS OF THE LITERATURE AND RESULTS 

Following the forum, a comprehensive review of the driving literature for each of the 

domains for the three primary categories (motor, sensory, and cognitive) was conducted 

by the author. In reviewing the findings from the extant literature, two distinct patterns 

became apparent. The first pattern was the variability in findings across studies for 

identical or similar measures. This finding is not surprising given the difference in 

methodology (study population, outcome measure, etc.) across studies. Importantly, the 

variability in methodology, criterion measures, populations, etc. precluded the use of 

meta-analysis techniques for this review. 

The second pattern, and one of greater significance for those interested in the 

development of batteries for the identification of medically at-risk drivers, is the 

difference in the significance of a measure when examined in isolation (e.g., when 

examined in univariate or bivariate analyses) as opposed to its ability to contribute 

unique variance in a battery of tests designed to predict driving outcome (e.g., on-road 

performance, crash, simulated driving performance). 

Data were presented from a number of studies, employing univariate/bivariate and 

multivariate techniques, seeking to find functional predictors of driving performance. The 

comparison of results between univariate/ bivariate and multivariate analyses within 

each study underscores the point made earlier that variables showing significant 

relationships to a criterion/outcome variable in no way guarantees that the variable will 

remain a significant predictor when combined with other variables. That is not to say 

that the extant literature cannot be used for the construction of a test battery, but rather 

the significance found in univariate/bivariate relationships only can be used as a starting 

point when the goal is the development of a test battery for identifying drivers with 

medical conditions whose driving has declined to an unsafe level. 


The results of the multivariate analyses across studies also underscore the importance 

of evaluating the variable’s or measure’s contribution to the prediction of the criterion 

variable in the context of the other variables. That is, selecting variables based on their 

unique contribution to overall predictive power can result in a battery that is more 

powerful, more efficient, and less costly to administer. 

Finally, the purpose of the battery (e.g., screening, group identification, individual 

prediction of driving competency) will determine the degree of rigor in terms of 

predictive power. There clearly will be more latitude in batteries developed for screening 

goals versus batteries designed for individual prediction of driving competency. 

Salient for licensing agency goals is the ability to predict competency at the individual, 

rather than at the group level. When evaluating the relevance of any test for licensing 

decisions, it is critical that the outcome of the research be evaluated in terms of how 

applicable and defensible decisions at the individual driver level would be. For licensing 

decisions involving declining competence, one would like to know about the accuracy of 

identifying individual drivers whose competence has declined to an unsafe level. It 

would be important to know how often an incorrect decision would be made for 

individual drivers using the test or test battery. Identifying a driver as having an elevated 

risk would not be sufficient for licensing decisions if many or even most of the drivers 

with that risk level would not have a negative driving incident. Whenever this is the 

case, the test or test battery is useful at the screening level, and further testing with a 

test or test battery shown to be effective for decisions at the individual driver level is 

necessary, or a shift to a different type of performance assessment (e.g., road test) is 

required. 

Finally, in addition to effectiveness of a test or test battery for identifying compromised, 

unsafe drivers, efficiency or cost effectiveness is of concern to licensing authorities. 

Tests requiring more than a few minutes are unlikely to be used if their function is 

screening, although those tests can be cost effective if individual driver decisions are 

possible and defensible. 

1 Definitions of each are available on request. 

REFERENCES 

Dobbs, B. M. (2006, June). Functions needed for driving. The search for the Holy Grail. 

Invited paper presented at the Office of the Superintendent of Motor Vehicles and 

Traffic Injury Research Foundation’s Driving and Function Forum, Vancouver, B.C., 

June 12-13 th . 

Eby, D. W., Trombley, D. A., Molnar, L. J., & Shope, J. T. (1998). The assessment of 

older drivers' capabilities: A review of the literature. (UMTRI-98-24). Ann Arbor, MI: 

University of Michigan Transportation Research Institute. 


Office of the Superintendent of Motor Vehicles and Traffic Injury Research Foundation 

(2006). Driving and function forum. Vancouver, B.C., June 12-13 th . 

Robinson, D.G., Murphy, E.C., Ritmiller, L.M., Davis, S.C., & Heslegrave, R.J. (1999). 

Development of a framework for the assessment of drivers’ cognitive fitness. 

Transport Canada Report No. T8080-8-1348. 

Richard, C. (2002). Functional model of driver behaviour. Victoria, BC: BC Office of the 

Superintendent of Motor Vehicles.

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