Approach to the evaluation of older drivers

INTRODUCTION — Older drivers are an increasing and growing proportion of drivers. According to the US Census Bureau, the population aged 70 and over is projected to increase by 53 million in 2030 [1]. In 2018, there were 29 million licensed drivers age 70 and over in the United States [2]. Almost 8000 older adults (aged 65 and over) were killed in motor vehicle crashes and over 250,000 treated in emergency departments for crashes. This means that each day in 2018, approximately 20 older adults were killed and another 700 were injured in motor vehicle crashes [3].

It is difficult to determine whether an older person can drive safely. Chronological age should not be the sole indicator of driving ability. There is not one effective, easily administered test or series of tests to evaluate driving competence [4-6]. The task of evaluating the older adult's functional capacity to drive often falls to their primary care provider. However, there are several interdisciplinary team members that may assist the primary care clinician in determining evidenced-based driving recommendations.

This topic will discuss the approach to evaluating and advising older drivers. Other issues related to driving are reviewed separately:

●(See "Driving restrictions for patients with seizures and epilepsy".)

●(See "Drowsy driving: Risks, evaluation, and management".)

●(See "Driving restrictions in patients with an implantable cardioverter-defibrillator".)

SCOPE OF THE PROBLEM — Older adults have higher motor vehicle fatality rates compared with other age groups, and those over 85 years of age have the highest rates [7]. Crash rates and fatal crash rates per miles traveled start increasing over age 70 years [2]. However, the increased crash risk per miles driven in older adults compared with other age groups may be inflated since they tend to do more driving in urban areas, which is riskier than highway driving [8]. Compared with younger drivers, older drivers are more likely to be involved in certain types of collisions, such as crashes involving angles, overtaking, or merging, and especially at intersections [9]. Failure to yield the right of way is the most common error by older drivers involved in crashes [3]. Older drivers are more likely to be found at fault in fatal intersection crashes, with the most common errors being inadequate surveillance, misjudgment of vehicle distance and speed, illegal maneuvers, medical events, and daydreaming [10].

Driving is an important issue for older adults. The majority of Americans rely upon private automobiles for their transportation, and most older adults regard driving as critical to their independence and self-esteem. Older adults who are forced to stop driving rely more upon their families, reduce their social activities, often become depressed, and may be at increased risk for long-term care placement [11].

Many older adults maintain robust functional abilities in late life. However, some may experience a decline in visual, cognitive, and/or motor skills, especially in the presence of disease. Most concerning for safe driving would be a cognitive decline in speed of processing and/or executive function [12]. Driving performance is usually impaired only after a considerable loss of function since most driving patterns are learned and become second nature. In addition, older drivers often regulate their habits; seniors drive fewer miles, shorter distances, less at night, and seldom in rush hour [13]. There is consensus among traffic safety experts that older drivers should be kept on the road as long as they can drive safely.

EVALUATING OLDER DRIVERS — Assessment of driving ability should be based on performance of objective measures rather than age alone. Several areas of the history, physical examination, and functional assessment are particularly relevant. There are also resources available in the community to supplement the primary care clinician's driving evaluation.

Factors affecting driving — In addition to normal age-related changes (eg, vision, psychomotor ability), older people are more likely to have medical conditions and take medications that can affect driving performance. Several studies have attempted to identify the specific medical conditions and functional deficits that are associated with motor vehicle crashes or adverse driving events such as failing a performance-based road test in the older population. The following factors have been identified:

●A history of falls in the past one to two years [14,15]

●The presence of visual [16-19] and cognitive deficits [20-22]

●A prior history of motor vehicle crashes [19,23]

●Current use of medications such as tricyclic antidepressants, opioids, and benzodiazepines [15,24-26]

●Age-associated medical conditions such as dementia [27], glaucoma [28], and Parkinson disease [29]

Pertinent medical history — Although medical conditions alone have not been found to have a strong effect upon driving performance, a past or current history of ischemic heart disease, dementia, cerebrovascular disease, movement disorders, diabetes mellitus, epilepsy, sleep disorders, and arthritis should be evaluated during the primary care examination [30].

Some acute conditions that impair consciousness, especially transient ischemic attacks, syncope, and seizures, make driving potentially dangerous [31]. For patients with a recent history of these conditions, the clinician should recommend cessation of driving for a period of time until recovery is assured and the baseline level of functioning has returned (table 1).

Medications, alcohol, and other substances — A careful history of prescription, over-the-counter, and herbal medications is important in all older adults. Medications with effects on the central nervous system, such as benzodiazepines, antihistamines, anticholinergics, and some tricyclic antidepressants, can be harmful alone and especially in combination. More than one-third of all benzodiazepine prescriptions are written for people ages 60 and older. The traffic crash risk increases by nearly 50 percent in the first week after starting benzodiazepine therapy [24]. A population study of older drivers involved in traffic crashes resulting in hospitalization found a fivefold increased risk for serious crash associated with the use of benzodiazepines (odds ratio [OR] 5.3); increased risk was also associated with use of antidepressants (OR 1.8) as well as opioids (OR 1.5) [32]. Almost one-fourth of older adults who use opioids and drive have self-reported a motor vehicle crash in the past year [33,34].

One common approach to medication assessment in the primary care setting is to ask the older patient to bring all their medications, including prescription, over-the-counter, and herbal, to the visit. These can be reviewed with a nurse or medical assistant during the medicine reconciliation process prior or during the clinician visit to determine the older adult's understanding of the indications for use and side effects. Given the large number of medications consumed daily in many older adult drivers [35], with the potential for drug interactions and driving-related side effects [36,37], it is wise to deprescribe where possible and use the lowest effective dose of potentially impairing medication. In those adults using multiple medications, it is often helpful to have a pharmacist review medications yearly for cost issues and drug interactions.

The use of alcohol and other substances is hazardous for drivers of any age. However, the physiologic changes of aging such as a decrease in lean body mass and increase in adipose tissue, as well as the potential for multiple drug interactions, make this a significant issue for older drivers. Although the prevalence of drinking and driving is lower in older adults, 15 percent of fatal crashes in those 65 years are reportedly alcohol related [38].

With the legalization of recreational and medicinal cannabis in many states, the prevalence of cannabis use is increasing, including among older adults [39,40]. Cannabis has been shown to impair driving performance and increase crash risk [41,42], and this risk could potentially be exacerbated in older adults given the higher prevalence of underlying health conditions and age-related neuro-sensory and physical declines. Clinicians should query patients on the use of medicinal and recreational cannabis to guide counseling on drug interactions and driving safety.

Social history — Areas of the history that relate to the older person's quality of life in the community, such as key driving destinations, medical trips, social support, activities of daily living, alcohol use, and transportation, are important to assess.

For all patients ages 65 and older, specific questions about driving should be included in the primary care history.

Initial screening questions:

●How often and under what circumstances do they drive?

●Any difficulties with driving, traffic violations, crashes, or close calls within the past two years?

Suggested follow-up questions:

●How did the older patient get to the primary care visit?

●Any episodes of getting lost while driving? Any road rage or difficulty with distractions?

●Does the older person feel comfortable and want to continue driving? Do others feel comfortable when the older adult is driving?

●Are there other people (eg, spouses, friends) who depend on the person driving for them?

In addition, if there is concern about driving, the clinician should inquire as to:

●Who would be able to drive to appointments or for groceries if they became ill or were unable to drive?

●Is the patient able to use ride-sharing apps (eg, Uber, Lyft)?

The clinician may want to contact the family, with the older patient's consent, for their observations.

Also, as with all patients who ride in cars, it is appropriate to ask about seatbelts and encourage their use.

Physical examination — The areas of the physical examination most closely related to driving safety are mobility and functional status [14,15,19], visual attention [16-19], and cognitive status [20,21]. The recommended functional assessment of older drivers is summarized in the table (table 2) [43].

Motor and sensory function — Aging precipitates changes in muscle strength, brake reaction time, and mobility, particularly of the neck, shoulder, and wrist. Decreased muscle strength can significantly impact operational aspects of driving a motor vehicle, although this is less critical with modern day cars and the plethora of adaptive devices. Grip strength appears to decline after age 75, but exercise can help to avoid significant loss [44]. Restrictions in neck, shoulder, and wrist movement, often caused by rheumatologic conditions, can restrict the field of view in traffic situations as well as the ability to control the steering wheel. Sensory and/or motor neuropathy is not uncommon with older adults and has the potential to impair the use of the brake and accelerator.

Psychomotor ability is not evaluated with a driver's license renewal, except in states that require on-the-road testing (information can be found on the Insurance Institute of Highway Safety (IIHS) website). Drivers with diminished strength, brake reaction time, or mobility may not pass the road test. Older drivers with limited flexibility can have their cars equipped with adaptive equipment, such as special mirrors or power assist devices, to enhance their driving ability.

Mobility issues relevant to driving can be assessed in several ways during the primary care visit:

●Evaluate range of motion of the neck, shoulders, and wrists.

●Evaluate balance and gait with the Rapid Pace Walk test as follows: Measure out a 10 foot walk. Say, "I want you to walk just as you normally do. If you use a cane or walker, you may use it if you feel more comfortable. I want you to walk all the way past the end of the course at the other end, turn around, and walk back like this." (Demonstrate.) "Now, I want you to walk down and back at a comfortable pace" (usual-pace walk). "Now I am going to time you. Go as fast as you feel safe and comfortable" (rapid-pace walk). Start timing when subject picks up first foot. Stop timing when last foot crosses finish line. Those at increased risk of impaired driving abilities score >9 seconds on this test [22,45].

●Measuring grip strength with a dynamometer can be useful for older drivers who have had a stroke. The general rule is that 35 pounds of strength in the dominant hand is necessary for safe driving [31].

Vision — The majority of visual impairment and blindness in older people is caused by age-related macular degeneration, glaucoma, cataracts, and diabetic retinopathy [46]. Age-related changes in vision that can affect driving include decreases in central visual acuity, visual fields, decreases in contrast sensitivity, diminished ability to accommodate, and heightened sensitivity to glare [44]. Over age 50, the total horizontal peripheral visual field declines from 170 to 140 degrees [43]. Many older adults avoid driving at dusk and twilight because of these changes.

Visual acuity and peripheral vision are evaluated in most states as part of the driver's license renewal process. Retesting visual acuity between the renewal periods is required only if there has been a driving incident. The most common acceptable requirements are a visual acuity of 20/40 in the better eye and 120 degrees of horizontal peripheral vision.

In the primary care setting, the most effective measures for detecting significant age-related eye problems are the history, visual acuity testing, and visual field testing by confrontation. In addition to past and current medical history and medications, the specific visual history should include a family history of eye disease and the presence of current visual symptoms. Distance visual acuity can be evaluated with the Snellen chart. Near visual acuity can be measured with the Rosenbaum pocket vision screening card or by having the older patient read a newspaper or magazine held 14 inches (at arm's length) from the eyes; generally, newspaper type is equivalent to 20/40 on the Snellen near visual acuity chart. There are now apps available on smartphones that can readily assess near visual acuity. Fundoscopic evaluation of the optic disc, macula, and red reflex may reveal macular degeneration, diabetic changes, glaucoma, and cataracts [46].

Visual acuity, contrast sensitivity, and visual fields are the most important visual factors for safe driving [47]. As mentioned above, the useful field of view test is a sensitive predictor of driving safety [16,18]. The test measures how well one can pay attention to a large area all at once, including how fast one can process visual targets on the screen and filter out irrelevant events in the environment to accomplish two tasks at one time. When there are concerns about visual acuity and the older adult's ability to drive, referral can be made to a rehabilitation setting or specialist for useful field of view testing. Visions issues detected on screening may be reversible, and appropriate referrals to ophthalmology are recommended where indicated.

Hearing — Significant hearing loss has not been shown to consistently cause impaired driving performance as measured by motor vehicle crashes in many large studies [48].

However, good hearing can be critical when responding to emergency vehicles or horn alerts from other drivers, at railroad crossings, with GPS systems, or when notified of in-car safety alerts. The whisper test can be used as a brief screening tool to determine whether there is a difference in hearing in each ear and whether referral for formal audiologic examination is necessary. In this test, one ear is occluded and the older patient is asked to repeat the words or numbers whispered softly by the clinician standing one to two feet away, usually to the back of the patient. The whispered words or numbers used for the test should be those with equally accented syllables, such as “baseball” or “22” [49].

Cognitive function — Because people are living longer, the number of people with age-associated dementias is also increasing. The Alzheimer’s Association estimates that the number of people diagnosed with Alzheimer disease will increase from 5.2 million in 2014 to 13.8 million in 2050 [12]. While older patients with cognitive impairment tend to self-limit their driving, a significant number still continue to drive, and dementia may not be recognized by their clinicians [50].

A systematic review of drivers with dementia found consistent evidence for poorer performance on road or simulated tests of driving compared with drivers without cognitive impairment but did not find consistent reports of higher crash rates [51]. However, statistics of motor vehicle crashes may underrepresent the risk since older patients substantially reduce their driving [52]. In another systematic review, subjects with very mild or mild dementia (Clinical Dementia Rating [CDR] scale of 0.5 to 1.0) were significantly more likely to fail an on-road driving test than those without dementia [53]. Studies of driving evaluations consistently demonstrate worse performance in patients with dementia compared with age-matched controls [51,52]. Mild cognitive impairment (MCI) by definition, does not have impairments in functional abilities. Therefore, the few studies published on driving impairment and MCI probably represent individuals that likely had dementia.

Studies are not available to determine whether compensatory strategies for patients with cognitive impairment (eg, driving with copilots, restricted licensing, education) are effective in improving driving safety. In a randomized trial of cognitive training for older subjects with no or mild impairment (Mini-Mental State Examination [MMSE] ≥23), those randomized to participate in 8 to 10 sessions of training to improve speed of processing, and reasoning, had lower rates of at-fault motor vehicle collisions at six years compared with controls [54]. Patients with Alzheimer disease that have severe episodic anterograde memory loss would unlikely be unable to be learn and retain new information. However, individuals are increasingly diagnosed in the earlier stages of the disease and sometimes with non-amnestic presentations. Therefore, future studies are needed to determine the benefit of cognitive interventions in selective populations of older adults with cognitive impairment.

In the primary care setting, evaluation of cognitive function should begin with the history and, if available, an informant or collateral source such as a family member. Mental status changes may become apparent in the older adult's responses to areas of the medical and social history. However, signs can be subtle and difficult to detect without formal cognitive testing. A systematic review of studies that evaluated predictors of driving capacity in persons with dementia found that the CDR scale (table 3) had the best evidence of utility in evaluating driving safety [53]. An American Academy of Neurology practice parameter suggests an algorithm for evaluating driving safety in patients with dementia based upon the CDR (table 3) [53]. However, the CDR may not be the most useful tool in a busy primary care practice. Another resource is the American Geriatrics Society (AGS)/National Highway Traffic Safety Administration (NHTSA) clinician’s guide on assessing and counseling of older drivers.

Alternative screens that may be used to identify at-risk driving include tests of psychomotor speed and visual search (Trails A, Trails B [55,56]), constructional praxis and executive function (clock drawing [57] and copying intersecting geometric figures [21,45,58,59]), a multicomponent Roadwise Review [60], and the MMSE [61]. While a 2010 guideline from the American Academy of Neurology suggests that a MMSE score ≤24 may be useful in identifying patients at increased risk for unsafe driving [53], there are conflicting data correlating MMSE scores with unsafe driving and crashes. For example, in a prospective study of over 17,000 individuals aged 55 and over who had a baseline MMSE and who drove at least one time per week, at 4.5 years there was no correlation between MMSE score and risk of motor vehicle crash [62]. The MMSE may best be used as a screen for the presence of dementia and to document specific elements that have been associated with driving impairment and may raise concerns (impaired constructional praxis, attention deficits). (See "The mental status examination in adults", section on 'Cognitive screening tests'.)

Mandatory reporting of moderate or severe dementia and other disorders of consciousness is required in some states in the United States (eg, California, Pennsylvania), as well as certain provinces in Canada and Australia [63]. Although a number of driving safety tests have been suggested, no guidelines have been broadly implemented [20,64,65]. Local programs may exist to evaluate these patients with neuropsychological and roadside tests. In the absence of these programs, the department of motor vehicles will often perform written and/or roadside testing, but patients must be informed that even if they pass they will need to be retested at regular intervals as their disease progresses. Families must be warned about potential liability for crashes. They may need to take possession of car keys, or even cars, and restrict all driving. Clinicians should be aware of local and state statues and laws that require them to know when and how to refer to the state licensing authorities.

Multimodal evaluation — Research is ongoing to identify specific functional tests that correlate with formal driving assessment and can be used to determine driving safety. One report, based on multivariate analysis of a number of tests for vision, cognitive ability, and motor performance, found that assessment for color choice reaction time, postural sway, motion sensitivity, and self-reported distance driven regularly could classify drivers as safe or unsafe (based on road testing) with a sensitivity of 91 percent and specificity of 70 percent [66]. Another multicomponent test, the Hazard Predictions Test, correlated to a modest extent with on-road driving performance [67]. A battery of tests using informant assessment of activities of daily living, tests of visual search and foresight (Trail Making test A or maze test) and constructional praxis (clock drawing test) were able to correctly identify 85 percent of a sample of demented participants as to their road test performance [68]. These test batteries need further validation in other populations of older drivers to confirm reliability.

COMMUNICATING WITH PATIENT AND FAMILY — Although it is challenging to identify the unsafe older driver during the primary care visit, once the driver is identified, the clinician and the family often find it even more difficult to talk with the older driver about their concerns. Many clinicians are also unsure of what to do if the clinical evaluation suggests that the older patient should stop driving.

A 2019 cross-sectional study used baseline data from participants 65 to 79 years of age, enrolled at five LongROAD sites in California, Colorado, Michigan, Maryland, and New York, to examine driving behaviors and outcomes (and their associations with health and functional variables) over time. They found that participants were twice as likely to discuss driving safety with family as with physicians. Most (over 60 percent) of the conversations were initiated by family, while most (55 percent) clinician conversations were initiated by older drivers. The most common reasons for initiating family discussions were driving safety concerns (64.8 percent), followed by a health issue (22.3 percent), driving infraction (8.7 percent), and a crash (8.7 percent) [69].

Communication can be facilitated by initiating discussion about the potential to develop driving limitations as part of routine health care for older adults before a crisis has been reached, essentially "advance planning for driving retirement" [70]. A proposed approach includes anticipating transportation needs, identifying available options for transportation, recognizing and addressing emotional factors related to loss of mobility and independence, and addressing the potential impact of not driving on social connectedness. These discussions need to be made in a sensitive manner and documented in the medical record. Older adults who are approaching the time to stop driving may benefit from multidisciplinary support, including clinicians, nurses, case managers, social workers, and physical and occupational therapists. Formal driving safety evaluations may be helpful in borderline cases or for older drivers who are reluctant to stop driving despite the recommendation.

RESOURCES FOR FAMILY AND CLINICIANS — The primary care history and physical examination can provide critical information about age-associated medical illnesses that may negatively impact driving performance. However, even after a complete examination with special attention to these areas, the answer to the question, "Is my husband or dad safe to drive?" may not be clear. At this point, if the clinician suspects that the older adult may not be safe to drive, and the patient, family, and the clinician desire an objective assessment, several resources are available to supplement the primary care driving evaluation.

The Alzheimer’s Association website is an excellent resource for clinicians, patients, and families on many aspects of dementia and Alzheimer disease, including driving. They describe the warning signs of unsafe driving, such as forgetting how to locate familiar places, failure to obey traffic signals, making slow or poor decisions, driving at an inappropriate speed, and becoming angry and confused while driving. These signs can be useful for the older adult and the family to identify the unsafe older driver.

The organization suggests the following approaches for caregivers who are unable to convince the older adult to stop driving. First, control the older adult's access to the car by hiding the keys, disabling the car by removing the battery or the distributor cap, or parking the car on another block or in another driveway. Second, arrange for substitute transportation. Third, ask the clinician to write a prescription for "Do Not Drive," and finally, if appropriate, arrange an on-the-road evaluation by the state department of motor vehicles. The latter approach is truly a last resort as there are many implications in involving the state department of motor vehicles in the evaluation of older drivers.

The American Association of Retired Persons (AARP) has an active older drivers program, Smart Driver Course, which offers online and classroom refresher on driving skills for a nominal charge. Graduates of the program who live in many states are eligible to receive a multiyear car insurance discount. The AARP website contains information about their driving programs as well as a helpful "Do You Know the Rules of the Road" that can be used to update the latest information on legal and technical changes in driving and information on driving assessment [71]. Both the AAA and AARP websites have information on the ergonomics and safety feature options available in newer cars. Many local driving schools will perform an on-the-road evaluation for a small fee. In addition, veterans' and rehabilitation hospitals also have driving assessment programs available. The veterans' hospitals are free of charge for veterans. The American Occupational Therapy Association website and the Association of Driver Rehabilitation Specialists maintain a national database of driving specialists who can test the person’s driving skills. The American Occupational Therapy Association is one of the sponsors of the CarFit program that offers older adults an opportunity to check on how well they are position and “fit” in their car. Again, there are usually fees associated with these assessments.

The American Geriatrics Society is also a good resource for clinicians and families. Their website contains information for clinicians on age-related issues as well as excellent patient education materials, including the fourth edition of the Manual on Assessment and Counseling of Older Drivers.

On-the-road driving evaluation is an effective way of convincing an older driver that they may not be safe to drive or validate that the individual may be allowed to continue active driving. This objective evaluation of driving performance takes the pressure off the family and the clinician who want to maintain a positive relationship with the older patient. However, driving is an overlearned task that taps into procedural memory, which may remain fairly robust in many older adults. Passing a road test is a fairly low bar, but one that is used for novice drivers and is the basis for licensing. Failing a road test should result in immediate cessation of driving. Passing a road test may not be reassuring, and all clinical information should be utilized (eg, history of at-fault crashes) to make a final recommendation.

Social workers and case managers can be very helpful in identifying other resources in the community and working with the older adult and family around transportation issues. Another strategy to use with resistant older drivers is to remind them that insurance companies may refuse to pay for damages that occur after their clinician recommends driving cessation [72].

US STATE LICENSE RENEWAL REQUIREMENTS — The United States public expects the states, through the department of motor vehicles or transportation safety, to detect, examine, and regulate problem drivers. Each state has different license renewal requirements. Clinicians should familiarize themselves with the requirements in their state. These are updated every six months on the Insurance Institute of Highway Safety (IIHS) website. Many states apply stricter licensing procedures to older drivers, such as shorter renewal periods and/or mandatory in-person vision testing. Three states (Illinois, Indiana, New Hampshire) have at some point mandated a road test for older drivers [73]. However, driving competency tests, usually vision and on-the-road examinations, can be requested at any time if drivers or family members suspect difficulties, or it may be required if others have reported driving problems.

The issue of age-based testing is controversial. Those in favor say that routine testing should be mandatory starting with a certain age because many older adults are unwilling to recognize their limitations. However, those against are concerned about age discrimination and advocate that testing should be mandatory based upon driving history and performance, not solely on the basis of age. In those states with age-based mandatory testing, less than 5 percent of older drivers actually lose their license after the testing. There is some evidence to suggest age-related testing is actually harmful. One study noted these policies not only did not reduce motor vehicle crash rates but actually increased pedestrian fatality rates, presumably because older drivers were delicensed [74].

A retrospective study that used a multivariate analysis to look at the relationship between fatal crashes and state laws in the United States found that for people aged 85 and older, states with in-person license renewal requirements were associated with a lower driver fatality rate (incident rate ratio 0.83, 95% CI 0.72-0.96) [75,76]. Requirements for in-person renewal in younger age groups did not reduce fatality rates. State-mandated vision tests, road tests, and more frequent license renewal for older drivers also did not reduce fatality rates.

LEGAL ISSUES IN EVALUATING OLDER DRIVERS

United States — A nationwide survey in the United States found that almost 30 percent of geriatricians did not know how to make a report in their state about an older patient with dementia who is a potentially dangerous driver [77]. In addition, the courts have provided little clear guidance on this issue. Although lawsuits have been filed by innocent people who were injured as a result of an crash, the courts have been inconsistent in their findings against clinicians who allowed their potentially impaired patients to continue to drive. For the most part, the legal decisions depend upon the issue of "foreseeability." Was the clinician able to "reasonably foresee" that the medical issues would significantly impair the patient's ability to drive safely [78]?

The Insurance Institute for Highway Safety website contains a comprehensive chart of driver’s license renewal procedures (including reporting requirements) by state . In many states, the reporter's name is confidential. However, reporting the older adult to the state is uncomfortable for many clinicians who consider it a breach of confidentiality and a threat to the clinician-patient relationship. Some states do provide civil immunity if health professionals report in good faith [79].

Canada — A policy in Ontario, Canada requires that clinicians report patients who are "suffering from a condition that may make it dangerous for the person to operate a motor vehicle" [80]. Clinicians are offered a small monetary incentive to report unfit patients. In a study of the impact of reporting, approximately one-half of the 59,000 patients reported one year after the incentive was introduced were older than age 60; road crashes resulting in emergency department visits for reported at-risk drivers decreased by 45 percent at one year [81]. However, medical warnings were also associated with an increase in emergency department visits for depression and with a decrease in return visits with the reporting clinician.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Time to stop driving? (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Advancing age alone is not an indicator of poor driving performance, and decrements in driving, if present, can usually be attributed to medical conditions that impact visual, cognitive, or motor functional abilities. Older adults have higher motor vehicle fatality rates compared with other age groups, and those over 85 years of age have the highest rates. (See 'Introduction' above and 'Scope of the problem' above.)

●Many states apply stricter licensing procedures to older drivers, such as shorter renewal periods and/or mandatory in-person vision testing. (See 'US state license renewal requirements' above.)

●Evaluation of driving capacity includes (see 'Evaluating older drivers' above):

•Assessment of pertinent history (prior crashes, decline in traffic skills) and medical conditions that can further reduce spare capacity (eg, ischemic heart disease, cerebrovascular disease, movement disorders, diabetes mellitus, epilepsy, sleep disorders, and arthritis).

•Patients with a recent history of conditions that impair consciousness (eg, transient ischemic attacks, syncope, hypoglycemia, vertigo, or seizures) should cease driving until recovery is assured (table 1).

•Review of all prescription, over-the-counter, and herbal medications as well as use of alcohol or other substances. Medications with effects on the central nervous system, such as benzodiazepines, antihistamines, anticholinergics, and some tricyclic antidepressants, are especially concerning.

•Physical examination that assesses visual, cognitive, and motor functional abilities (table 2).

●Some states or provinces have mandatory clinician reporting of unsafe drivers. Clinicians should be aware of their local regulations. (See 'Legal issues in evaluating older drivers' above.)

●If an unsafe driver is identified during a medical visit, next steps include anticipating transportation needs, identifying available options for transportation, and recognizing and addressing emotional factors related to loss of mobility and independence, as well as the potential impact of not driving on social connectedness. (See 'Communicating with patient and family' above.)

●Resources for clinicians, patients and families are available and include those from the Alzheimer’s Association, the American Association of Retired Persons (AARP), and the American Geriatrics Society. (See 'Resources for family and clinicians' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Maryjoan Ladden, PhD, RN, FAAN, who contributed to an earlier version of this topic review.