Clinician's Guide to Assessing and Counseling Older Drivers

Published by the National Highway Traffic Safety Administration (NHTSA) and the American Geriatrics Society, the Clinician's Guide to Assessing and Counseling Older Drivers (4th Edition) is designed to help health care practitioners assess the ability of older adults to drive safely, counsel older adults and caregivers, and help access alternative transportation resources.

It offers recommendations, tools, and resources for the clinical team involved in the care of older adults across a variety of care settings by providing:

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

This webpage includes selections and highlights from the Clinician's Guide. The full guide can be downloaded using the link in the following paragraph or accessed by chapter of interest in the sections below. It can also be accessed through Geriatrics Care Online with free registration. A Safe Older Drivers app is also available for both Android and Apple devices

Download entire PDF of The Clinician's Guide to Assessing and Counseling Older Drivers (4th Edition) here.

Clinical Levels of Care for Driving Health

There are three clinical levels of care regarding driving ability in older adults:

• Primary: Keeping people driving safely as long as possible
• Secondary: Restoring driving skills and preventing further loss
• Tertiary: Stopping driving and transitioning to other transportation

Assessing and managing potential driving disability can be challenging and time-consuming, because many clinicians often consider it a personal rather than a clinical issue. Legal and ethical questions may also deter clinical team members from addressing driving ability in older adults

Yet as medical conditions arise and progress with advancing age, older adult drivers and their caregivers will increasingly turn to clinical team members for guidance on safe driving. The challenge is in balancing the safety of older adults against their transportation needs and the safety of society.

The Clinician's Guide is intended to help answer the following questions and, if necessary, help clinical team members counsel patients about transportation planning, including driving cessation.

• At what level of severity do medical conditions impair safe driving?
• What can be done to help older adults prolong their driving life expectancy (time behind the wheel)?
• How can transportation planning ensure safe mobility and continued participation in valued activities (e.g., hair dresser, breakfast club, place of worship)?

Plan for Older Drivers' Safety (PODS)

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

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

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

The PODS algorithm is included in the Clinician's Guide on page 15. Additional information can be found in Chapter 1. For Florida-specific information, visit the Driving page.

Careful observation is often an important step in diagnosis. During all patient encounters, clinicians should observe the older adult and be alert to:

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

Clinical Risk Factors for Impaired Driving

Risk Factor	Signs and Symptoms
Physical capabilities	Impaired balance Vision and/or hearing impairment (not hearing emergency sirens or horns honking, not seeing street signs) Functional impairment, such as sensory or range or motion (particularly ankle) with regard to use of gas or brake pedals Decreased ability to turn the head to fully visualize an area Slow response to visual or auditory cues Problems with reflexes (not reacting quickly when there is a need to brake suddenly)
Cognitive ability	Decreased short-term memory Decreased or impaired way finding Easily distracted Inability to learn new information quickly Inability to recognize unsafe situations Confusion over names and dates Difficulty with instrumental activities of daily living
Driving ability	Not using turn signals appropriately Difficulty turning the wheel and making turns Difficulty staying in the correct driving lane Difficulty judging the space between cars or upcoming exits Hitting curbs when parking or backing up Stopping in traffic inappropriately Not following stop signs, yield signs, traffic lights, etc. Not noticing workmen or activity on side of the road Inappropriate speeds for the weather/driving conditions History of traffic violations, minor crashes, or warnings

Questions to Ask About Driving

A health risk assessment is a series of questions intended to identify potential health and safety hazards in the older adult's behaviors, lifestyle, and living environment. The health risk assessment is tailored to the older adult and generally focuses on physical activity, falls, drinking (alcohol), medication management, sleep, nutrition, and driving.

Relevant questions about driving as part of the health risk assessment are shown on page 21 (Table 2.2) in Chapter 2 of the Clinician's Guide.

Red Flags for Further Assessment

Older Adult Driver's or Caregiver's Concern

Regardless of the setting of care, older adult drivers and their caregivers may express concerns about driving safety. If so, the cause of concern should be investigated, specifically if there have been recent motor vehicle crashes, near-crashes, traffic tickets, instances of becoming lost, trouble making sudden lane changes, trouble with left hand turns, drifting into other lanes, braking or accelerating suddenly without reason, failing to use the turn signal, keeping the signal on without changing lanes, or if there is poor night vision, forgetfulness, or confusion. Function should be evaluated using the Clinical Assessment of Driving Related Skills (CADReS) tests (Chapter 3 and Chapter 4).

Acute Events

Any acute health event, whether requiring hospitalization or not, is a red flag for immediate assessment of driving safety. If the older adult has been hospitalized, it is particularly important to counsel him or her as well as caregivers on driving safety issues. As noted above, acute disease exacerbations can serve as an opportunity to address, or readdress, driving concerns. As a general recommendation, older adults should cease driving after an acute event until their primary care provider indicates they are able to drive again. This is particularly important after any of the following common acute events or associated treatments

• Acute myocardial infarction
• Acute stroke or other traumatic brain injury
• Arrhythmia (e.g., atrial fibrillation, bradycardia)
• Lightheadedness, dizziness
• Orthostatic hypotension
• Syncope or presyncope
• Vertigo
• Seizure
• Surgery
• Delirium from any cause
• Newly prescribed sedating medications or those that can cause confusion or dizziness
• Acute psychiatric diseases impairing cognitive function or decision making

Red Flag Symptoms

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

For detailed information on chronic medical conditions related to these and other symptoms see Chapter 9 of the Clinician's Guide.

Medications

Many nonprescription and prescription medications have the potential to impair driving ability, either alone or in combination with other drugs. Combinations of drugs may affect drug metabolism and excretion, and dosages may need to be adjusted accordingly. In addition, clinicians should always ask about alcohol and marijuana use and timing of intake. For a comprehensive list of Potentially Driver-Impairing (PDI) medications, see Table 9.13 on page 147 in Chapter 9 of the Clinician's Guide.

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

This chapter focuses on the assessment of functional abilities needed to safely operate a motor vehicle, or "fitness to drive." All the recommended tools discussed are available in Appendix C of the Clinician's Guide. In determining fitness to drive, it is important to distinguish between screening and a comprehensive driving evaluation.

When screening, the intention is to identify risk. Further evaluation will identify at-risk drivers who may benefit from intervention strategies or need to cease driving. This more comprehensive evaluation may include referral to occupational therapy or driving rehabilitation to obtain the data necessary to determine a client-centered, individualized plan. The goal is to optimize the ability of older adults to continue to drive safely for as long as possible.

In response to the complexity of driving terminology, the Transportation Research Board of the National Academies for Science, Engineering and Medicine's Committee for Safe Mobility for Older Persons has developed definitions for screening, assessment, and evaluation. For these definitions, see Table 3.1 on page 31 in Chapter 3 in the Clinician's guide.

Functional Areas Assessed for Driving

Three key functional areas are considered as the foundation for determining fitness to drive: vision, cognition, and motor/somatosensory function. Any impairment in these areas has the potential to increase the older adult's risk of being involved in a crash and/or lost. Once these areas are assessed, the health care provider can determine if more information is required in one or all areas or if referral to a specific specialist for further evaluation or intervention is needed (e.g., ophthalmologist, neuropsychologist, occupational therapist, physical therapist, DRS).

Vision

A vision assessment includes assessment of visual acuity, visual fields, and contrast sensitivity.

Motor and Somatosensory Function

Motor and somatosensory function assessment includes functional assessments of functional range of motion, proprioception, and endurance.

Cognition

Cognitive assessment includes functional assessments of memory, visual perception, processing speed, attention, executive function, language, and insight.

Clinical Team Assessment Tools

Current assessments used in fitness-to-drive evaluations range from simple paper and pencil tools that are performed by general clinicians in their offices to complex assessments that should only be performed in the scope of practice of a clinical neuropsychologist or DRS (e.g., on-road assessment). In contrast, the Clinical Assessment of Driving Related Skills (CADReS) is offered as a toolbox of practical, office-based functional assessment tools in the major areas of vision, cognition, and motor/sensory function related to driving for the clinical team member who is screening or assessing an older driver. Clinical team members should choose from tools in each area that best address their patient's needs and document their encounters.

In the case of cognitive screenings, it is not always necessary to do all the tests. Depending on the outcome of the less challenging assessments, it may be unnecessary to progress further. Note: The justification of assessment tool selection and scoring is addressed in Chapter 4.

General

• Driving history:

A brief driving history can be useful as an initial screen to identify the older adult's perception of his or her driving, as well as that of a caregiver if available. Recent traffic violations, crashes (including unreported), or near misses are all red flags for concern (see Chapter 2). The Driving Habits Questionnaire is available but is lengthy. A modified version is available in Appendix C.

• IADLs (Instrumental Activities of Daily Living) questionnaire:

A checklist of other IADLs can also be used as an initial screen to identify if the older adult is having difficulties with other complex tasks of daily living. Driving uses the same underlying functions (e.g., visual processing, executive functioning, memory, processing speed) as other IADLs, similar to those for financial management, shopping, or cooking. If the older adult is having difficulty with any IADL tasks, further evaluation is warranted. A report from a caregiver may also be helpful when the older adult appears to have cognitive impairment. An example is the AD8TM Dementia Screening Interview, an eight item caregiver questionnaire that differentiates between dementia and normal aging (copyrighted by Washington University) and has preliminary data that suggests it is useful in combination with other tools to determine fitness to drive.

• Medication review:

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

The Evolution of Computer-Based Tools

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

• Useful Field of View:

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

• DriveABLE

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

Read Chapter 3 in the Guide to learn more. For Florida-specific information, visit the Being Proactive as a Drivers page.

This chapter provides information to support interpretation of CADReS assessment outcomes. However, recommendations stated here are subject to individual state reporting laws and state licensing agency requirements. Links to individual state requirements are provided in Chapter 8. Examples of interventions that may help manage and treat any functional deficits identified through CADReS are also provided.

Remember that the goal of clinical evaluation is to identify, correct, and/or stabilize any functional deficits that may impair an older adult's driving performance and to refer to a DRS, if appropriate (see Chapter 5). Contributing medical conditions and potential medication effects as discussed in the American Geriatrics Society Beers Criteria are discussed further in Chapter 9.

The Clinical Assessment of Driver-Related Skills (CADReS)

Motor and sensory ability, vision, and cognition are all important for driving. However, they may not be equally important for a particular older adult. Depending on the older adult's medical conditions, one area of function may require greater attention than another. Depending on the assessment outcome in each area, the outcome action may be different.

Vision

Screening for visual field cuts is important, because most older adults with visual field loss are unaware of the deficit until it becomes quite significant, such as in stroke, glaucoma, or macular degeneration. In most cases, referral to an ophthalmologist is the best outcome if there is any cause for concern.

Contrast sensitivity is a good screen for all older adults, followed by providing appropriate education and information to the older adult driver and caregiver on how to compensate for a deficit. A problem solely with contrast sensitivity does not merit a report to the state licensing agency.

Cognition

Screening for cognitive deficits is essential, along with careful interpretation of the findings. There is clear evidence that the Mini-Mental State Exam is not related to outcomes in crashes or driving abilities. However, the tools recommended in the CADreS have been particularly chosen to provide reasonable information in the office-based setting on skills known to be related to driving.

Motor Ability

If the only problems are with motor and/or somatosensory areas, these individuals should be referred to a driver rehabilitation specialist (DRS) to take advantage of advancements in technology (see Chapter 5). For older adult drivers who are cognitively intact, learning to compensate for motor and/or somatosensory deficits justifies getting expert advice on strategies, available vehicle adaptations or devices of the type best suited for individual issues, and the training to use them for continued driving.

Read Chapter 4 in the Guide to learn more. For Florida-specific information, visit the Being Proactive as a Driver page.

Driving evaluation and rehabilitation are appropriate for older adult drivers with a broad spectrum of sensory (i.e., visual, perceptual), physical, and/ or cognitive impairments. Driving rehabilitation specialists (DRS) work with drivers diagnosed with dementia, stroke, arthritis, low vision, learning disabilities, limb amputations, neuromuscular disorders, spinal cord injuries, mental health problems, cardiovascular diseases, and other causes of functional deficits, including changes of normal aging.

All older adults should be encouraged to develop a transportation plan, and to become familiar with and able to successfully access alternative forms of transportation. Planning ahead is invaluable to support aging in place while bridging short- or long-term disruptions in the most common and familiar form of transportation - the personal vehicle.

Read Chapter 5 in the Clinician's Guide to learn more. For Florida-specific information, visit the Health Care Provider Resources page.

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

A discussion of driving alternatives can begin by asking if the older adult has made plans to stop driving or how he or she currently finds rides when driving is not an option. Alternative transportation methods should be explored, as well as any barriers the older adult foresees (e.g., financial constraints, limited service and destinations, required physical skills for accessibility, rural community, living out of the mainstream).

This might be a good time to refer to clinical teams, including a social worker, occupational therapist, nurse, or a gerontologic care manager. The team may be aware of alternative modes of transportation and/or may deal with the older adult's feelings of social isolation or depression.

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

Laws, regulations, and policies vary not only by state but also by local jurisdiction. They are also subject to change, and the state licensing agency should be contacted for the most up-to-date information. For a state-by-state list of licensing agency contact information and additional resources for locating licensing requirements and renewal criteria, reporting procedures, etc., see Chapter 8.

Many physicians are uncertain of their legal responsibility, if any, to report unsafe drivers to their state licensing agency. The situation is further complicated by the risks of damaging the clinician-patient relationship, violating patient confidentiality, and potentially losing patients. As a result, clinicians are often faced with a dilemma: should they report the unsafe driver, or should they forego reporting and risk being liable for any potential patient or third-party injuries for failing to report? Furthermore, how should clinicians engage caregivers to lessen the burden of a driving restriction or cessation?

Read Chapter 7 in the Clinician's Guide to learn more. For Florida-specific information, visit the Laws page.

Each state has its own licensing and license renewal criteria for drivers of private motor vehicles. In addition, certain states require health care professionals to report unsafe drivers or drivers with specific medical conditions to the driver licensing agency. State law restrictions for older drivers vary according to age requirements of additional drivers, length of renewal cycle, vision requirements, license restrictions, level of mandatory reporting by health care professionals, civil immunity, anonymity protection, and process for evaluation by medical advisory boards. The effectiveness of driving restrictions in reducing vehicle crashes or fatalities involving older adults also varies from state to state.

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

Read Chapter 8 in the Clinician's Guide to learn more. For Florida-specific information, visit the Laws page.

This chapter contains reference tables of medical conditions, functional deficits, and medications that may impair driving skills, with associated consensus recommendations. Whenever scientific evidence supports the recommendations, it is included. These recommendations apply only to drivers of private motor vehicles and should not be applied to commercial drivers. Although many of the listed medical conditions are more prevalent in the older population, the recommendations apply to all drivers with medical impairments, regardless of age.

General Recommendations

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

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

Various medical conditions and functional deficits that may affect driving safety are addressed in Chapter 9 of the Clinician's Guide and organized into sections with corresponding tables. Conditions treated with medications that may impair driving are discussed within each section and cross-referenced to the medications section for additional detail

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

Chapters one through nine of the Clinician's Guide to Assessing and Counseling Older Drivers provide the clinical team with recommendations and tools for enhancing the driving safety of older adults. As in other aspects of patient care, however, further research can lead to more effective care. Further progress on the following would be beneficial:

• In-office tools that can help predict crash risk or determine fitness to drive
• Improved access to driver assessment and rehabilitation
• Training in the appropriate use of advanced technology in vehicles as these technologies evolve
• Safer roads
• Expansion of transportation alternatives
• Increased crashworthiness of vehicles
• Intervention trials to lower risk, maintain driving life expectancy, and/or improve driving safety

To accomplish these objectives, coordinated efforts among the health care and transportation communities, policymakers, community planners, the automobile industry, and government agencies are needed to achieve the common goal of safe transportation for the older population. As this population continues to expand and live longer, the challenge is to keep pace with its transportation needs.

Read Chapter 10 in the Clinician's Guide to learn more.

Current Procedural Terminology (CPT) codes can be used for driver assessment and counseling, when applicable.

These codes were taken from Current Procedural Terminology (CPT) 2018 Professional Edition. Chicago, IL: American Medical Association; 2017.

This section contains patient education materials for older adults and their caregivers that includes a self-screening tool for driving safety, safe driving tips, driving alternatives, and a resource sheet for concerned caregivers. Links for accessing recommended resources from reputable organizations are also provided.