Driver Screening and Evaluation Program
Volume III: Guidelines for Motor Vehicle Administrators
Projections that more than one in five drivers will be age 65 or older within the next twenty years have raised a number of concerns among those working to ensure public health and safety. In 1986, Congress passed the Commercial Motor Vehicle Safety Act (CMVSA), followed by the Surface Transportation Act a year later in 1987. These Acts established the need for screening and testing practices to identify commercial driver's license (CDL) applicants who may have medical or mental conditions or impairments that limit their functional capability to safely operate a motor vehicle. The standards promulgated in the CMVSA have been widely hailed as a timely and appropriate response to a legitimate public safety concern. Now there are calls at all levels to develop, apply, and enforce standards for fitness to drive beyond the arena of commercial operations, expanding the requirements to obtain and renew a license to operate private automobiles to include not only vision but other functional abilities that are most important for safe driving.
Program initiatives in this area are motivated in large part by anticipated increases in crashes and fatalities due to age-related functional decline. Already, based on the number of miles driven, the rate of fatal crashes for the oldest drivers in our society is higher than that of any other group, including teenagers. In absolute terms this problem is diminished by the smaller number of seniors, and the fact that, on average, they drive fewer miles than young and middle-aged drivers. But easily the fastest growing segment of the driving population is persons age 85 and older. For these individuals, maintaining one's health and overall quality of life depends overwhelmingly upon remaining independent, and independence requires mobility. Thus, it is prudent to assume that virtually all who can continue to drive will continue to drive.
The loss of functional abilities through normal aging is well documented. Because people age differently, chronological age alone is a poor indicator of functional status. But across the population, a steady decline in visual acuity and contrast sensitivity, in attentional and perceptual processes, in memory and cognition, and in physical strength, flexibility, and range of motion can be very reliably associated with advancing age. Even without considering the accelerating rates of disease and pathology--and in particular, dementia--that are evidenced in older persons, at some point most older persons are likely to experience an impairing condition serious enough to significantly elevate crash risk. Fortunately, such impairments can often be partially or fully remediated. When combined with appropriate restrictions on driving exposure, at least a degree of independence can be preserved for most people. To realize this personal and societal benefit, however, functional impairments must first be detected. And the earlier, the better.
It might be presumed that such impairments are best identified by individuals' physicians or other health care professionals. In this line of reasoning, the licensing authority must then rely on physician reporting, which presently has a number of drawbacks. Physicians, while primarily concerned with patients' confidentiality, may also be confused about their own liability in reporting a condition that could result in the loss of driving privilege. Several jurisdictions have enacted legislation to protect physicians in such circumstances, in certain cases including stiff penalties for failing to report. During 1999, the American Medical Association (AMA) Council on Judicial and Ethical Affairs adopted recommendations that underscore physicians' traditional respect for the individual and desire to promote patient autonomy. At the same time it articulated physicians' responsibility to recognize impairments in patients' driving ability that pose a threat to public safety and, when clearly documented, to notify the Department of Motor Vehicles. Still, physicians are trained to make medical diagnoses, not identify functional impairment. Doctors have long requested explicit guidance about the degree of driving impairment that will result from a particular stage of a given disease--for example, diabetes--but neither DMV's nor the larger scientific community has until recently been in a position to provide it. Emerging research findings now can begin to define which functional abilities should be measured, and how to measure them, establishing a framework for DMV's and the medical/health care community to work together to keep people driving safely longer.
The particular age-related changes in functional abilities at the center of identification and assessment programs undergoing pilot testing by licensing authorities in the U.S. and abroad are described in appendix A.
Undoubtedly, the problems underlying successful implementation of a driver screening and evaluation program in a given jurisdiction will involve a great deal more than deciding upon measurement targets and techniques to assess drivers' functional status. At a minimum, seniors, their families, and the public at large must understand the goals of the program and trust that it will be fairly applied. Other stakeholders involved in the administration of the program, including a broad array of public and private sector partners, must all feel that they have had a say in its development. The funding and availability of physical and staff resources to not only evaluate drivers, but to counsel and refer them as appropriate for further assessment, remediation, and access to alternative transportation options in the community must be assured. Effective liaison with the health care community--rehabilitation medicine and occupational therapists in particular--is essential. And exercising leadership and providing coordination of program activities by a dedicated administrator or Medical Advisory Board official is paramount.
Development of the Model Program has been driven first by the scientific evidence indicating which functional abilities deserve periodic reevaluation, but there is also clear concern about the extent to which jurisdictions will find it feasible to augment existing license control practices with more extensive screening activities. The incremental cost of implementing the Model Program depends in part on the resources presently committed to monitor driver qualifications. Without a cost analysis that is beyond the scope of these Guidelines, an understanding of present commitments in each jurisdiction can be fairly represented by the information in appendix B. This appendix describes the nature and extent of requirements for license renewal applicants across North America in 2001, and highlights differences between jurisdictions vis-à-vis special requirements for older drivers.
Examination of appendix B reveals that current practices vary widely with regard to the standards drivers must meet and the procedures they must follow to renew their licenses. Most notable are differences in the length of the renewal cycle; allowances for mail-in versus in-person renewal; and varying vision testing requirements and standards for low-vision programs. Approximately one-half of the jurisdictions in North America now have more stringent requirements in place for seniors, most often reflected in shorter intervals between renewals, requirements for in-person renewal, and/or mandatory vision tests beyond a specified age threshold. Such age thresholds are as low as age 50 and as high as age 75, but for the vast majority of jurisdictions they fall within the 65-70 age range.
The use of extended renewal cycles (longer than 4 or 5 years) combined with flexible renewal options (e.g., telephone or Web-based processes), while undeniably popular with older drivers, runs counter to the goals of the Model Program. Such practices have the combined effect of allowing drivers to avoid DMV examination or observation for 8 to 10 years or more, depending on jurisdictional renewal cycles, and preclude what is perhaps the best opportunity for DMV's to provide information and educational materials that can help older drivers remain safely mobile.
To gauge the feasibility of introducing or expanding driver screening procedures among jurisdictions, a survey developed under NHTSA sponsorship was completed by AAMVA in 1998. This survey was mailed to Driver License Administrators in the 50 United States, plus Washington, D.C., and 12 Canadian Provinces and Territories (excluding Nunavut). The survey questions, and a tabulation of response frequencies to each item as received from 60 of the 63 jurisdictions contacted by AAMVA, are presented in appendix C.
The 1998 NHTSA/AAMVA survey indicated that 90 percent of responding jurisdictions would apply any new or expanded screening procedures either to "high risk" drivers referred to the DMV only, or to this subgroup plus drivers over a specified age (which might vary from one jurisdiction to another); only 10 percent responded that a screening program in their State or Province would be limited to drivers who exceeded an age threshold.
With specific regard to the cost of new procedures, approximately one-half of responding jurisdictions stated that program costs would have to be offset "substantially or completely" by savings elsewhere in the Department regardless of expected payoffs in safety. Another quarter of respondents stated that program costs would need to be offset by such savings "to a significant extent but not completely." But, 24 percent stated that the cost of test procedures would have to be offset "only minimally, or not at all" if significant safety benefits have been demonstrated in another State or pilot program.
The practical upper limit on the time that could be devoted to administering functional tests to drivers was also addressed in the survey, with a nearly even distribution of responses among the alternatives provided: 25 percent stated that the maximum allowable time to administer functional tests is 15 minutes per driver; 29 percent would allow 15 to 30 minutes; 25 percent responded that 30 to 45 minutes would be feasible; and 20 percent would allow 45 minutes to an hour, or would impose no limit on test time. A majority of responding jurisdictions (63%) indicated that the DMV would likely not implement all screening and evaluation activities wholly within the Department, but would privatize some of the included procedures.
Next, the NHTSA/AAMVA survey asked licensing officials to answer 'yes' or 'no' to indicate whether "current policies and priorities in your Department would make it feasible" to implement various candidate components of the Model Program. Strong levels of affirmative responses were recorded in virtually every instance. The practice of "graduating" older drivers away from full privileges as capabilities suffer progressive decline was endorsed by 67 percent of respondents, though two-thirds of these stated that a change in legislation would be required for program implementation. Implementing community outreach activities to educate the public about the relationship between functional ability and safe driving, promote self-assessment and self-referral, and connect to local transportation alternatives would be feasible in 85 percent of States and Provinces. And fully 97 percent of responding jurisdictions affirmed the feasibility of testing driver functional capabilities--with consequent licensing action if warranted by test results--without regard to renewal cycle for any individuals referred into a screening program.
Additional judgments by licensing officials requested in the NHTSA/AAMVA survey addressed the feasibility of implementing alternative criteria and procedures related to vision testing; the testing of functional abilities other than vision; the use of alternative referral mechanisms; and the tailoring of subsequent evaluation procedures to the conditions leading to referral or detected through screening. Again, as documented in appendix C, responses were overwhelmingly affirmative.
Caution must be applied not to interpret the findings of the 1998 survey as an uncritical endorsement of driver screening program activities. Also, specific details of how a screening and evaluation program should operate were not addressed in the survey. Not surprisingly, jurisdictional licensing authorities revealed a keen sensitivity to the challenges of program implementation, through extensive supplementary comments. At the same time, survey data provide at least qualified support for ongoing efforts to develop and implement pilot tests in this area, while establishing broad parameters for program scope and content.
AAMVA Policy relevant to the screening and evaluation of drivers, at the time of license application or at other times, is presented in appendix D. A review of this material indicates broad agreement with key provisions of the Model Program, namely a close liaison with the medical community and other health care professionals to detect functionally impaired drivers; the endorsement of the NHTSA/AAMVA Guidelines for application by jurisdictional Medical Advisory Boards; the periodic reexamination of all drivers; and the recognition of vehicle-related trauma as a major public health problem amenable to prevention efforts by a combination of medical and highway safety professionals. The AAMVA Policy sections dealing with examination content and examining procedures, while not inconsistent with the Model Program, provide considerably less detail about the range of functional tests that may be of value in detecting impaired drivers.
The provisions of the Uniform Vehicle Code (UVC) pertinent to establishing qualifications for driver licensure, and disqualification on the grounds of functional impairment, are presented in appendix E. The mandate for Departments of Motor Vehicles to develop and apply licensing standards that protect the public from unsafe drivers is unambiguous. A provision whereby licensing authorities may disqualify persons with limitations under the UVC when there is "good cause to believe that such person by reason of physical or mental disability would not be able to operate a motor vehicle safely" is also clearly stated. Further, the UVC provides guidance with respect to the nature, composition and functions of Medical Advisory Boards that closely parallels the Model Program, specifically asserting that "the report of the Medical Advisory Board will be the determining factor" in deciding if a license should be issued.
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