Interventions With the Older Driver

Although some older drivers can benefit from driving refresher courses (eg, American Association of Retired Persons [AARP] Driver Safety), most should be referred to occupational therapists who specialize in driving rehabilitation (called driving rehabilitation specialists). Driving rehabilitation specialists can be located by contacting local rehabilitation facilities, the Association for Driver Rehabilitation Specialists, or the American Occupational Therapy Association.

Occupational therapy driving rehabilitation specialists usually do comprehensive driving assessments that include clinical tests of vision, motor, and cognitive skills as well as on-road evaluations. During on-road evaluations, the specialist goes in a vehicle with the older driver to evaluate actual driving skills in varied traffic conditions. The vehicle used during the evaluation should be equipped with features that allow the specialist to maintain safe control (eg, passenger-side brake). At the conclusion of the comprehensive driving evaluation, the specialist provides recommendations regarding the individual’s driving ability. These specialists can also assist by

• Recommending a tailored rehabilitation plan to increase motor skills, cognition, and perception in the driver’s daily life

• Providing adaptive driving equipment and training in using the equipment (eg, a spinner knob to help with one-handed steering, more complicated devices such as hand controls)

• Evaluating the response to the rehabilitation plan and providing feedback to the driver, involved relatives, and the physician as to whether the driver's driving abilities are adequate to continue driving or whether driving restrictions are indicated

• Providing mobility counseling or advice on alternate modes of transportation

In most states, the cost of a rehabilitation driving assessment is not covered by insurance (Medicare or private) and is an out-of-pocket cost. If a driving rehabilitation specialist is not in the area or costs are prohibitive, options include referral to a local occupational therapist who specializes in older adult medical conditions and/or a referral to the state drivers licensing department for complete retesting of vision and written and road testing.

If older drivers deny or are unaware of their limitations or if deficits do not respond to treatment, medical practitioners may need to be proactive. In these situations, practitioners should discuss issues relevant to driving safety, potential driving cessation, patient transportation needs, and alternative transportation resources with the patient and family members.

The practitioner should balance the benefits of safety to the patient, pedestrians, and other drivers against the costs of social isolation, worsening functional status, impaired quality of life, and clinical depression. For some patients (eg, those with moderate or severe dementia), the benefits of driving cessation clearly outweigh the costs.

Alternative transportation options should be discussed; these vary from community to community, but national resources such as the National Aging and Disability Transportation Center, the Alzheimer's Association's Dementia and Driving guidance, and the Eldercare Locator provide updated information on options.

Family members can find online information about having conversations with older drivers about stopping or limiting driving. See, for example, The Hartford's At the Crossroads: Family Conversations About Alzheimer’s Disease, Dementia & Driving, the AARP's We Need to Talk, and the Alzheimer's Association's Having the conversation.

Newer transportation options such as web-based, on-demand taxi services may be an option for the older driver who may no longer be able to drive safely. However, it is important to assess the older driver’s ability to independently utilize even these services. Often the same functional deficits that limit safe driving also limit the ability to independently schedule and use alternative forms of transportation. Sometimes, family members and/or friends need to drive the older person; when possible, it is helpful to have a structured schedule in which a number of friends and family contribute. Providing transportation options allows the older adult to remain active and involved in the community and avoid isolation, inactivity, and depression. 

The loss of driving privileges can precipitate depression and be relatively devastating in terms of maintaining independence. If alternative transportation cannot be arranged and the ability to maintain activities of daily living is adversely affected, loss of driving privileges sometimes prompts the need to move in with a family member or transition to an assisted-living facility or retirement community.

If the driver’s functional limitations or medical status seems to warrant driving cessation, practitioners should follow the reporting requirements of their state Department of Motor Vehicles. States vary in their reporting laws. All states have voluntary reporting laws, but some states have mandatory reporting laws. In most states, statutes protect the practitioner’s anonymity or provide immunity to the practitioner. Legal consultation may be beneficial when an office or institution is developing a reporting policy and procedure.

Before making a report, practitioners should discuss recommendations for driving cessation directly with the older driver and family rather than simply filing a report. Practitioners should make every attempt to educate the driver regarding the need to cooperate with driving restrictions. Such discussion should include why the driver’s limitations make driving unsafe for themselves and other drivers, and why the practitioner is obligated to report.

In some situations, practitioners must report functional limitations or medical status to state agencies against the wishes of their patients; this action often has a negative impact on the practitioner-patient relationship. Regardless, medical information can be legally disclosed if a patient’s driving impairment might jeopardize public safety; practitioners who do not notify appropriate authorities may be legally liable for subsequent injuries.