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Medical Assessment of the Older Driver

By David B. Carr, MD, Alan A. and Edith L. Wolff Professor of Geriatric Medicine, Professor of Medicine and Neurology, and Clinical Director, Division of Geriatrics and Nutritional Science, Washington University School of Medicine ; Peggy P. Barco, MS, BSW, OTD, OTR/L, SCDCM, CDRS, Assistant Professor of Occupational Therapy and Medicine, Washington University Medical School

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Patient Education

Medical assessment of the older driver includes a thorough review of medical conditions and/or drugs that can impair driving ability. Such medical conditions can be chronic disorders that impair important functional abilities needed for driving (eg, macular degeneration that decreases vision) or acute events that impair consciousness (eg, seizure, syncope). The following are a few of the more common medical illnesses or syndromes that are associated with increased driving risk (eg, motor vehicle crashes [MVCs], poor performance on road tests).


Falls and MVCs share common causative factors (eg, impaired vision, muscle strength, cognition). A history of falls in the past 1 to 2 yr indicates increased risk of MVCs and should prompt further evaluation of physical functioning (see Functional Assessment of the Older Driver : Physical function).

Cardiac disorders

Cardiac disorders may increase driving risk. General guidelines include refraining from driving for

  • 1 mo after MI, coronary artery bypass surgery, or stabilization of unstable angina symptoms

  • 3 mo after arrhythmia with syncope

  • 6 mo after internal cardioverter-defibrillator placement or after resuscitation required because of sustained ventricular tachycardia or ventricular fibrillation

However, patients should discuss these specific recommendations with their cardiologist or primary care physician.

Patients with severe heart failure (eg, class IV heart failure, dyspnea at rest or while driving) should refrain from driving until they can be evaluated with on-road testing.

Neurologic disorders

Neurologic disorders also increase driving risk. Specific disorders include

  • Stroke or transient ischemic attack (TIA): Drivers with a single TIA should wait 1 mo before resuming driving; those with recurrent TIAs or stroke should be event-free for at least 3 mo before resuming driving. Physical examination should be done to assess how residual disability due to stroke may affect driving ability.

  • Seizures: Regulations for drivers who have seizures are state-specific, but most states require a seizure-free interval (often 6 mo) before they reinstate driving privileges. Anticonvulsants can adequately control seizures in about 70% of patients, although relapses may occur when these drugs are withdrawn.

Alzheimer disease or progressive dementing disorders will eventually impair all functional abilities, including those required for driving. Monitoring patients for new driving errors that can be attributed to changes in cognition or identifying significant impairments in psychometric tests (see Functional Assessment of the Older Driver : Cognitive function) may be useful in determining referrals for on-road evaluation or possibly driving cessation.

Many other neurologic disorders (eg, Parkinson disease) cause disability and should be monitored by functional assessment and possibly an on-road test.

Diabetes mellitus

Diabetes mellitus poses a risk because patients may become hypoglycemic while driving. Patients who have had a recent hypoglycemic episode with unawareness should not drive for 3 mo or until factors contributing to the episode (eg, diet, activity, timing and dose of insulin or antihyperglycemic drug) have been assessed and managed. Sensory changes in the extremities, retinopathy, or both caused by diabetes can also impair driving ability.

Sleep disorders

Sleep disorders, most notably obstructive sleep apnea syndrome, can cause drowsiness leading to MVCs, and patients should refrain from driving until they are adequately treated.


When starting a new drug that could affect visual, physical, or cognitive function, patients should refrain from driving for several days (depending on the time required to reach a steady state) to be sure no adverse effects occur.

A large number of drugs potentially can impair driving, typically those with CNS adverse effects (eg, confusion, sedation). Many of these drugs have been shown to impair actual driving in road tests and/or driving simulators and to increase MVC risk. These drugs can also increase fall risk. Despite these risks, many of these drugs should not be stopped abruptly because they may need to be tapered.

Drugs that increase driving risk include

  • Antihistamines, benzodiazepines, opioids, anticholinergics, hypnotics, antihypertensives, or tricyclic antidepressants: These drugs increase driving risk because they can cause drowsiness; some can also cause hypotension or arrhythmias.

  • Antiparkinsonian dopamine agonists (eg, pergolide, pramipexole, ropinirole): These drugs occasionally cause acute sleep attacks, which may pose an increased risk of an MVC.

  • Antiemetics (eg, prochlorperazine) and muscle relaxants (eg, cyclobenzaprine): These drugs are cause for concern because of their potential for altering sensory perception.

Instructing patients to bring all drug containers to the office can help identify drugs that increase risk.

Older adults are involved in fewer alcohol-related fatal MVCs. Fewer older adults consume alcohol, but limiting alcohol consumption is still important because blood alcohol level per amount of alcohol consumed is higher in older adults. Also, concurrent use of alcohol and other drugs, particularly multiple drugs, further impairs cognition, increasing the risk of MVCs.