Fitness to drive

General Considerations

There is no single test or historical factor that can accurately determine driving risk; clinicians can only make qualitative judgments.
Patients with mild dementia are at a higher risk for unsafe driving and should be encouraged to consider stopping driving (Iverson et al.).
It is crucial to discuss driving safety with all patients experiencing cognitive impairment.
Avoid over-relying on Mini-Mental State Examination (MMSE) scores alone.
Some individuals with mild dementia may still drive safely.
Suspending a patient’s license solely based on a mild dementia diagnosis is not appropriate.
Having a driving co-pilot is not a recognized method for ensuring driving safety in dementia patients.
An on-road driving test performed by an occupational therapist is considered the gold standard for assessing driving competence.
Neuropsychological test results generally do not align consistently with on-road driving performance.

Red flags

Accidents, new bumps/scratches, near misses
Disorientated/lost on familiar routes
Difficulty reading maps and following detours
Difficulty making quick decisions at intersections or busy roads
Not seeing vehicles, pedestrians or cyclists sharing the roadway
Difficulty controlling the car
- staying in lane
- obeying signals and lights
- giving way
- using controls and pedals
Other questions
- Patient or others concerned with his/her driving
- Forgetting purpose of trip
- Self-regulating driving e.g. avoiding night driving, busy roads or long distances

1. Driving History

Accidents or Near Misses: Document any accidents, minor crashes, or referral for previous driving assessments.
Family Concerns: Family input about driving behavior or hesitancy to be driven by the patient can offer valuable insight.
- number of crashes
- any time that patient has gotten lost.
- Note: patients have poor correlation of their ability.
Progressive Conditions: If the patient has a progressive condition (e.g., dementia), have early discussions about eventual cessation of driving.

2. Physical and Functional Assessments

Vision:
- Use Snellen chart to assess acuity (6/12 or 20/40 or better in one eye).
- Visual fields should cover 110 degrees horizontally, with 10 degrees above and below the midline.
Hearing:
- Test ability to detect important sounds like approaching cars, horns, and sirens (whisper test, audiometry).
Reaction Time:
- Use quick tests like the ruler drop or braking reaction time tests to measure response speed.
Coordination:
- Finger-Nose Test: Ask the patient to alternately touch their nose and your finger, assessing hand-eye coordination.
- Rapid Alternating Movements: Test how quickly the patient can perform repetitive motor tasks like tapping their feet or alternating hand movements.
- Grip Strength and Dexterity: Assess hand function to ensure they can effectively control the steering wheel and other vehicle controls.
Balance and Spatial Awareness (Romberg Test):
- Romberg Test: This test helps evaluate balance and proprioception. Ask the patient to stand with their feet together and eyes closed.
- Swaying or losing balance could indicate underlying issues with spatial awareness, which may affect their driving.
- Failing the Romberg test on its own does not necessarily mean that a person cannot drive, but it could signal underlying conditions that affect balance and spatial awareness. Whether someone is fit to drive depends on the underlying cause of the failed test and how it impacts their ability to safely operate a vehicle. Conditions affecting balance, proprioception, or vestibular function can lead to:
  - Impaired reaction time.
  - Difficulty maintaining proper posture or orientation.
  - Dizziness or unsteadiness while driving.
- Gait Assessment: Have the patient walk a straight line to assess overall balance, coordination, and mobility.
Problem-Solving and Cognitive Function:
- Clock-Drawing Test: A simple tool to assess spatial orientation, problem-solving, and planning. Ask the patient to draw a clock with a specific time.
- Trail Making Test: This assesses cognitive flexibility, visual attention, and task switching, which are essential for safe driving.
- Mini-Mental State Examination (MMSE): Although not specific to driving, it can help assess general cognitive function. Scores alone should not determine driving fitness but can inform further assessment.
Neurological Examination
- Motor Strength: Ensure they have the strength to control a vehicle.
- Reflexes: Abnormalities may suggest underlying neurological issues that could impair driving.
- Sensation and Proprioception: Assessing these can provide insights into their ability to perceive their position in space, which is crucial for driving
Joint Mobility and Musculoskeletal Health
- Range of Motion (ROM) Testing: Assess the patient’s ability to move their neck, arms, legs, and feet freely to ensure they can perform essential driving maneuvers such as turning to check blind spots.
Cardiovascular and Respiratory Fitness
- Blood Pressure and Heart Rate: Assess the cardiovascular system to identify any issues like syncope, arrhythmias, or other heart conditions that could cause blackouts or dizziness while driving.
Tools for Assessing Driving in Patients with Dementia
- 10-Minute Office-Based Dementia and Driving Checklist
  Found in the Dementia and Driving Toolkit for Health Professionals (Champlain Dementia Network and Regional Geriatric Program of Eastern Ontario, Canada).
- Assessment of Driving Related Skills (ADReS)
  Developed by the US National Highway and Traffic Safety Administration in collaboration with the American Medical Association.

Drop a ruler and measure how quickly the patient can catch it.

3. Cognitive and Behavioral Indicators

Insight: Evaluate the patient’s understanding of their driving abilities and limitations.
Comprehension: Test understanding of road signs, signals, lane discipline, and verbal instructions.
Decision-Making: Determine whether the patient can make quick decisions at intersections and busy roads.
Anxiety or Confusion: Monitor for confusion on familiar routes or anxiety related to driving tasks.

4. Conditions Likely to Affect Driving (Consult Austroads Guidelines)

Blackouts or syncope
Cardiovascular disease (e.g., myocardial infarction, cardiac arrest)
Diabetes with history of hypoglycemia
Musculoskeletal conditions (affecting mobility)
Neurological conditions (e.g., dementia, epilepsy, cognitive impairments)
Psychiatric conditions (e.g., depression, anxiety)
Sleep disorders (e.g., sleep apnea)
Vision problems
Substance misuse or dependency

mandatory waiting periods

Epilepsy – 12 months
A single seizure – 6 months
MI – 2 weeks
Cardiac Arrest – 6 months
DVT 2 weeks
Diabetes is a special case.

6. Private vs Commercial Driving Standards

Private Drivers: Standards depend on the type of vehicle and its intended use (passenger vs. goods).
Commercial Drivers: More stringent standards, requiring visual, spatial, and cognitive abilities. Longer wait periods after certain medical events may apply (e.g., seizures, cardiac arrest).
Specialist Input: Often needed to certify fitness for commercial licenses.

7. Practical Considerations for Driving Cessation

Impact of License Loss: Losing the ability to drive can lead to loss of independence, especially in rural areas, and is often linked to increased rates of depression.
Alternative Transportation: Discuss public transport options, family assistance, community transport services, and taxi subsidies (where available).
Psychological Impact: Be aware that patients may self-regulate their driving by avoiding night driving or long trips but may not fully recognize their declining abilities.
Rural context
- Difficult to lose license in rural area
- loss of independence
- loss of contact with community

8. Reporting Requirements

Self-Reporting: Patients are required to self-report medical conditions affecting driving to the driver licensing authority (DLA).
Mandatory Reporting: In some jurisdictions (e.g., South Australia, Northern Territory), doctors are legally required to report patients with certain conditions.
Voluntary Renunciation: Encourage voluntary surrender of driving licenses where possible.
Medical Reviews: Regular medical reviews and reassessments may be required for completion of forms, especially for commercial drivers.

9. Referral and Further Evaluation

Occupational Therapy (OT) Driving Assessment: The “gold standard” for assessing driving ability, though resource availability can be limited.
Specialist Referral: If uncertain about the patient’s fitness to drive, refer to a geriatrician, neurologist, or specialist for further evaluation.

10. Risk Assessment Approach for Progressive Diseases (e.g., Dementia)

Assess Driving Abilities:
Regularly evaluate the patient’s ability to control the vehicle and respond to driving demands. Key factors to assess include:

Reaction Time
Problem-Solving
Spatial Awareness
Emotional Control when managing multiple stimuli.

Early Planning for Cessation:
Begin discussions about driving cessation early in the disease process. As cognitive decline progresses, driving ability will deteriorate. Early conversations allow for:

Voluntary, gradual retirement from driving.
Emotional and practical preparation for both the patient and family.

Ongoing Review and Assessment:

Frequency: Patients with mild dementia should undergo a driving safety review every six months.
Voluntary or Involuntary Cessation: Decisions to stop driving may be voluntary or necessary, depending on disease progression and safety concerns.
Referral: If needed, refer the patient to an occupational therapist for an on-road driving assessment, considering resource availability and costs.

Impact of Driving Cessation

Maintaining autonomy is a significant concern for elderly individuals, both socially and economically.
Transitioning to non-driving is associated with higher rates of depression and an increased likelihood of needing residential care.
Discuss alternative transportation options, such as public transport or family support.
Consider the potential consequences of an accident for the individual and others.
Inform patients that they may face civil or criminal prosecution if an accident occurs.
Clarify that car or life insurance policies may be invalidated if the patient drives while deemed medically unfit.

Impact of Driving Cessation: How It Affects Patients and How a GP Can Help

Impact on Patients:

Loss of Autonomy: For many elderly individuals, driving represents independence, so losing the ability to drive can be a major blow to their sense of autonomy. This can affect both their social engagement and emotional well-being.
Increased Risk of Depression: Studies have shown that the cessation of driving can lead to higher rates of depression, as individuals may feel isolated or lose their connection to daily activities and social circles.
Higher Likelihood of Residential Care: A lack of independence in transportation may increase the need for residential care, as the patient may struggle to maintain regular healthcare visits, social engagements, or essential activities like shopping.

How a GP Can Help

Discuss Alternative Transportation Options:
- Public Transport: GPs can provide information on local public transport routes and services that can help patients remain mobile.
- Community Services: Community buses and volunteer driver services can be crucial alternatives, especially in rural or less accessible areas.
- Taxi Subsidy Schemes:
  - In Australia, many states and territories offer taxi subsidy schemes for elderly or disabled individuals who are unable to drive. This reduces the financial burden of using taxis, making it a more affordable option.
  - A GP can assist by providing the necessary medical documentation or referrals to apply for such programs.
Family Support:
- Encouraging family members to help with transportation or to engage in discussions about alternatives can ease the transition from driving.
- GPs can also help families recognize the importance of the patient’s social and medical needs in maintaining their quality of life.
Legal and Safety Considerations:
- Potential Legal Consequences: It’s essential to inform patients that continuing to drive when unfit poses legal risks, including civil or criminal prosecution if an accident occurs.
- Insurance Issues: Explain that driving while deemed medically unfit can void insurance policies, leaving patients and their families financially exposed in the event of an accident.
Addressing Emotional and Mental Health:
- The psychological impact of losing driving privileges should not be underestimated.
- GPs can play a crucial role by offering mental health support or referrals to counseling services, helping patients navigate feelings of loss, frustration, or isolation.
Regular Reviews and Reassessments:
- GPs should offer regular follow-ups to assess the ongoing impact of driving cessation and adjust care as necessary.
- This might include revisiting the patient’s mood, lifestyle, mobility options, and engagement with their community, ensuring they are supported in the long term.
Encouraging Social and Physical Activity:
- Encourage patients to stay physically and socially active through other means, such as walking groups, community centers, or online social activities if mobility is limited.
- Staying active and connected can reduce the emotional toll of no longer driving.