Licensing drivers is within the States’ authority. Although the American Association of Motor Vehicle Administrators (AAMVA) recently began a project, in cooperation from the NHTSA, to develop model guidelines for State DMVs, currently 51 separate sets of regulations define licensing procedures across the States and the District of Columbia. An example of the variety in these regulations can be found in driver-reporting laws that apply to physicians. Currently, 6 States require some level of physician reporting. Some are very specific about the types of conditions that can be reported, but others provide little guidance. Twenty-two States have some sort of protocol for physicians to report voluntarily but do not require it. Five States encourage self-reporting, and 44 States allow a family member to report an impaired driver. States also follow up on these reports in a number of ways; all notify the individual that they have been reported, and most give the option of contesting a report stating that the driver is unsafe. Driver notification is most commonly done by mail, and significant time can elapse between reporting and notification.
Following are examples of several current programs. The first six require physician reporting while the last three employ alternate methods, including reporting by the individual driver or by nonmedical personnel. For more information regarding specific State regulations, the appendix of the Physician’s Guide to Assessing and Counseling Older Drivers (Wang et al., 2003) contains a State-by-State quick reference guide to licensing and renewal procedures. The Web site of the American Association of Motor Vehicle Administrators contains a similar guide as well as a summary of the activities of the various State medical advisory boards. That more-than-400-page report was prepared by TransAnalytics, LLC. (Staplin and Lococo, 2003).
Physicians in California are specifically required to report all patients diagnosed with Alzheimer’s disease. In the absence of a diagnosis of any disorder that is characterized by lapses in consciousness, they are not required to report unsafe drivers, although they are authorized to do so if they feel it is in the public’s best interest. Physicians are protected from any legal liability for reporting conditions that are required by law. The California DMV is responsible for notifying and following up with reported drivers. Follow-up involves a driving evaluation and determination of an appropriate course of action, which may include revocation of the license or ordering periodic reexaminations. The California DMV also accepts reporting from other sources, including individual drivers and their family members.
Oregon is in the process of phasing in a statewide, mandatory, medical-impairment–based reporting system that requires medical personnel who qualify as primary care providers to report people with functional or cognitive impairments that cannot be corrected or controlled by surgery, medication, driving modifications, or adaptive techniques. Physicians, law enforcement officials, family members, and friends may also report drivers who are unsafe because of their medical conditions. The license of the reported individual is immediately suspended, and, for individuals with dementia, a medical file and driving record are sent to the State Health Office to determine if the individual is safe to drive. The individual may request the opportunity to demonstrate fitness to drive via written and on-road tests.
Physicians in Delaware are required to report all citizens who are subject to loss of consciousness due to disease of the central nervous system. Failure to file a report is punishable by a fine of $5 to $50. Drivers are notified of the report, and their licenses are suspended until further examination takes place. Legal immunity is available to the reporting physician. The Delaware DMV also accepts reports from courts, other DMVs, police, and family members, and it protects the identity of all reporters. If the DMV receives questionable reports, they are sent to the Delaware Medical Advisory Board for evaluation.
New Jersey statutes require all physicians to report to the DMV any patients who experience a recurrent loss of consciousness, but the regulations do not specifically mention individuals with dementia. The license of the reported driver is then scheduled to be revoked, but that driver may request due process in an administrative court. While the physician is provided with legal immunity, the State offers no legal protection or anonymity to other reporters. The police, family members, other DMVs, and courts may also report unsafe drivers, but the report must be signed and anonymity is not protected.
In Nevada, physicians must report patients who experience any disorder characterized by a lapse of consciousness, but the regulations do not specifically mention individuals with dementia. The DMV notifies the reported driver by mail and may suspend that driver’s license. Legal immunity and protection are given to the reporting physician. Family members, the courts, other DMVs, and the police are also permitted to submit reports, and all are granted anonymity if it is requested.
Pennsylvania law requires all physicians or people authorized to diagnose or treat disorders and disabilities to report any condition that may affect driving safety to the Pennsylvania Department of Transportation (PENNDOT) within 10 days of diagnosis. Alzheimer’s disease is specifically mentioned as a reportable condition. PENNDOT then notifies the individuals and asks them to submit specified medical forms in order to determine their fitness to drive or need for assessment. The State provides that no civil or criminal actions may be brought against any person or agency for providing the information required. PENNDOT also accepts reports from courts, other DMVs, police, emergency personnel, family members, caregivers, and neighbors. While all reports must be signed, the department protects the identity of the reporter.
Illinois physicians are encouraged to inform patients of their responsibility to report to the Secretary of the State any medical condition that may affect their ability to operate a motor vehicle safely. The driver is notified of the referral and required to submit a medical report. The DMV determines if further action is needed. Illinois accepts reporting from courts, other DMVs, law enforcement officials, members of the Illinois medical advisory board, National Driver Register, Problem Driver Pointer System, Secretary of State, management employees, the Federal Motor Carrier Safety Administration, and driver rehabilitation specialists. Because Illinois is not a mandatory reporting State, there is no legal protection for reporters.
Florida law allows any person with knowledge of a licensed driver’s mental or physical driving impairment to submit a report to the Department of Highway Safety and Motor Vehicles (DHSMV). After notifying the driver in writing, the department investigates the report and takes action if it appears to be warranted. The law provides that no report can be used as evidence in any civil or criminal trial or proceeding, and anonymity is available.
Kansas law allows physicians to provide information concerning the mental or physical condition of any patient only if patients sign a form authorizing the release of such information to the State DMV. Upon such notification, the DMV informs the individual via a written referral. Physicians who submit a report in good faith are protected from civil actions for damages, but all such reports must be signed and anonymity is not preserved since affected drivers may request copies.
The Maryland Motor Vehicle Administration (MVA) works with physicians, family members, and people with Alzheimer’s to ensure they are on the road safely for as long as possible. Currently, the MVA’s Medical Advisory Board reviews more than 13,000 drivers per year. Medical conditions referred to the board for investigation include any disorder that impairs the ability to make decisions or produces any kind of confusion.
When taking medical histories of patients with dementia, Maryland physicians are asked to review their driving histories as well. Physicians are also encouraged to request relevant information from family members. Physician concerns are then reported in writing to the MVA, which may order screening tests to determine the fitness to drive of the person with Alzheimer’s, including an on-road test. Maryland law grants immunity to any physician reporting in good faith.
If the person with Alzheimer’s has no treating physician, family members may contact the Motor Vehicle Administration to request an evaluation. A phone call or letter from a family member is sufficient to initiate a review, and the report is kept confidential. The Medical Advisory Board asks for a short description of the driving problems or incidents that are of concern. The family member’s referral initiates a request for more information on the driver’s medical condition from a doctor, family members, and from that driver.
Currently, there is no information concerning the effectiveness of fatality-prevention programs. Most are too new for such statistics to be gathered. (For example, Oregon’s law was passed in 2003, and implementation was only completed in 2005.) However, a study by Grabowski, Campbell, and Morrisey (2004) examined the efficacy of State licensing regulations by looking at all fatal crashes in the United States during the years 1990–2000, as identified by the Fatality Analysis Reporting System. The study determined that State-mandated vision and road tests, and more frequent license renewals, were not effective in reducing fatality rates among older drivers. Only in-person license renewal had any effect on driver fatality, and then only for the oldest drivers (those 85 and older). This effect may be due to driver self-assessment that causes those in the 85-and-older population group not to attempt to renew their licenses. This could possibly result in safe drivers being taken off the road too soon due to a desire to avoid the process of license renewal (Grabrowski et al., 2004).
Most of the programs described above reference the need for periodic monitoring of drivers with dementia. States whose driving laws specifically mention Alzheimer’s disease include California and Pennsylvania. Oregon’s laws refer to individuals with cognitive impairments, while the District of Columbia, Florida, Georgia, Iowa, Kansas, Kentucky, Nebraska, Nevada, North Dakota, Rhode Island, South Carolina, Utah, and Virginia all reference the need to monitor those with some degree of mental disease or impairment. All of these descriptions could include the individual with dementia. A report submitted to the DMV in these States would most likely require review and, in some instances, could be heard by the State Medical Advisory Board.
The second part of this literature review focuses on what happens when the driver with dementia moves into the passenger seat. What happens to the person’s ability to get around in their community and continue engaging in quality-of-life activities after driving cessation?