2.1 License Screening and Testing
State licensing agencies vary considerably in their procedures for screening and evaluating driver abilities and skills (Potts et al., 2004, Strategy C2; American Geriatrics Society, 2016; Lococo, Stutts, et al., 2017; NHTSA, 2017). Many do not include all the recommendations on medical conditions from the American Medical Association’s 1st and 2nd editions of the Physician’s Guide to Assessing and Counseling Older Drivers (Carr et al., 2010; Wang et al., 2003). In 2016 the American Geriatric Society assumed the role of updating the Physician’s Guide, and changed the name for the 3rd edition to the Clinician’s Guide to Assessing and Counseling Older Drivers (AGS, 2016), to be inclusive of the varying health care practitioners involved with health care issues associated with older people. The 4th edition was released in 2019 and is available at https://geriatricscareonline.org/ProductAbstract/clinicians-guide-to-assessing-and-counseling-older-drivers-4th-edition/B047.
NHTSA conducted extensive evaluations of the state of driver medical review practices and licensing outcomes (Lococo et al., 2016; Lococo, Sifrit, et al., 2017; Lococo, Stutts, et al., 2017). States that have medical review practices in the form of medical professionals on licensing review panels or have Medical Advisory Boards benefit from their inputs in addition to the referrals by the driver’s physician (NHTSA, 2017).
NHTSA and AAMVA have developed Model Driver Screening and Evaluation Program Guidelines for Motor Vehicle Administrators (Staplin & Lococo, 2003). This was the final stage in a research program that investigated the relationships between functional impairment and driving skills; methods to screen for functional impairment; and the cost, time, legal, ethical, and policy implications of the guidelines (Staplin, Lococo, Gish, & Decina, 2003a).
The Model Driver Guidelines’ goal is to keep drivers on the road as long as they are safe, through early identification and assessment together with counseling, remediation, and license restriction when needed (Staplin & Lococo, 2003). The guidelines, tested in Maryland, outlined a complete process of driver referral, screening, assessment, counseling, and licensing action (Staplin & Lococo, 2003; Staplin, Lococo, Gish, & Decina, 2003b). They include 9 simple visual inspection tests licensing agency personnel can administer to screen for functional ability (Staplin & Lococo, 2003). The results of a survey of State motor vehicle departments outlines some of the legal, policy, cost, and other criteria required before the implementation of guidelines in some States (Staplin & Lococo, 2003, Appendix C).
In 2008 the screening and testing of older drivers was a major discussion at the North American License Policies Workshop sponsored by the AAA Foundation for Traffic Safety. One of the general themes of this workshop was “while certain declines are generally associated with aging, consensus is lacking on whether or at what age people should be required to be screened or tested. Regardless, it is generally accepted that final licensing decisions should be based on functional performance, not age, as there is wide variation in how people age” (Molnar & Eby, 2008, p.3). In 2009 NHTSA and AAMVA also developed the Driver Fitness Medical Guidelines; see aamva.org/uploadedFiles/MainSite/Content/SolutionsBestPractices/BestPracticesModelLegislation(1)/DriverFitnessMedicalGuidelines_092009.pdf.
Use: All States screen and test referred drivers, though their procedures and criteria vary considerably (Potts et al., 2004, Strategy C2). See also the AAAFTS (2016a) “Driver Licensing Policies and Practices” database showing each State's driver licensing policies and practices regarding older and medically at-risk drivers. As of 2016 Utah was evaluating its restricted licensing practices; results are yet unavailable (AAAFTS, 2016b; See the Older Drivers chapter, section 2.3 License Restrictions for more information).
Effectiveness: There is strong evidence that State screening and assessment programs identify some drivers who should not be driving at all or whose driving should be limited. The Maryland pilot test of the model guidelines concluded, “the analysis results ... have provided perhaps the best evidence to date that functional capacity screening, conducted quickly and efficiently, in diverse settings, can yield scientifically valid predictions about the risk of driving impairment experienced by older individuals” (Staplin et al., 2003b). In a study evaluating the use of a screening tool on Alabama drivers 18 to 87, older drivers (65 and older) performed significantly worse than drivers less than 65 years old, and older drivers with a crash history, performed worse than older drivers without crashes (Edwards et al., 2008).
A NHTSA-sponsored project conducted by Eby et al. (2008) sought to improve existing self-screening tools for older drivers by focusing on symptoms associated with medical conditions. The researchers created a self-screening survey to provide feedback to older drivers to increase general awareness of issues associated with driving and the aging process, and to provide recommendations for behavioral changes and vehicle modifications they could make to maintain safe driving. Evaluation results found the self-screening instrument had a positive value, but primarily as a “screening tool to determine gross impairment rather than fitness to drive” (Eby et al., 2008, p. 19).
Costs: The model guideline functional screening tests can be administered for less than $5 per driver, including administrative and support service costs (Staplin et al., 2003a).
Time to implement: States should be able to modify their driver license screening and assessment procedures in 4 to 6 months.