Monitoring, like assessment, often falls to the primary-care physician. Patients with dementia are routinely evaluated to determine the progression of their disease during regular office visits. Maslow (2004) notes that serious medical conditions may coexist with dementia. Some of these, such as diabetes, should by themselves prompt discussion about driving, yet this subject is not typically discussed during physician office visits. Moreover, many older people have multiple chronic health conditions and may take several medications for them, another reason for concern about critical driving skills (Lococo and Staplin, 2005b). However, physicians do not often refer patients for driving competency assessment, nor are they present during actual driving evaluations. In their discussion of the CanDRIVE research initiative, Molnar, Byszewski, Marshall, and Man-Son-Hing (2005) make similar observations regarding physician assessment of fitness to drive in Canada. Middleton, Westwood, Robson, and Kok (2005) in the UK report on the AGILE project (AGed people Integration, mobility, safety, and quality of Life Enhancement through driving) review a new modular, older-driver assessment system co-funded by the European Union (See also Middleton et al., 2003). Thus, the topic of driving skill assessment is a concern that is being raised across the globe.
Departments of Motor Vehicles see drivers periodically at the time of license renewal (unless renewal is by mail or through the Internet). Researchers in Australia are working on a model license-reassessment program for older drivers in their country (Fildes et al., 2001). In a report on Medical Advisory Board activity for NHTSA prepared by Lococo and Staplin (2005a), 20 DMV jurisdictions indicated that they train their licensing personnel on how to observe for impairing conditions, with four of the jurisdictions having specialized training in impairments in older adults (Szlyk et al., 2002).
As noted previously, 1 in 10 people over 65, and nearly half of those over 85, have Alzheimer’s disease or a related form of dementia (Alzheimer's Association, 2005). This has prompted five jurisdictions—the District of Columbia, Illinois, New Hampshire, Oregon, and Pennsylvania — to implement age-based testing as a way to screen for high-risk drivers. In these programs, the start age of screening varies from a mandatory test at age 75 in Pennsylvania to random selection starting at age 40 in Pennsylvania. O ther jurisdictions shorten the renewal cycle for older drivers while still others eliminate the option to renew by mail, necessitating in-person visits.
Lococo and Staplin’s (2005a) report for NHTSA contains recommendations concerning how often people with dementia should be reevaluated. These include multiple on-road evaluations in different areas to be conducted every three to six months. Adoption of such a program would have significant implications for people with dementia and their families, especially with regard to the cost in money and time involved in multiple-day testing.
In California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania, physician reporting is required for drivers who are medically impaired and may suffer a loss of consciousness. States that encourage or allow physician reporting, but do not make it mandatory, are Alabama, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Iowa, Illinois, Kentucky, Maine, Maryland, Michigan, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Carolina, North Dakota, Rhode Island, West Virginia, Wisconsin, and Wyoming. The remaining States may not encourage reporting, or they may consider it a violation of patient/doctor privilege.
In a study by Adler, Rottunda, and Kuskowski (1999), 46 percent of licensed drivers with dementia of the Alzheimer’s type reported that they would be reluctant to discontinue driving based solely on a physician’s advice. Eighteen percent of drivers and 32 percent of their caregivers believed it was the physician’s responsibility to determine when the patient was no longer able to drive safely, but the majority believed that the individual with dementia should make that determination. Some observers worry that even if impaired individuals do initially comply with driving assessments, the disease progression might cause them to forget their decision and attempt driving. Anecdotal evidence supports this concern, but no validation study has yet been done (Sainz, 2004). Officials working in State transportation departments have also expressed concern regarding the lack of uniformity in driving regulations from State to State. It is thought that some retirees may relocate to States with less stringent licensing procedures in an effort to maintain community mobility longer (Bener, 2005). This would be an especially dangerous practice for drivers with dementia, given the importance of periodic assessment of driving skills.