2.2 Referring Older Drivers to Licensing Agencies
Older drivers come to the attention of licensing agencies at regular license renewals, as discussed in Section 2.1, 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%) (Stutts, 2005). The remaining 15% came from crash and violation record checks, courts, self-reports, and other sources.
Referrals by Law Enforcement: LEOs have the opportunity to 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. NHTSA has developed and field-tested a set of cues that officers can use to identify potentially impaired drivers (NHTSA, 1998; see also Potts et al., 2004, Strategy C3, and Stutts, 2005, Chapter 7).
States can increase driver referrals by establishing and publicizing procedures for referring drivers, establishing referral policies and providing appropriate training and information to LEOs, and informing physicians and health professionals of their responsibilities. The presence of MABs and/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 a person’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 useful for State licensing agencies 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 components of this product have been incorporated into the Clinician’s Guide to Counseling Older Drivers (American Geriatrics Society & Pomidor, 2016). NHTSA plans to revise a simple pull out reference specifically for DMV personnel, and otherwise refer them to specifics in the Clinician’s Guide.
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, varying 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, if appropriate. As of 2016, 6 States require physicians to report patients who have specific medical conditions, such as epilepsy or dementia (AAAFTS, 2016a). Other States require physicians to report “unsafe” drivers, with varying guidelines for defining “unsafe.” In all 50 States and the District of Columbia, physicians are permitted to report medically-at risk drivers. Physicians must balance their legal and ethical responsibilities to protect their patient’s health and confidentiality with their duty to protect the general 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 (Wang et al., 2003, Chapter 7).
Licensing decisions based on drivers’ medical fitness to drive can be established through review by a medical advisory board (MAB) and/or with one or more medical professionals performing reviews of the referrals (NHTSA, 2017). Having medical professionals or a 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 six 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 to result in changes to driver license statuses, and the presence of a MAB may serve to promote physician referrals (NHTSA, 2017). See Lococo, Stutts et al., 2017 for a summary of the medical review structures and referral processes in all States.
The Clinician’s Guide to Assessing and Counseling Older Drivers (AGS & Pomidor, 2016) provides detailed information for physicians and medical professionals. The guide was prepared by AGS, and is an update to the Physician’s Guide to Assessing and Counseling Older Drivers (Wang et al., 2003; Carr et al., 2010). Chapter 8 has an extensive summary of State licensing and reporting laws. Chapter 9 contains a list of medical conditions and medications that may impair driving and consensus recommendations on what action to take for each. Other chapters include information on treatment and rehabilitation options that may allow patients to continue to drive and on how to counsel patients about retiring from driving. See also Lococo (2003, Appendix C) for State-level information and Potts et al. (2004, Strategy C3) for overall discussion of different strategies. See Lococo et al., 2016 for a classification of medical review practices and Lococo, Stutts et al., 2017 for detailed information on State medical review practices and procedures.
Chapter 3 of the Clinician’s Guide to Assessing and Counseling Older Drivers (AGS & Pomidor, 2016) discusses the assessment of functional abilities and provides physicians with the instructions and basic forms needed for them to conduct 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 five-module curriculum including slides, video case segments, and handouts was developed by the AMA and revised in 2016 by the American Geriatrics Society (3rd edition, AGS & Pomidor, 2016). The guide’s goal is to heighten knowledge and skills necessary for a clinician to evaluate driver fitness in a typical care encounter, and to develop a plan for further evaluation by other specialists or licensing authorities, if needed. An evaluation of this curriculum, performed when it was launched by AMA, found continuing education training can enhance the confidence and clinical practices of health professionals as related to driver fitness evaluations and mobility planning (Meuser et al., 2010).
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 in light of 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 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). For example, fitnesstodrive.phhp.ufl.edu/us/ is a questionnaire that caregivers or friends and family can use to evaluate an older drivers’ fitness to continue driving. See www.michigan.gov/sos/0,4670,7-127-1627_8665_9066-23762--,00.html for an example of information on driver referrals that can be submitted by families and friends in Michigan.
Use: A survey of all State licensing agencies found less 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 (Stutts, 2005, Appendix E). The number of referrals varies substantially across the States, from a few hundred to 50,000.
Effectiveness: Establishing and publicizing effective referral procedures will increase referrals. Potts et al., 2004, Strategy C3 provide examples. and web links. As one example, Pennsylvania increased physician referrals substantially by sending letters to all physicians (Potts et al., 2004, Strategy C3).
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 removing barriers to physician referrals by increasing awareness of the law and requirements and providing training to identify at-risk drivers may help improve safety benefits of mandatory laws.
Mandatory physician referrals may improve other measures of older driver safety. A study of Missouri’s voluntary reporting law (enacted in 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. 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 LEOs, driver license office staff, physicians, family members and others) retained their drivers’ licenses after the process (Meuser et al., 2009). As part of this law, reported people are required to undergo a physician evaluation. 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 reporting forms submitted by family members each indicating an older individual who is potentially unfit to drive. Of the 689 older adults, 448 were reported to have a cognitive issue (e.g., confusion, memory loss, and becoming lost while driving) and 365 cases included diagnostic labels 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 for cognitive impairment/dementia 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.
The mandatory reporting law in Oregon was enacted in 2002 and requires primary physicians and other health care providers functioning as a primary provider, to report cognitively impaired drivers to the Department of Motor Vehicles. Reports by primary care providers result in automatic suspensions of driving privileges, but the suspended driver has the opportunity to request retesting and/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, with the majority of the reported drivers being 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 driving privileges (Snyder & Ganzini, 2009).
Costs: Costs for establishing and publicizing effective referral procedures vary depending on the procedures adopted, but should not be extensive. 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.