Driver Screening and Evaluation Program
Volume III: Guidelines for Motor Vehicle Administrators
Achieving the cooperation of public and private sector partners in implementing a driver screening program, while fostering a more favorable reception by the media and by the public at large, begins with a clear statement of program goals. The central objective of the program described in these guidelines is twofold--to keep people driving safely longer, while protecting the public through early identification of functionally impaired drivers. It is recommended that all consortium members in a State emphasize and reiterate these expected outcomes as the design of its program evolves.
To develop a plan of action to meet this central objective in a driver screening and evaluation program, it is useful to also define a number of secondary goals. They pertain to the resources and procedures required to carry out the functions of primary program components. Primary program components include: catchment and referral mechanisms that bring drivers to a point where functional tests are performed; screening and assessment techniques for determining functional status; education and counseling activities to improve understanding about functional impairment and driving risk, as well as what steps to take when functional loss is detected; and restriction and remediation options that govern the extent to which driving privileges may be retained in the future. The following sections in this chapter are organized accordingly.
In addition, early program planning and oversight efforts should identify which consortium partners and stakeholders bring knowledge and experience to particular program components; and, which procedures can best be administered at the local or county level, versus which must be administered through jurisdictional agencies. As consortium members take ownership of developing or implementing specific components, they should be recognized for their contributions in such roles; a sense of teamwork can result that will prove essential over the long term, as well as a shared sense of responsibility to meet program funding demands.
This section first distinguishes between two broad avenues of entry into a driver screening and evaluation program--internal and external referrals. Contacts between State and Provincial licensing systems and older drivers in North America come about principally through the renewal process and by the direct observations of licensing personnel when an older driver appears at a field office to transact business ("internal" referrals). These contacts are augmented by referrals from physicians, law enforcement and the courts, family and friends, and others ("external" referrals). The relative emphasis placed upon internal versus external referral mechanisms presently varies from one jurisdiction to another. The Model Program assumes that this situation will persist, creating a need for each jurisdiction to preserve flexibility in this area.
At-risk drivers may be identified through activities undertaken by a motor vehicle agency. Applicants for renewal (and, ideally, original applicants), should be "pre-screened" through direct interactions with counter personnel, resulting in the identification of candidates for functional screening based upon predetermined, standard and objective criteria. Screening might also be triggered by crash or violation experience; by age; or by a statistical sampling procedure (reflecting, for example, the relationship between age and crash rates). Self-selected populations, such as those applying for handicapped status, also could be required to undergo screening. Chapter 6 of the Uniform Vehicle Code [§6-116(b) and §6-110(a)] provides the authority for a department to require drivers to undergo and pass tests to determine their fitness to drive safely.
Direct Observation by DMV Line Personnel. The practice of requiring drivers to renew their licenses in person presents the opportunity for licensing personnel to objectively evaluate general cognitive and physical fitness, through simple observation and communication with the renewing drivers and prompt further assessment. Several jurisdictions already using this practice have comprehensive procedure manuals and field employee training to ensure that observations are made for relevant capabilities, and in a respectful manner. The majority of jurisdictions surveyed by AAMVA in 1998 indicated that this practice would be feasible to implement in their jurisdictions. This practice also has passed the scrutiny of courts which examined it in cases brought under the Americans with Disabilities Act (ADA). In-person renewal with a requirement that DMV line personnel complete a very brief checklist of structured observations is therefore strongly recommended as a Model Program component.
Guidelines for conduct of DMV personnel are straightforward, preserving quality customer service through courtesy and efficiency. "Verifying Questions" such as "please spell your name;" and, "please verify your address and date of birth" should be used instead of interrogatories such as "tell me what your name/address is," or "I want to see what you know/remember." DMV staff should make note of any physical impairments the applicant may have without letting the applicant know that the way he or she walks or uses his or her arms or hands is being observed. When an apparent functional limitation has been observed, the DMV should address it with the applicant only in a private setting and always according to established Department procedures for which adequate prior training has been provided. Alternately, a DMV may elect to have all observations of apparent functional limitation referred to the Medical Advisory Board or to other specially-trained staff within the Department for follow up.
If observations by line personnel are conducted as part of a set of more comprehensive procedures that include vision screening and/or paper and pencil or automated test procedures to detect gross functional impairments, the same emphasis on customer service applies. Under these circumstances, the driver would be directed to the next station or examiner charged with test administration, after the checklist of structured observations is completed during the initial interaction with DMV staff.
The training provided to DMV line personnel to "pre-screen" for functional limitations is critical. Written documentation should be provided that defines each to-be-observed functional ability and provides the standard, so the DMV employee understands the benchmark of performance. A person who does not meet a standard, and whose license is not properly restricted, may be required to submit to additional functional screening measures, to complete a driving skills test or evaluation, and/or to file a medical report.
A description of relevant functional abilities and standards for observation by DMV personnel follows in table 2.2
If mail-in renewal practices are permitted, a policy requiring third-party screening for gross impairments in relevant visual, mental, and physical abilities and clear guidelines for conducting, documenting, and reporting the results of these procedures to the DMV prior to granting license renewal is strongly recommended.
|Lower body strength, range of motion, mobility and coordination to use foot-operated vehicle controls.||Person is able to walk to a DMV service 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.|
|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.||Person is able to turn the 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 which interferes with proper grasping. No excessive shaking, tremor, weakness, rigidity or paralysis.|
|To hear other traffic and vehicle-warning devices (i.e., horn or emergency siren).||Person is able to hear the normal spoken voice during the licensing process, with or without a hearing aid.|
|To see other traffic, road conditions, pedestrians, traffic signs, and signals.||Person is able to meet applicable vision requirements by passing a DMV vision screening or presenting evidence of similar testing by a vision specialist.|
|Cognitive skills (i.e., to think, understand, perceive, and remember).||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 control (i.e., ability to respond to stimuli).||Person exhibits normal consciousness and bodily control (i.e., no self-disclosed or obvious incident 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.|
Medical Condition/Symptom Questions on License Application/Renewal Forms. A substantial number of medical referrals--one-fifth or more--may be triggered initially through driver responses to questions on application forms about their medical conditions and symptoms, and about the prescription medications they are taking. Studies have found that drivers who provide affirmative answers to medical questions have significantly worse prior crash-involvement records than a randomly selected comparison sample.3
Medical fitness questions included on a driver license application form should be designed to identify applicants who may have the following conditions: diabetes; cardiovascular; pulmonary; neurologic; epilepsy; learning and memory; psychiatric; alcohol and drugs; visual acuity; musculoskeletal/chronic debilities; or functional motor impairment. Because drivers may not consider their particular health condition as one that affects driving performance, or may not recognize it in a list of body systems, the wording of medical conditions questions should be non-technical and easily understood by the general public. For example, it is preferable to phrase questions about "heart" instead of "cardiovascular" conditions. Also, specific examples of conditions and symptoms of primary interest (e.g., irregular heart beat, heart attack, heart surgery, high blood pressure) should be cited. An example of a form that satisfies these guidelines is presented in table 3.
The form should include a statement that the applicant signs which certifies that his or her statements are true, accompanied by relevant State law describing penalties for false affidavit perjury. State law should reflect verbatim, or be in substantial conformity with, the Uniform Vehicle Code §6-302:
"Any person who makes any false affidavit, or knowingly swears or affirms falsely to any matter or thing required by the terms of this chapter to be sworn to or affirmed, is guilty of perjury and upon conviction shall be punishable by fine or imprisonment as other persons committing perjury are punishable."
A follow-up visit with a physician, with a report submitted to and reviewed by the DMV, should take place before any licensing action is undertaken for an individual. If the physician report clears the individual to continue to drive, an immediate screening to establish current measures of functional capability should be performed. This will serve as a useful baseline to assist the individual, his or her physician, and the DMV in subsequent reviews of license status.
Driving History: Crashes and Violations. Crash and violation history over the prior 3-year period should be accessed for all license renewal applicants as a potential trigger for screening and evaluation program activities. The recommended trigger for functional screening is an incidence of crash involvement coupled with an entry on the investigating officer's crash report of one or more violations or driver/vehicle contributing factors among those listed below:
|Diabetes: Diabetes (high blood sugar or sugar diabetes that you control with diet, medication, or insulin), hypoglycemia, or other metabolic conditions such as thyroid. Yes? No?|
|Cardiovascular: Heart condition, with or without symptoms (heart attack, heart surgery, irregular rhythm, general heart disease) or hypertension (high blood pressure) currently requiring medication for control. Yes? No?|
|Pulmonary: Pulmonary (lung) condition (asthma, emphysema, passing out from coughing, etc), sleep apnea or shortness of breath. Yes? No?|
|Neurologic: Neurological condition (stroke, head injury, narcolepsy, cerebral palsy, multiple sclerosis, muscular dystrophy, Parkinson’s Disease, and other spinal cord or brain diseases?) Yes? No?|
|Epilepsy: Epilepsy, seizures, and other episodic conditions that include any recurrent loss of consciousness or control.
Any time in life? Yes? No?
|Learning and Memory: Learning and memory difficulties observed personally or reported to you by others. Yes? No?|
|Psychiatric: Psychological condition (anxiety, severe depression, behavioral mood conditions, schizophrenia, etc.) for which a physician has recommended that you take medication. Yes? No?|
|Alcohol and Drugs: Excessive use of alcohol and/or prescription drugs; use of any illegal drugs; or treatment or recommendation for treatment of alcohol use or chemical dependency.|
|Visual Problems: Awareness of decrease of vision worse than 20/40 in either eye, or a decrease in peripheral vision (side vision). Also includes cataracts, glaucoma, macular degeneration, diabetic retinopathy.
Do you have a prescription for corrective lenses? Yes? No?
|Musculoskeletal/Chronic Debilities: Loss or paralysis of all or part of an extremity; or onset of a general debilitating illness requiring treatment. This includes osteoporosis, HIV, amputations, and congenital abnormalities.
New or changed past 5 years? Yes? No?
Present longer than 5 years? Yes? No?
|Functional Motor Impairment: Need for use of a brace, prosthesis, or compensating accessories for driving. Includes reductions in muscular strength, coordination, range of motion of joints, spinal movement and stability that affect your ability to drive safely.
New or changed past 5 years? Yes? No?
Present longer than 5 years? Yes? No?
|Other: Other health problems or use of medications which might interfere with driving ability or safety.
A special reexamination is also recommended at any time (i.e., mid-cycle, not waiting until the time of license renewal) when a licensee has been involved in a crash, and the investigating officer's report or the person's own account of the crash identifies one or more of the actions or factors listed above. If a jurisdiction also employs an age threshold for initiating such actions, cost-effectiveness is likely to be reduced significantly if the threshold is set lower than age 60. Law enforcement referrals for suspected medical impairments should lead to functional screening and evaluation regardless of driver age.
Driver Age. Driver age affects license renewal practices in 33 jurisdictions, most often by requiring older persons to comply with a shortened renewal cycle relative to the general population, and/or by requiring them to apply in person for license renewal. Less commonly, driver age is used as a trigger requiring a vision test, medical review by a physician, knowledge test, and/or road test for renewal. In these guidelines, across-the-board testing based on driver age alone is not mandated; but, neither is it ruled out. Early identification of impairing conditions will be enhanced by establishing baseline functional status, with a clear benefit to individuals in terms of lowering their own driving risk. A public health benefit of this preventive measure is also presumed, but is difficult to quantify. It is expected that technical, economic, and political considerations together will influence decisions regarding age-based testing by DMV's, on a jurisdiction-by-jurisdiction basis.
If driver age is to be used by a jurisdiction as a trigger for screening, what age can be recommended? Statistically, very little is gained by requiring age-based medical reexaminations for drivers under the age of 60. A survey of age thresholds adopted for other license renewal practices, and the scientific literature describing changes in critical functional abilities with advancing age in the general population, suggests that a value in the 70-75 age range will be most widely accepted if a jurisdiction embarks on a policy of across-the-board screening to detect driving impairments.
In some jurisdictions, "external" referrals may provide the primary means of entry into driver screening and evaluation programs. In others, it may be the only means. The referral sources considered under this heading include physicians; ophthalmologists and other vision care specialists; occupational and physical therapists; hospitals and rehabilitation facilities; law enforcement and the courts; social service providers; and family and friends. Coordinating the activities of the various external sources of driver referral, while standardizing reporting procedures, is essential. In addition, lines of communication back and forth between the sources utilized in a jurisdiction and the motor vehicle agency should be formalized, including procedures for the agency to report back to a source regarding the disposition and status of referral cases, within legal bounds of privacy and confidentiality.
Physician Reporting. Physician reporting, whether compulsory or on a voluntary basis, can greatly assist the licensing agency to identify drivers with physical and mental impairments that place them and others at risk when driving. Physicians' expertise and position of trust place them in a key role to diagnose likely driving impairments, as prescribed by their jurisdictional Medical Advisory Board. Studies indicate that health care providers are seniors' preferred source for information and advice about whether it is safe for them to continue to drive or if they should modify their driving habits.
A dilemma for physicians is how to protect the confidentiality of their physician-patient discussions, if reporting is not mandatory in their jurisdiction. Physicians may also be reluctant to report an individual with whom he/she has held a long-term relationship, knowing the devastating impact on quality of life that can result from restriction or loss of driving privileges. At the same time, these professionals bear an ethical responsibility to alert licensing officials whenever they judge an individual to pose a health risk to themselves and to the public. This responsibility is underscored by recent guidelines issued by the American Medical Association's Council on Ethical and Judicial Affairs which state that, "physicians [have] legal and ethical obligations with respect to reporting physical and mental conditions which may impair a patient's ability to drive" (see appendix F).
Physicians also may be concerned about their potential legal liabilities if they report to the DMV. This may be addressed through legislation that requires physician reporting, and/or the physician must be granted immunity from legal action arising out of such reporting. Fourteen jurisdictions currently require physicians to report conditions that are associated with increased driving risk to licensing agencies. All of these grant the physician immunity from legal action by the driver. Another ten States and three Provinces permit physicians to report potentially impaired drivers to the licensing agency, and all but two of these grant immunity to physicians making these reports. Other jurisdictions allow the physician to report impairing conditions to licensing agencies, but only if the patient refuses to report himself or herself.
The Medical Advisory Board, or other jurisdictional agency as appropriate, must provide physicians with unambiguous guidance regarding the "potentially impairing conditions" they should report. Medical conditions covered by existing statutes vary from jurisdiction to jurisdiction; while conditions such as epilepsy that may cause loss of consciousness are near universal as triggers for reporting, only one jurisdiction (California) presently identifies dementia among the conditions physicians are mandated to report.
Reportable conditions should include:
Until such time that uniformity exists among the jurisdictions with regard to medical qualifications of drivers, it will be up to the individual physician to become familiar with the medical classifications of drivers and the examination forms and procedures used by their jurisdiction. One jurisdiction4 asserts that, "The physician has much of the responsibility for determining medical competence to drive. This implies that the physician has four duties: (1) to be aware of such medical conditions; (2) to detect these conditions in their patients; (3) to discuss with their patients any limitations on driving imposed by the medical condition; and (4) if necessary, report the patient's condition to the appropriate [State] agencies." These guidelines also list specific questions a physician may pose to a patient to help identify if he/she is at risk:
The DMV should provide physicians with information that explains the ways in which specific medical conditions increase driving risk. The link between medical conditions, functional impairment, and driving difficulties that increase the likelihood of a crash must be well understood by physicians; this information underscores physicians' desire to act in their patients' best interests, even if it means reporting to the DMV. It also aids in counseling their patients about how they should modify or limit their driving. This information, also including risk ratios for a wide range of medical conditions, may be found in recently-developed preliminary medical guidelines for assessing fitness to drive that are published by NHTSA in cooperation with the Association for the Advancement of Automotive Medicine (AAAM). The American Medical Association (AMA) and NHTSA will publish final guidelines in 2003.
Of particular importance to physicians is an understanding of how driving risk changes with progressive diseases, most notably dementia. Alzheimer's Disease (AD) is the most common cause of dementia among older adults, with prevalence estimated as high as 12 percent for persons aged 65 and older and 48 percent for those age 85 and older. Drivers with dementia are less likely to report driving problems, and their perception of their own driving ability is not reliable. Therefore, they are much less likely to self-limit their driving exposure than persons with, for example, declining vision, and reporting by physicians is more critical. During the early stages of dementia, the crash rate for AD patients is only slightly higher than that for the general driving population. But as the disease progresses, the AD-related crash rate more than doubles, and regular reassessments (every six months) are recommended. More extensive information about dementia and other progressive diseases is provided in the NHTSA/AMA guidelines.
Finally, a jurisdiction should provide physicians with a listing of providers to whom they can refer patients with functional impairments for treatment and rehabilitation that may extend their safe driving years. These will include ophthalmologists, occupational and physical therapists, providers of classroom courses in traffic safety, and behind-the-wheel instruction from driving schools tailored to the needs of special populations.
Referrals from Vision Specialists. While some DMVs perform periodic vision screening as a requirement for license renewal, most do not; and where screening is performed, it is limited to only a subset of the visual capabilities needed for safe driving. Given research findings from Pennsylvania indicating that over half of those who fail a DMV vision exam are unaware that they have a vision problem, it is apparent that ophthalmologists, optometrists and other eye care specialists can be important external referral sources for detection of impaired drivers. It also emphasizes the need for periodic vision exams as a central element of driver screening and evaluation programs, where all providers of such services comply with measurement standards and vision screening procedures established by each jurisdiction.
A useful starting point for establishing requirements for periodic vision testing are the recommendations of the American Optometric Association (AOA), which advises individuals to get eye exams that include:
Current AOA guidelines recommend that people ages 10 to 40 be tested every 2 to 3 years; people ages 41 to 60 every two years; and people age 61 and older every year. Individuals age 61 and older have an increasing risk for the development of cataracts, glaucoma, and macular degeneration and other sight-threatening or visually disabling conditions. Also at elevated risk of driving impairment due to reduced visual function, are people age 65 and older who are diagnosed with diabetes or hypertension; who have a family history of glaucoma or cataracts; and who are taking prescription or nonprescription drugs with ocular side effects.
A certification that a jurisdiction's standards have been met is likely to be the least burdensome reporting requirement for vision care providers in a driver screening and evaluation program. Vision care providers should also be mandated to inform their patients of the driving risks associated with loss of visual function. If an impairment is remediable, an additional exam certifying compliance with jurisdictional standards may be needed. In such cases, a review of any licensing actions (restrictions) should follow visual correction or remediation.
Occupational/Physical Therapist Referral. While physicians are required to report drivers with specific disorders that may impair driving ability in certain jurisdictions, and may report with immunity in others, many consider reporting to be a breech of confidentiality or fear that the patient will seek a new physician. An alternate approach within a driver screening and evaluation program is to require the physician to refer potentially at-risk patients to a driving program, which will utilize occupational therapists (OT's) and driving instructors to objectively determine driving ability.
After the assessment, the OT will explain performance outcomes to the patient and family, and will provide a written report to the individual's physician. This gives the family and physician an objective determination of driving ability to back up any recommendations for driving restriction or driving cessation. However, it is not sufficient that the OT or driving instructor report results only to the physician, because physically and mentally unfit license holders often continue to drive despite medical advice not to. It is therefore a program requirement that the professional who performs testing also reports to the licensing authority. Reports should include: a determination of current fitness to drive; the presence of impairments that are and are not remediable and, in the former case, recommended actions; and a timeframe when the individual's driving capability should next be reevaluated. Because occupational therapy practitioners are trained to look at physical and cognitive issues, they are in a good position both to evaluate and to rehabilitate drivers who are frail, disabled, or impaired as a consequence of disease or injury.
Hospital Plan of Discharge/Care Plan Referral. Drivers who have been hospitalized for a condition that results in impaired driving ability may learn about or be referred to rehabilitation services provided by occupational and physical therapists at the time they are discharged. Yet, a 1997 study of stroke survivors in Alabama reported that nearly half (48%) did not receive any advice about driving when leaving the hospital, and 87 percent did not receive any type of driving evaluation. Thirty percent of stroke survivors who drove before the stroke resumed driving after the stroke, with one-third of this group driving 6 or 7 days and/or 100 to 200 miles every week.
It is recommended that, as one activity during care plan development for patients about to leave the hospital, there is DMV notification for license holders who manifest any of a list of medical conditions or symptoms. This list should be developed with reference to the NHTSA/AMA guidelines discussed earlier under the Physician Reporting section.
Law Enforcement and Court Referral. Law enforcement agencies have the ability to identify and refer impaired older drivers in virtually all jurisdictions, and account for at least one-fourth and as many as two-thirds of reports concerning impaired drivers (of all ages). Not all law enforcement officers are properly trained to be observant for cues indicating functional problems, however, which can lead to unnecessary referrals and reexaminations. After stopping an individual who has violated a traffic law or is driving erratically, an officer should observe for cues of possible impairment that include observations of the driver's awareness and cognitive status (e.g., does he/she know time of day, day of week, and month of year; can he/she state the origin and destination of the trip; does the person stumble over words, or ramble); observations of appearance (e.g., does the person exhibit poor hygiene or inappropriate clothing); and observations of physical disability or frailty (does the person take a long time to walk a short distance, stumble/fall, shake, or seem uncoordinated).
Once stopped by a law enforcement officer, a driver identified as potentially functionally impaired should be referred directly to the DMV for screening and evaluation, and/or to the courts for a disposition of the case. Jurisdictions including Ohio and Florida recommend an offer of relief from legal action associated with the offense triggering the traffic stop, following participation in a screening, education, or remediation program. In any event, the participation of potentially impaired drivers in such programs should be mandatory, if a driver is stopped for unsafe driving. It should also be a requirement that evidence of an offending driver's participation in a screening and evaluation program activity is communicated back to the law enforcement unit that initiated the referral.
Courts should not give drivers who are identified by a police officer as potentially functionally impaired the option of only paying a fine, without further contact with a program activity where fitness to drive can be determined. In addition, the court may rely on a driver's pattern of crashes or convictions as a basis for referral into a screening and evaluation program where functional abilities are assessed. Depending upon the results of this assessment, a road test may be requested.
Education and counseling focused on the relationship between functional decline and driving risk, procedures for self-evaluation, changes in driving habits appropriate to declining abilities, and alternative transportation options in the community should be provided to all drivers referred for screening and evaluation by law enforcement officers or the courts, regardless of screening outcome.
Referrals from Social Service Providers. The Department of Health and/or Office on Aging in each jurisdiction can serve as referral sources that offer particular benefits to individuals and to the community, in terms of early detection of at-risk drivers prior to a crash, conviction, or traffic stop for negligent driving behavior. Education and counseling activities stressed as essential components of a screening and evaluation program also may be delivered most credibly and most effectively by social service providers, given the overall mission and the range of other supports available in these settings.
In many jurisdictions, the Health Department undertakes comprehensive evaluations of older individuals referred by family, friends, clergy, etc., who are at risk of losing their independence (through nursing home admission) because of health, social, or environmental problems. This assessment helps to determine the person's functional status and what an individual's needs are to maintain community living for as long as possible. A typical evaluation consists of medical, psychosocial, environmental, psychiatric, and economic assessments (performed by licensed social workers and nurses, in addition to consulting physicians and psychiatrists). The results of the evaluation are kept confidential, but a letter may be sent to the DMV indicating that a person should not be driving. This letter does not mention specific information about diagnosis, but instead describes only problem behaviors, thus meeting strict guidelines to avoid infringement of patient confidentiality.
The Office on Aging, if it exists in a jurisdiction, typically takes the lead in planning, coordinating and delivering programs and services for older adults to promote their health and well-being. These services are provided at the local level, through Area Agencies on Aging. Case management, a Title IIIb service under the Older Americans Act, begins with initial client intake and continues through the application process, assessment of need, service planning for a client, provision or arranging for provision of services, review and reassessment of client need, and revision of service plans as appropriate. Screening and assessment are performed to determine new applicants' eligibility for services, or ongoing eligibility for services for existing clients. Functional assessment outcomes that affect safe driving ability could be reported to a motor vehicle agency, in the same manner that the Department of Health would refer a client.
Family/friend referral. Family and friends are a unique source of referrals because of their ability to observe impaired drivers over longer periods of time, and their awareness of conditions or behaviors not observed by visits to physicians or during interactions with licensing agency personnel. In jurisdictions with policies in place for family reporting, these referrals account for between 5 and 10 percent of requests for reexamination by the DMV. Jurisdictions that act upon referrals by family or friends should conduct a pre-investigation before requiring a re-test, to make sure the report is legitimate. Anonymous referrals are discouraged. However, if a jurisdiction allows anonymous referrals, it is strongly recommended that such information is investigated and validated before confronting the accused.
At the same time, steps need to be taken to facilitate referrals by family and friends. These steps may include distribution of information to the public detailing if, when, and how one should refer an impaired driver. In addition, since physicians are the most frequent contact, and are often reluctant to get involved with families and issues of driving cessation, education campaigns must include and target health care personnel. This is a sensitive issue when a parent or grandparent is involved; family and friends require the support of physicians, law enforcement personnel, and the DMV in their attempts to protect their loved ones.
To keep people driving safely longer while protecting the public through early identification of functionally impaired drivers requires a cost-effective approach to the administration of valid screening and assessment techniques. The Model Program guidelines distinguish screening activities as those that can be applied quickly by a licensing agency, to gauge the priority for further evaluation of an individual's functional status. In contrast, techniques for assessment are applied diagnostically, to determine an underlying medical or neurological condition that explains the functional loss and may suggest a course of treatment or remediation.
The full range of functional impairments for which candidate screening techniques were evaluated during Model Program development is detailed in appendix A.
Screening activities are further distinguished by their feasibility of implementation, with specific reference to the personnel qualifications, training requirements, and needs for space, equipment, and other resources to carry out functional testing and interpret test results. For more information on these topics, see the later discussion on Program Implementation.
Following the 1992 NHTSA/AAMVA Guidelines, the abilities for which it is important to detect functional loss as early as possible can be clustered loosely into visual abilities, mental abilities, and physical abilities. In each category screening activities leading, where appropriate, to more in-depth or comprehensive driver assessments can be recommended as Model Program components. It is essential to remember that: a screening "failure" is not in itself grounds for licensing action, but serves as a trigger for further evaluation.
In fact, recommendations for the implementation and scoring of driver screening procedures have been developed at two levels. The results of screening procedures may be used to assign a driver to a low priority or high priority for further evaluation. According to this two-tiered approach, not one but two performance thresholds or "cutpoints" must be identified for each measure of functional ability included in a screening battery.
The cutpoint used to indicate a low priority for further evaluation connotes an early stage of functional decline, where prevention is stressed and the opportunities for remediation or to make changes in driving habits to keep driving safely longer are greatest. Individuals who score above (i.e., those who perform better than) this "prevention threshold" on all functional measures in the screening battery effectively receive a clean bill of health. For these persons, a functional performance baseline will be established against which future decline may be monitored. This may be accomplished through screening in subsequent license renewal years; testing by others, such as health care providers; or self-testing. Educational materials should be provided to these intact, healthy individuals to underscore the importance of early detection of functional loss. But without any medical basis for action by the licensing authority, it may be assumed that these individuals can safely continue to drive with whatever level of restriction--if any--was on their license before the screening.
Individuals who score below the "prevention threshold" on one or more functional measures in the driver screening battery should receive further evaluation. The nature and the urgency of such evaluations depend upon how far below this threshold a driver scores, however. If an individual scores below the "prevention threshold" but above a second cutpoint connoting an "intervention threshold," he/she has the lowest priority for further evaluation. And the types of further evaluation undertaken with these drivers would typically be limited to an interview; medical history review; pharmacological review; and potentially, a diagnostic assessment through clinical referral, to support a prescription for remediation. It would not be expected that road testing would often be required at this relatively modest level of functional decline.
Individuals having the highest priority for further evaluation are those who not only score below the "prevention threshold," but also fail to perform at or above the lower cutpoint, or "intervention threshold." This cutpoint connotes a more advanced stage of decline on one or more functional measures, where intervention is stressed to protect both the individual and the public. Drivers demonstrating this degree of functional loss would be subject to all evaluation activities noted above, but on an accelerated schedule. And, it is expected that many would also be required to complete a behind-the-wheel evaluation. The premise for establishing multiple cutpoints may be represented graphically, as shown in figure 1.
Establishing the cutpoint scores identifying a "prevention threshold" and an "intervention threshold" is obviously a key aspect of any jurisdiction's driver screening program. These scores should reflect analysis of very large, population-based samples that provide an accurate understanding of (a) how functional abilities change with normal aging, and (b) the extent to which functional decline can be related to motor vehicle crash involvement, in particular "at fault" crash involvement.
Practical considerations for choosing cutpoints are discussed below, followed by recommendations for the functional domains that should be targeted by jurisdictions for use in driver screening and evaluation programs. The focus on a particular aspect of functional ability, rather than a particular test procedure, acknowledges that there are often a number of reliable measurement techniques in a given area and that what may be feasible in one setting is not appropriate in another.
The goal in establishing the "prevention threshold" in a driver screening program is to set the bar low enough so that very few people who are at increased risk of a crash due to functional impairment are missed. Of course, this strategy also increases the number of potential "false positives"--people who will never be crash-involved or, if they are, it will be for another reason that is unrelated to the functional ability under consideration. This places a premium on the administrative feasibility of the driver screening techniques, to minimize the "cost side" of the cost-benefit equation. At the same time, the benefits of implementing driver screening at this level include anticipated gains in personal mobility--because problems more often are detected early enough to be remediated such that people can keep driving safely longer--in addition to savings realized through crash reduction.
By contrast, the goal in establishing the "intervention threshold" is to identify, with much higher specificity, those individuals who pose immediate risk to themselves and others by continuing to drive. This goal justifies the higher costs of diagnostic assessment and road testing. Since the bar is set higher, making it more difficult to fail the screen, there are many fewer people affected. The benefits of implementing driver screening at this level will be reflected less in terms of mobility gains--because the potential for remediation of functional loss is significantly lower at a more advanced stage of decline--and more in terms of actual crash reduction. Also, at this level it is essential to minimize false positives, to maintain credibility.
The screening activities recommended here as being most useful in helping an agency advance personal mobility and public safety goals within its jurisdiction are geared to the clusters of functional abilities identified earlier--visual, mental, and physical abilities.
Recommended vision tests include the measurement of (1) near and far acuity and (2) contrast sensitivity, and testing for (3) visual field loss. These visual functions help determine how well and under what conditions a person can sense objects in the environment. As perform-ance in visual function declines, the probability that hazards, traffic control messages, naviga-tional cues and other safety-critical information will be detected early enough so that a driver can understand and apply the information to maneuver safely falls to an unacceptably low level.
Commercially available, effective methods for performing acuity and contrast sensitivity testing include manual and automated techniques. In the latter case, both standalone testing machines and computer-based testing programs are available; respectively, these require proper maintenance and careful adherence to instructions regarding viewing distance and control over ambient lighting conditions. These same concerns also apply with manual techniques (e.g., wall charts). Testing for limitations in visual field size is more difficult. Manual (sometimes called "confrontational") techniques are notoriously unreliable. While vendors of standalone vision testing machines commonly advertise this measurement capability, a clinical (ophthalmological) perimetry evaluation is most reliable.
Recommended tests of mental functions include the measurement of (1) working memory plus (2) visual (divided) attention processing speed, (3) directed visual search, and (4) the ability to visualize missing information. These capabilities enable motorists to seek and acquire information needed for everyday driving, to recognize and anticipate safety threats, and to make timely and appropriate maneuver decisions to avoid hazards and conflicts with other road users.
The measurement of working memory, of directed visual search, and of a person's ability to visualize missing information can all be accomplished using manual methods drawn from neuropsychological test batteries. With training, including periodic follow-up for quality control, these measures can be applied quickly and reliably at very modest cost, based on extensive field tests sponsored by the NHTSA. Automated (computer-based) methods are also available and have been used by DOT's in pilot applications.5 Manually obtaining measures of how fast a driver can divide and switch his/her attention is problematic, however; because response times are measured in fractions of a second, only computer-based tests of these abilities are feasible.
Recommended tests of physical ability include tests of drivers' (1) lower limb strength and mobility and (2) their head-neck rotation capability. Measures of the former ability predict how quickly a driver can move his/her foot from the accelerator to the brake in an emergency situation, while the latter ability influences how well the driver can scan the environment for conflicts, especially at intersections and when merging or changing lanes.
While the targeted abilities can be measured quickly, cheaply, and reliably in an office setting, testing should be performed in private--and may be done off-site.
In summary, these guidelines recommend that nine specific aspects of functional ability be measured in the Model Driver Screening program. These abilities, the type of test methods that can be used to measure each ability, and the testing time that will accommodate an estimated 85 percent of older drivers in the general population6 are summarized in table 4. The three vision tests are already included in (or can be easily added to) the screening protocols offered by most manufacturers of automated vision testing equipment used by DMV's. The two physical abilities are simple and straightforward to measure, within 1-2 minutes and at very modest cost. As shown, three of the four mental abilities are the most time-consuming to test. But, functional losses in these areas also bear the strongest relationships to crash involvement.
Finally, jurisdictions are discouraged from collapsing measures to expedite testing. A significant decline in any of the targeted functional abilities can result in driving impairment. Similarly, pass/fail criteria or "cutpoints" should be specific to individual measures, not to any sort of combined criterion. Up-to-date guidance about the most feasible and effective techniques for measuring each ability, together with suggested cutpoints to trigger program interventions, should be obtained through reference to the most current information available from NHTSA.
Providing information to older drivers and their families about the link between functional decline and driving safety, and about resources that exist to help preserve or extend their mobility as they grow older, is central to the Model Program. Community outreach and public education about these topics was endorsed by 85 percent of the jurisdictions in the 1998 AAMVA/NHTSA survey of license administrators in North America. When individuals may go for extended periods without examination or observation by licensing staff (up to 18 years in Florida, for example) they are deprived of information they need to remain safely mobile. And in addition to the drivers themselves, physicians, vision care specialists, and other health care providers--who may also be reached through professional and trade organizations--are a critical audience for educational efforts within a jurisdiction's driver screening and evaluation program.
Educational materials designed for direct distribution to the public should emphasize that older persons themselves are at greatest risk if they drive while functionally impaired. A clear explanation of the visual, mental, and physical abilities deemed essential for safe driving should be provided, including examples of their roles in common driving tasks. Procedures for screening, providers of screening services, and the consequences of scoring below specified cutoffs should also be stated--underscoring the fact that a "poor" screening outcome may lead to early detection of a problem that has a much better chance of remediation than if detected at a later time. Above all, educational materials should convey to the public that self-knowledge and an understanding by one's physician, about the status of one's functional abilities as highlighted in these guidelines, are essential to prolonging the safe driving years.
|Targeted Functional Ability||Test Method and Duration of Testing|
|1. Visual Acuity (Near and Far)||Manual Test Administration: 1 minute
Automated Test Equipment: 1 minute
|2. Visual Contrast Sensitivity||Manual Test Administration: 1 minute
Automated Test Equipment: 1 minute
|3. Field of View||Automated Test Equipment: 1 minute|
|4. Working Memory||Manual Test Administration: 1 minute|
|5. Directed Visual Search||Manual Test Administration: 6 minutes
Automated Test Equipment: 3 minutes
|6. Visual (Divided) Attention Processing Speed||Automated Test Equipment: 4 minutes|
|7. Visualization of Missing Information|| Manual Test Administration: 3 minutes
Automated Test Equipment: 3 minutes
|8. Lower Limb Strength and Mobility||Manual Test Administration: < 1 minute|
|9. Head-Neck Rotation||Manual Test Administration: < 1 minute|
One example of a brochure that may serve as a useful starting point for jurisdictions wishing to develop educational materials for the general public is presented in appendix G ("How Is Your Driving Health?"). NHTSA-sponsored research supporting the development of educational materials geared to the health care profession was initiated in 2000.
Education materials distributed in several jurisdictions now include a guide for self-assessment by older persons and their families. Insurance companies and the AARP also offer self-assessment guides. Such guides describe procedures that can be carried out quickly, easily, and cheaply in one's own home. This can be a valuable component of a screening and evaluation program, to the extent that older persons gain awareness of their current functional status; this knowledge establishes a baseline against which any future decline serves as a "red flag" that may be brought up during their next visit to the doctor. Guides for self-assessment should include suggestions about which changes in driving habits make sense when functional decline in one or more safe driving abilities is revealed.
In the Model Program, the availability of counseling services to help explain test results and answer drivers' questions about what to do next is a necessary accompaniment to functional screening, wherever it is performed. For those who do not evidence any gross functional impairments, this service must address changes in driving that may be necessary with future decline, or, that may be considered sooner to make driving a more comfortable experience. Those who are impaired with respect to one or more safe driving abilities should receive an appraisal--pending further evaluation--of whether continued driving, albeit with restrictions, is an option. If so, the nature of the restrictions the DMV is likely to impose, and their impact on the driver's mobility and quality of life should be discussed. If continued driving depends upon remediation of a functional deficit, the nature and amount of time required to complete the remediation, its eligibility for coverage under Medicare or other insurance, and its prospects of restoring full or partial driving privileges should be addressed empathetically but realistically.
Driver counseling may be provided on an in-house or referral basis. The best course will vary from jurisdiction to jurisdiction, depending upon resources available in the agency and in the community. Peer counseling provided by others who have confronted restriction or cessation of their driving privileges can be extremely effective in helping individuals cope with emotional distress and life changes in this difficult situation. Further, while agency staff in a jurisdiction may need to coordinate this activity, peer counseling can often be performed by volunteers. This is only one component of driver counseling, however, and agency staff must keep in mind that peer counseling alone is not likely to meet all of the driver's needs.
Community-based and social service programs may also aid in a number of areas that are critical for the person who ceases driving; in addition to trip planning, these include managing the cost burden of maintaining and insuring an automobile that may no longer be needed--or deciding how these resources can be better used to meet transportation needs. Perhaps most important is to provide guidance and support for older persons in the practical aspects of utilizing alternative transportation services. Not only should the individual's present physical condition be taken into consideration in this regard, but future needs and the transportation options that can accommodate them must be addressed to assure an uninterrupted continuum of care and the best quality of life possible given further functional decline.
A geographically diverse sampling of programs for counseling older and functionally impaired persons, that span the full range of issues associated with driving cessation, follows:
Regardless of who provides counseling services, drivers--especially those with gross functional impairments without clear potential for remediation--must be "connected" to alternative transportation options in the community. Alternative transportation provides the "safety net" that allows individuals who cannot or choose not to continue driving to maintain the dignity and quality of life afforded by independent mobility.
Options at the community level will likely include some public providers, but principally private providers, of transportation services. Surveys of senior citizens consistently show very small rates of use of public transportation services--5 percent or less. This underscores the fact that older persons who no longer drive are consumers of transportation services who, quite understandably, make choices based on available information about the option that best meets their needs and preferences while accommodating their budgets, schedules, and functional limitations. In the vast majority of cases--95 percent and up--this choice is not a publicly-funded option, whether fixed-route or demand-responsive (e.g., paratransit).
Connecting persons in need of alternative transportation to appropriate providers thus begins with accurate and up-to-date information describing public and private options, the names and numbers of contact persons, hours of service, fees, and restrictions, if any, on the availability and nature of service. For example, door-to-door services must be distinguished from curb-to-curb services. The need to acquire and regularly update such information on a city, county, and regional basis cannot be emphasized too strongly. But in many jurisdictions, this responsibility may well be viewed as outside the scope of a screening and evaluation program. The need for a simple sequence of actions by the DMV is thus identified, extending through counseling of persons who can no longer drive--as discussed above--to a "hand off" to a point of contact who can provide all information necessary to support an informed choice about which alternative(s) in the person's home community will work best for him/her.
The recommended point of contact in this regard in the U.S. is the Area Agency on Aging closest to the driver's home. To enter the network encompassed by the National Association of Area Agencies on Aging, an unbiased source of information for seniors and their families, the Eldercare Locator service accessible toll-free at 800-677-1116 is most helpful. This is a public service of the Administration on Aging of the U.S. Department of Health and Human Services. Each office within the nationwide Area Agencies network is staffed by trained professionals dedicated to helping aging persons find local support services, including transport-ation options, which will enable them to remain independent.7
Restrictions may be imposed by the licensing authority, or may be self-imposed; in both cases the intent is to preserve at least limited privileges and independent mobility for individuals who experience diminished capabilities in one or more of the functions needed to drive safely. Remediation of functional deficits to expand an individual's driving privileges, or to permit restricted driving where privileges would otherwise be completely disallowed, is central to the goal of the Model Program to help people keep driving safely longer.
Self-Restriction. In driving habits surveys, older drivers commonly report driving less often and driving fewer miles during nighttime, poor weather and poor visibility conditions, and peak traffic conditions than younger drivers. They also avoid specific roads, intersections, and other locations that they regard as high-risk. In other words, older drivers who are aware of functional disabilities frequently limit their driving exposure to situations they perceive as least demanding. This may vary greatly, however, depending upon the nature of the functional decline. Certain losses of vision or hearing, as well as physical impairments, are relatively easier to identify and to compensate for or (potentially) to correct. At the same time, the prevalence of undetected eye disease increases with age, and drivers with diminished cognitive abilities may completely lack awareness of their functional loss. In particular, drivers with dementia overestimate their capabilities and may not restrict their driving to times and situations that reduce risk. In addition, drivers who have no access to alternative transportation and who live alone may be more likely to drive even when they realize they are at higher risk; reports from older driver focus groups consistently indicate that when there is no choice but to drive to get to a doctor appointment, the grocery store or pharmacy, they will do so.
For the reasons above, self-regulation alone is not sufficient to mitigate the risk to themselves and to others posed by functionally impaired drivers. Self-regulation complements, but does not replace, a formal screening and evaluation program. At the same time, the Model Program goal to foster self-evaluation, and evaluation by friends and family members, will further whatever safety gains are to be realized through self-restriction. The education and counseling resources provided within the Model Program will help older persons, their friends and families understand which capabilities are important to drive safely, how to test them, what their score means, whether and how they may be able to compensate for a functional loss, and where to go if they wish to pursue remediation for their loss.
Education and counseling provided within the Model Program also should help older persons who remain functionally intact to understand that they may unnecessarily limit or prematurely stop driving. While some older persons may choose to cease driving, for personal reasons, others may gain confidence from the knowledge that their visual, mental, and physical abilities are within the normal range, and safely continue to independently meet their own mobility needs.
Restriction by the Motor Vehicle Agency. While practices vary from one jurisdiction to another, it is a universal practice to try to accommodate drivers with diminished functional abilities by applying license restrictions that limit exposure and/or mandate the use of adaptive equipment to preserve driving privileges. The determination of which restrictions are appropriate to a particular impairing condition, as well as the resolution of disputes when a restriction is contested by a driver, including all clinical examinations and/or road tests that may be performed, should be carried out under the auspices of a Medical Advisory Board (MAB) or an equivalent office within the agency.
In the Model Program, it is expected that the MAB will establish restriction codes (or confirm the appropriateness of existing codes) that correspond to conditions which are self-reported at the time of first licensing or license renewal. Many common conditions such as the wearing of corrective lenses to meet vision standards will be accommodated in this manner. Guidelines released by NHTSA and the AMA regarding the consequences for safe driving of a wide range of diseases and medical conditions will support the process of establishing appropriate restrictions and restriction codes. A formal review process whereby the MAB will determine any/all restrictions that should be recommended to licensing officials should be developed if it does not already exist within a jurisdiction.
Examples of adaptive equipment requirements or restrictions that may be recommended for specified physical impairments are provided in table 5, as follows.
|Physical Ability||Adaptive Equipment/Restrictions|
Includes all disorders that limit the driver’s ability to coordinate motion of bodily members. All body members are present, but cannot be adequately controlled.
|Range of Motion
Disorders that limit the ability to reach and operate various components of the automobile
|Strength of Motion
Disorders that limit the strength and endurance of the driver.
In cases of visual loss, examples of restrictions that may be recommended include, but are not limited to: corrective lenses only; daylight driving only; and outside rearview mirror(s) required. Examples of restrictions that may be recommended for loss of mental function include, but are not limited to: area restriction ( __ mile radius of driver’s home); road restriction (no driving permitted on ___ street/avenue/route − must be specific); road class restriction (e.g., no freeway driving); speed limit restriction (no driving on roads with posted speed limit of __ mph or higher); driving permitted only within ____ city/village limits; driving not permitted within ___ city/village limits; and driving permitted only between the person’s residence and a named destination (e.g., place of work, doctor’s office, etc.).
Restrictions applied by the motor vehicle agency must be enforceable-a law enforcement officer must be able to determine if the restriction on the license is being observed. This rules out restrictions such as “must take medication,” or “must check blood sugar before driving.” If adaptive equipment restrictions are to be applied, the equipment should be in place at the time a driving examination or evaluation is performed; the restricted driving privileges in such cases are contingent upon successful completion of the driving evaluation.
Many visual, medical, and physical rehabilitation options are available that can add substantially to the safe driving years of normally-aging individuals. In many cases, rehabilitation with or without adaptive equipment can restore function sufficient to permit at least restricted driving for persons with disease or trauma, as well.
The specific service providers a functionally-impaired person can and should access depend on the type and severity of the impairment, and also upon the medical status of the particular diminished capability as categorized by the insurance industry. Vision-related problems, for example, may be remediated using either non-surgical or surgical methods, and require contact with either an optometrist or an ophthalmologist. And, vision care is generally considered to be a “medically-necessary” activity by the health insurance industry, and as such, is generally a covered expense. This is also the case for remediation of other medical conditions (e.g., stroke, traumatic brain injury, and cardiovascular problems), but not currently for activities that are specifically designated as remediation to permit continued driving. This is because driving is not presently categorized as a “medically necessary” activity by the insurance industry. Therefore, driving evaluations and adaptive equipment are not usually Medicare reimbursable; but, portions of evaluations (neurological, for example) may be covered if the client was referred to a physician for symptoms of cognitive decline that affect activities of daily living or instrumental activities of daily living. This distinction strongly impacts the affordability of, and access to, remedial services for older persons with driving impairments.
Considering the extent to which the prospects for remediation depend upon diagnosis and referral by a driver’s physician or other health care providers, it is reasonable to expect that the most up-to-date and definitive information on remediation options also will be provided to functionally-impaired drivers by these professionals. Knowing which questions to ask is always helpful, however, and will be facilitated if drivers and their families have access to general information concerning: the nature of interventions; who they serve and when they are needed; their availability; their expected benefits; and, their approximate cost. This information should be maintained and provided to participants in a jurisdiction’s screening and evaluation program.
Tables 6 and 7 provide an overview of the range of options to address visual, physical, and medical conditions, and to remediate deficits in knowledge or driving skills, respectively.
|Remediation||Who is served or when is service needed?||Availability||Benefits||Approximate Costs|
|Non-Surgical Visual Correction||
||Optometrists & ophthalmologists nationwide||Correction of visual acuity and prevention of blindness (between 40 - 50% of all blindness can either be prevented or effectively treated)||
|Surgical Visual Correction||Drivers with cataracts, diabetic retinopathy, macular degeneration||Ophthalmologists nationwide||Restoration of vision to 20/40 or better, for cataract removal and interocular lens implant||For cataracts, $2,000 to $3,000, depending on surgery location|
|Physical Therapy||Drivers with restricted range of motion , general muscle, weakness, poor endurance, fatigue, lack of body balance, poor muscle control||Physical therapists and physiatrists nationwide||Improvements in strength, coordination, endurance, and range of motion in the affected body parts||$75 to $150 per hour|
|Exercise Program||All older persons||Fitness centers, YMCA/YWCA, other community-based programs||Improvements or maintenance of strength, flexibility, range of motion, endurance, and postural stability (falls reduction), increased feeling of well-being||Cost ranges based on type of facility (e.g., free for exercises done in the home or walking, to $ 30+per month at an exercise center)|
|Occupational Therapy & Prescriptions for Adaptive Driving Equipment||
||Occupational therapists (or Certified Driving Rehabilitation Specialists) nationwide||
|Risk Reduction from Side Effects of Medications||All older persons||Physicians, nurse practitioners, and pharmacists||Review of medications that singly or in combination result in impairment to driving skills and change in driving habits as needed||Undetermined: Could be part of annual physical exam ranging from $50 - $200+|
|Remediation||Who is served or when is service needed?||Availability||Benefits||Costs|
|Refresher Driver Education Classes||Mature drivers, age 55+||Nationwide through AARP (“55-Alive”); AAA (“Safe Driving for Mature Operators”); National Safety Council (“Coaching the Mature Driver”)||
||Ranges from $5 to $40 depending on program and part of the country|
|On-Road (Behind-the- Wheel) Training||
||Driving schools staffed with Certified Driver Rehabilitation Specialists, and affiliated with the Association of Driver Educators for the Disabled, the Department of Veteran’s Affairs, or State Rehabilitation Services Agencies||
|Trip Planning/Navigational Assistance||All older persons||
|On-Board Navigational and Emergency Assistance||Older persons who restrict their driving because of concerns about their personal safety in the case of a breakdown||
2From: Section 235 "Evaluating Medical Conditions or Disabilities," Driver Licensing Manual, State of
3 Janke, M and Hersch, S.W. (1997). Assessing the Older Driver: Pilot Studies. California DMV Publication No. RSS-97-172. Sacramento, California.
4 See The Physician, the Older Patient, and Driving Safety: A Physician's Guide, Texas Medical Association (with Texas Department of Transportation and Texas Department of Public Safety), 1991.
5 Ref. Florida Department of Highway Safety, Department of Motor Vehicles, Florida Aging Driver Council Study.
6 pers. comm., Mr. Jack Joyce, Office of Driver Safety Research, Maryland MVA, January 23, 2002.
7 pers. comm., Ms. Phyllis Madachy, Administrator, Howard County, MD, Area Agency on Aging and President, Maryland Association of Area Agencies on Aging, July 8, 2002.
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