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Effectiveness: Proven for identifying at-risk drivers 4 Star Proven for identifying at-risk drivers Cost: $$
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Older drivers come to the attention of licensing agencies at regular license renewals, as discussed in Countermeasure “License Screening and Testing,” or when they are referred to the licensing agency for reevaluation of their driving skills.

Licensing agencies in all States accept reevaluation referrals for drivers of any age. A survey of all State licensing agencies found three sources accounted for 85% of referrals: law enforcement (37%), physicians and other medical professionals (35%), and family and friends (13%) (TRB, 2005). The remaining 15% came from crash and violation record checks, courts, self-reports, and other sources. Furthermore, case studies of driver referrals from 6 States (Maine, Texas, Wisconsin, Ohio, Washington, and Oregon) were performed in 2012 (Lococo, Sifrit, et al., 2017). A random sample of 500 drivers referred for initial medical review were selected from each State. Many of these were referrals by the driver (self-referral), physicians, licensing agency staff, or law enforcement officers. The States varied in terms of the licensing outcomes. Overall, 99% of cases in Oregon and Texas resulted in changes in licensing status. While overall changes in licensing status were lower in the 4 remaining States (ranging from 76 to 88%), most physician referrals (ranging from 90 to 97%) resulted in licensing status changes. The authors concluded that the identification of the source of referrals has implications for educational countermeasures to increase the number and quality of referrals.

States can increase driver referrals by establishing and publicizing procedures for referring drivers, establishing referral policies and providing appropriate training and information to law enforcement officers, and informing physicians and health professionals of their reporting responsibilities. The presence of medical advisory boards (MABs) or medical professionals providing case review of medically at-risk driver referrals may help improve licensing decisions at little extra cost to the program (Lococo et al., 2016; Lococo, Sifrit, et al., 2017; NHTSA, 2017). In 2009 NHTSA, in collaboration with the American Association of Motor Vehicle Administrators, produced Driver Fitness Medical Guidelines to provide guidance to licensing agencies for use in making decisions about an individual’s fitness for driving (NHTSA, 2009). Guidelines are provided for a variety of physical limitations and impairments as well as medical conditions. In addition, this guide provides information that State licensing agencies can use to educate medical professionals about the effects of functional impairments and medical conditions on safe driving in order to encourage them to refer drivers for additional evaluations related to driving. Many of the components of this guide have been incorporated into the Clinician’s Guide to Counseling Older Drivers (Pomidor, 2019).

NHTSA published a literature review on the effects of medication use and medical conditions on older drivers’ functional driving performance and safety (Lococo et al., 2018). A range of medical conditions were reviewed considering their potential effects on crash risk, and the researchers prioritized eight conditions as particularly concerning for older driver safety: diabetes, dementia, obstructive sleep apnea, glaucoma, hepatic encephalopathy, macular degeneration, stroke, and Parkinson’s disease.


Referrals by Law Enforcement

Law enforcement officers can observe drivers directly at traffic stops or crashes. With appropriate training, they can identify many drivers who should be referred to the licensing agency for assessment. The International Association of Directors of Law Enforcement Standards and Training (IADLEST) has developed a training course for law enforcement instructors covering a range of topics related to older people and driving. This course aims to train instructors on how to provide law enforcement officers with the information they need to effectively interact with and evaluate older drivers. Additionally, the University of California at San Diego’s Training, Research and Education for Driving Safety (TREDS) has created law enforcement training and tools aimed at helping law enforcement officers identify and refer medically impaired drivers. NHTSA also provides a series of video and web-based resources to help law enforcement officers determine signs of older driver driving impairments. See Key Resources for more information.

Referrals by Health Care Providers

Health care providers (HCPs), including physicians, nurse practitioners, and physician assistants, are in an excellent position to assess if changes in their patients’ physical or cognitive abilities may increase their crash risk. In addition, various clinicians, such as pharmacists, nurses, occupational or physical therapists, social workers, or case managers, can, in the course of their work, assess for physical, cognitive, or functional limitations warranting further evaluation, counseling, or referral to the licensing agency. As of 2019 six States require physicians to report patients who have specific medical conditions, such as epilepsy or dementia (Graham et al., 2020). Other States require physicians to report “unsafe” drivers, although States vary in their definitions of “unsafe.” In all 50 States and the District of Columbia physicians are permitted to report medically at-risk drivers (Dunlap and Associates, Inc., 2019). Physicians should balance their legal and ethical responsibilities to protect their patient’s health and confidentiality with their duty to protect the public from unsafe drivers. Physicians have been held liable for damages from crashes involving patients because they failed to report the patient to the licensing agency (Pomidor, 2019).

Licensing decisions based on drivers’ medical fitness to drive can be established through review by an MAB or with one or more medical professionals performing reviews of the referrals (NHTSA, 2017). Having medical professionals or an MAB perform case reviews provides certain advantages, including legal immunity to physicians voluntarily referring at-risk drivers (Lococo et al., 2016; NHTSA, 2017). NHTSA conducted a study of MAB structures, referrals, and outcomes in 6 States, and found that physician referrals resulted in changes in license status in 90% of cases studied (Lococo, Sifrit, et al., 2017). In fact, physician referrals were most likely type of medical referral to result in changes to driver license statuses, and the presence of an MAB may serve to promote physician referrals (NHTSA, 2017). See Countermeasure “Medical Review Protocols” for more information.

The Clinician’s Guide to Assessing and Counseling Older Drivers (Pomidor, 2019) provides detailed information for physicians and medical professionals. The guide was prepared by the American Geriatrics Society and includes information on performing a brief in-office Clinical Assessment of Driving Related Skills (CADReS). The CADReS screening tool assesses some aspects of the key functional areas of vision, cognition, and motor/sensory functions to help physicians identify specific areas of concern as they relate to driving. An evaluation of an earlier version of CADReS (McCarthy et al., 2009) suggests that while this tool was able to identify all the study participants who failed the behind-the-wheel test included as a part of the study, the tool may need to be revised to give physicians a more effective and efficient tool for in-office assessments.

To encourage use of the Clinician’s Guide to Assessing and Counseling Older Drivers, a multi-media curriculum was developed by the AMA with the goal of heightening knowledge and skills necessary for a clinician to evaluate driver fitness in a typical care encounter. The guide also provides information on developing a plan for further evaluation by other specialists or licensing authorities, if needed. An evaluation of this curriculum found continuing education training can enhance health professionals’ confidence and clinical practices related to driver fitness evaluations and mobility planning (Meuser et al., 2010). To further facilitate clinicians’ ability to assess driving fitness and challenges, Medscape creates and hosts CME/CE content for medical professionals in collaboration with NHTSA. See Key Resources for more information.

Referrals by Families and Friends

Many States have established procedures for family members and friends to report drivers of any age whose abilities may be impaired (Lococo, Stutts, et al., 2017). Some States only accept referrals submitted on specific forms while others accept referrals in the form of a letter. Many States offer online guidance for families and friends to determine how and when to report safety concerns. The AAAFTS publishes a database of licensing practices and policies for medically at-risk drivers that summarizes State-level policies (Dunlap and Associates, Inc., 2019). Tools exist to help family members identify at-risk drivers. The Fitness-to-Drive Screening Measure (FTDS) is a free online 54-item tool, taking approximately 20 minutes to complete, that was previously created to be completed by a driver or proxy (someone who has been a passenger with the driver). A review of use data indicated that the length of the FTDS may inhibit completion and ultimately the utility of the screening tool (Classen et al., 2018). Therefore, Classen et al. created and validated a short form version (FTDS-SF) that includes 21 items and requires less time to complete. The FTDS-SF successfully predicted on-road outcomes with acceptable accuracy. The authors note that the FTDS-SF misclassified 59 (out of 200) participants as at risk and therefore recommend use of the tool to initiate conversations with potentially at-risk drivers. 


A survey of all State licensing agencies found fewer than 100,000 drivers 65 and older are referred each year from all sources, or less than 0.4% of the 28.6 million older licensed drivers (TRB, 2005). The number of referrals varies substantially across the States, from a few hundred to 50,000. Law enforcement officers provide more than one-third of all referrals to licensing agencies for driver screening and assessment (TRB, 2005).


Establishing and publicizing effective referral procedures will increase referrals. Potts et al. (2004) provide examples and web links. As one example, Pennsylvania increased physician referrals substantially by sending letters to all physicians (Potts et al., 2004).

A recent analysis of older driver hospitalizations in 37 States from 2004 to 2009 showed no significant association between mandatory physician reporting laws and older drivers’ crash-related in-patient stays. This was true even among the 27 States that provide legal immunity to referring physicians (Agimi et al., 2018). The authors note that a lack of association between mandatory reporting laws and crash-related hospitalizations may be a result of insufficient awareness of the law and requirements, attempts to avoid damaging rapport, and insufficient training to identify at-risk drivers.

Licensing referrals may improve other measures of older driver safety. A study of Missouri’s voluntary reporting law (enacted January 1, 1999) and the resulting licensing outcomes found crash involvement of reported drivers decreased after implementation of the law and, to a lesser degree, mortality declined as well. The sharp decline in crashes among reported drivers was presumably a result of driving reduction or cessation following the reporting or licensing review process. Though the Missouri law is not specific as to age, the mean age of reported drivers was 80 and only 3.5% of the 4,100 people (reported by a combination of law enforcement officers, driver license office staff, physicians, family members, and others) retained their drivers’ licenses after the process. This low percentage may be, in part, a result of drivers prematurely giving up their license due to an intimidating or onerous process. Half of reported drivers failed to complete the first step of the process (physician review within 30 days of notification), which resulted in license revocation (Meuser et al., 2009).

A mandatory reporting law in Oregon was enacted in 2002 and requires primary care physicians and other health care providers functioning as a primary provider, to report drivers with cognitive impairments to the Department of Motor Vehicles. Reports by primary care providers result in automatic license suspensions, but the suspended driver can request retesting or a hearing to appeal the suspension. A study of this Oregon law found over 1,600 drivers reported as being cognitively impaired from 2003 to 2006; most of the reported drivers were older than 80. The most common cognitive impairments were in judgment and problem solving, but impairments in memory and reaction time were also reported about half the time. Of the 1,664 people reported who lost their licenses less than 20% requested retesting or a hearing to contest their license suspensions, and only about 10% of the total number reported and suspended (173) regained their licenses (Snyder & Ganzini, 2009).

To better understand the observations and concerns of family members and to investigate why older drivers were referred to the licensing agency, Meuser et al. (2015) reviewed Missouri reporting forms submitted by family members indicating an older person was potentially unfit to drive. Of the 689 older adults, 448 were reported for cognitive issues (e.g., confusion, memory loss, or becoming lost while driving) and 365 included a diagnostic label such as Alzheimer’s disease, cognitive impairment/dementia, or brain injury. When the observations of family members and physicians were compared, agreement was high for Alzheimer’s disease (100%) and for acute brain injury (97%). However, agreement was lower for cognitive impairment/dementia (75%). This discrepancy suggests that family members and physicians may understand cognitive impairment differently. Overall, the researchers concluded that physicians and driver licensing authorities would do well to consider family member observations when assessing fitness-to-drive in older people.


Costs for establishing and publicizing effective referral procedures vary depending on the procedures adopted but should not be expensive. Educational and training publications are available for use with law enforcement and medical professionals. Funds will be required to distribute this material and for general communications and outreach. If referrals increase substantially, then licensing agency administrative costs will increase.

Time to implement:

States seeking to improve referrals will require at least 6 months to develop, implement, and publicize new policies and procedures.