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I.C. DEVELOP TOOLS NEEDED TO IMPLEMENT MODEL PROGRAMS

I.C.1. Identification Procedures/Program Intake Mechanisms

(a) Internal (DMV) Identification
(b) External Referral of At-Risk Drivers
(c) Problem Identification Through Self-Testing Activities

IC1(a)i. Direct Observation by Counter Personnel

A questionnaire was developed and distributed to Driver License Administrators in the 50 United States and 12 Canadian Provinces to broadly determine cost and time parameters that could influence implementation of Model Program activities, while addressing details of the Model Program concept which conceivably could be impacted by their legal, ethical, or policy implications in each State and Province (Staplin and Lococo, 1997). When asked whether it would be feasible to "Implement a referral mechanism for functional screening/evaluation in which DMV counter personnel use a checklist to record a brief, structured set of observations, and/or question-and-answer responses, for members of the driving public who appear before them," sixty-four percent of the respondents (38 of 59) reported that this practice would be feasible to implement while 36 percent (21 of 59) replied that it would not be feasible.

Reasons for why this practice would not be feasible were:

• Not all of their customers go to a service outlet, and as such, this procedure would not be "watertight."

• DMV counter personnel are well able to observe customers and make notes on them for review, but are generally not qualified to use structured lists without training that may be inappropriate to their classifications.

• Questions and answers would be acceptable, but not the use of a set of observations.

• "Another good idea that would require extensive training and increase lines in the offices."

• "Our right to examine a disabled person based upon visual observations has been challenged in court based upon the Americans with Disabilities Act (ADA). Clear standards for initial screening are necessary to accommodate the ADA. We must turn to rehabilitation specialists to evaluate those who are disabled. Only trained physical therapists can install special equipment and train the disabled persons to operate this equipment. After the training is completed, DMV personnel should conduct the standard road test to avoid the accusation of discriminations under the ADA."

Cobb and Coughlin (1997) conducted a telephone survey of 51 DMV line examiners in the 50 U.S. States and Washington D.C. Most respondents revealed that the single most important criteria for identifying an impaired driver is how he or she looks coming through the door at the DMV. There is a heavy reliance on the examiner's skill and judgment when attempting to determine a driver's fitness. However, the survey also found that the legal requirement to appear in person before a licensing official is not used by many States as a means of controlling unsafe drivers. Also, respondents reported that administrative resources and tools to adequately judge an individual's performance are not as good as they would like. Adequate time for assessments is beyond most States' budgets, and many test techniques rely on imperfect methods (e.g., strength tests performed by having a driver press against an examiner's hand or reaction tests performed using a ruler-drop test).

Fields and Valtinson (1998) provide a table showing State license renewal requirements for passenger car vehicles in the United States. Currently, 28 States require all drivers to come to the DMV each time they renew their licenses (generally, every 4 to 5 years, with the exception of Wisconsin, which has an 8-year renewal cycle). This includes: Alabama, Arizona, Arkansas, Colorado, Delaware, District of Columbia, Georgia, Hawaii, Indiana, Kansas, Kentucky, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, New Mexico, North Carolina, North Dakota, Ohio, Pennsylvania, Rhode Island, South Dakota, Virginia, Washington, and Wisconsin. Many States allow mail-in license renewal; only a few of these States specify an age limit where the individual must appear in person (see Notebook section IC1(a)iv for license renewal distinctions for older drivers). Some States require in-person renewal at every other renewal cycle (resulting in a DMV only seeing a person every 8 to 10 years). Florida requires in-person renewal at every third cycle, which means that a driver with a clean record will not step foot into a DMV for 18 years (or 12 years for an unclean record).

Petrucelli and Malinowski (1992) state that "the examiner's personal contact with the applicant is the only routine opportunity to detect potential problems of the functionally impaired driver. This opportunity should not be lost because of inadequate examiner training." They also provide the following statistics. Fourteen jurisdictions provide some level of orientation to their examiners to enable them to observe for and recognize potentially hazardous signs and symptoms (British Columbia, Connecticut, Florida, Indiana, Iowa, Maryland, Missouri, Montana, North Carolina, North Dakota, Oregon, Prince Edward Island, and Washington). The orientation programs are based on the 1976 training program, "Screening for Driver Limitation" (DOT-HS-802-136).

The American Association of Motor Vehicle Administrators (AAMVA) Associate Director of Services (see Janke and Hersch, 1997) stated that driver licensing staff could ask questions of renewing drivers to separate medically (functionally) impaired drivers from normal (unimpaired) drivers. Questions such as "please spell your name; verify your address and date of birth" (e.g., verifying questions) are much less insulting than "tell me what your name/address is...I want to see what you know/remember" types of questions.

There are currently two chapters in the Florida Examiner's Manual that deal with identification of driver limitations: Chapter 10 contains information for an examiner to adequately screen for driver limitations, and Chapter 11 contains information to help an examiner identify a physical impairment or handicap and to know what physical skills are affected by the handicap. Guidelines are provided in the form of signs and symptoms for the identification of cardiovascular conditions, neurological conditions, mental and emotional conditions, diabetes, and age-related problems. Signs and symptoms listed for age-related problems are: (1) slowed reactions, stiffness of the joints, lack of attention, and disorientation; (2) nervous system conditions, identified by tremors, retarded reflexes, and slower adjustment to stimuli; (3) cardiovascular conditions, identified by wheezing, gasping, and general breathing difficulty, bluish tint to skin especially under fingernails, and extreme fatigue; and (4) visual impairment.

Chapter 11 provides the following information in the section "Identifying a Physical Handicap:"

While checking the application form or giving the eye test, notice any physical defects the applicant may have. In the majority of cases, it is not necessary to let the applicant know that the way he [she] walks or the way he [she] uses his [her] arms or hands is being observed. If anyone has a noticeable limp, an arm or leg missing, walks with crutches, is particularly small, or has a brace, question him [her] closely, but tactfully about his [her] ability to drive.

A list of physical skills is provided (coordination, range of motion, strength of motion), as well as adaptive equipment and restrictions that may be necessary for compensation of physical impairments.

Wisconsin has written a chapter for their field staff about how to determine a customer's functional ability by visual inspection. It defines functional ability and provides the standard, so the employee knows what the benchmark should be. The functional abilities that need to be observed and the functional standards that need to be applied are presented below. A person who does not meet these standards, and whose license is not properly restricted, may be required to submit to an actual driving skills test or evaluation, file a medical report, or both. This information was taken from Section 235 "Evaluating Medical Conditions or Disabilities."

An ADA (Americans with Disabilities) suit was filed with the Department of Justice against the Wisconsin DMV by an out-of-state driver in a wheelchair who came to the DMV for a license transfer. The person did not have any restrictions on his out-of-state license, which is unusual; there should have been a restriction that he must only operate a vehicle with hand controls. So, the DMV required him to take a road test, and he thought that was discriminatory, because the person behind him in line was also out-of-state and did not have to take the road test (but also was not in a wheelchair). Wisconsin's practice was not considered discriminatory by the ADA (the driver did not win the suit). Nor did the ADA have any comments about how to improve their practices. A state can require a road test for the purpose of assuring highway safety. The Wisconsin Supreme Court has held that the operation of motor vehicles in Wisconsin is a privilege, not a right, and is subject to reasonable regulation by the police power. Like the U.S. Department of Transportation, the DMV has a legislative mandate to protect public safety and maintain safe highways. The driving evaluation is rationally related to the achievement of such purposes and is not based on prejudice, stereotypes, or unfounded fear. It is therefore not a violation of the spirit or letter of the ADA to conduct a driving evaluation as may be necessary to determine if a person adequately compensates for a medical condition or functional impairment, to safely operate a motor vehicle with or without license restrictions. Wisconsin DMV sent their chapter about determining functional ability to other states to see what they thought. A DMV representative stated that some states go overboard worrying about ADA when really, Wisconsin found that the focus should be on doing the right thing, which is preserving highway safety.

Conclusions/Preliminary Recommendations:

The practice of requiring drivers to renew their licenses in person presents the opportunity for licensing personnel to objectively evaluate general cognitive and physical fitness to drive, through simple observation and communication with the renewing drivers. Several States already participate in this practice and have comprehensive procedure manuals and field employee training to ensure that observations are made for relevant capabilities and in a respectful manner, while the majority of surveyed States/Provinces indicated that this practice would be feasible to implement in their jurisdictions. This practice has passed the scrutiny of the ADA, and is recommended as a means of identifying at-risk drivers in the Model Program.

References:

• Cobb and Coughlin (1997)
• Fields and Valtinson (1998)
• Florida Department of Highway and Motor Vehicle Safety: Counter Procedures
• Janke and Hersch (1997)
• Petrucelli and Malinowski (1992)
• Staplin and Lococo (1997)
• Wisconsin Department of Transportation: Counter Procedures

Ic1(a)ii. Responses on License Application/Renewal Forms

Summary:

The NHTSA/AAMVA Model Driver Screening and Evaluation Program: Guidelines for Motor Vehicle Administrators (NHTSA, 1992) states that medical fitness questions included on a driver license application should be designed to identify applicants who may have: loss of consciousness, cardiovascular disease, alcoholism or a drinking problem, mental illness, drug addiction or dependence, diabetes, and vision impairment. It further states that medical questions can take two forms: (1) those that ask for medical conditions, and (2) those that ask for symptoms. The questions selected for inclusion on the application should have the potential to identify individuals with medical disabilities that might impair their driving. In order to simplify the application, AAMVA recommends that agencies use common lead-in lines for several questions, such as, "Have you in the last three years..."" or "Have you ever been...?" Driver License Application forms from several jurisdictions are included at the end of this section.

Practices vary widely across jurisdictions (see examples of forms used in Alabama, Maryland, Utah, and Wisconsin at the end of this section). In Oregon, screening at renewal consists of a short medical questionnaire on the renewal application, and a mandatory vision (acuity) screening for drivers over age 50. About 22 percent of Oregon medical program referrals come from answers to medical questions on renewal applications. In previous years, field office employees received at least brief training in informal screening of renewal applicants. However, that practice has been discontinued in recent years, with the result that fewer applicants are referred based on informal screening, and more of the referrals received are inappropriate.

In Ohio, when individuals go to the DMV to apply/reapply for a license, they are asked only two questions: (1) Do you have any physical or mental conditions that could impair safe driving performance? (2) Are you taking any medications that may impair safe driving performance? If the applicant answers "yes" to either question (or indicates that they have some sort of progressive disability (e.g., Multiple Sclerosis, Parkinson's, Muscular Dystrophy, Cerebral Palsy, Narcolepsy, high blood pressure) or has suffered the loss of a limb, then a medical packet is mailed to the individual, who then must undergo a physical examination by a physician.

In Utah, applicants must answer whether they have had any of 12 medical conditions in the past 5 years (diabetes; cardiovascular; pulmonary; neurologic; epilepsy; learning and memory; psychiatric; alcohol and drugs; visual acuity; musculoskeletal/chronic debilities; functional motor impairment; and other). Descriptions and examples are included on the form for each category.

Janke and Hersch (1997) stated that although affirmative answers to medical questions are not common, an analysis of 579 license applications showing affirmative answers to health questions found that self-reporting drivers (median age=37.3) had significantly worse prior crash-involvement records than a randomly selected comparison sample (median age=37.8 years). The authors concluded that the application's medical impairment question serves a beneficial traffic safety purpose.

The practice of including medical questions on driver licensing applications has been brought before the ADA, and has passed investigation. In 1993, an action was filed against the Alabama Department of Public Safety (DPS) by an applicant who alleged that the licensing requirements discriminated against him, under the ADA Act of 1990. The applicant reapplying for an Alabama driver's license, had sought help from a psychologist who diagnosed him with depression and recommended in-patient treatment at a private psychiatric hospital for 30 days. The licensing application procedure used by AL DPS includes, among other things: (1) use of a license application form that contains broadly worded questions seeking information about whether an applicant has "ever" been treated for a "mental" or "nervous condition" or has "ever" received in-patient treatment in a "mental facility;" (2) a requirement that an applicant answering questions of this type in the positive to furnish copies of all prior medical records for review by the Defendant without regard for time frame, nature of the medical history, or its impact on an applicant's ability to safely and responsibly operate a motor vehicle; and (3) use by the Department of a Medical Advisory Board (MAB) to advise the applicant on medical criteria relevant to the licensing process and to screen applicants.

The applicant stated that the existing driver's licensing process results in overt denial of treatment of individuals with disabilities, or the establishment of exclusive or segregative criteria that act to bar individuals with disabilities from participation in services, benefits, or activities, and more specifically, the opportunity to obtain and hold a lawfully issued driver's license. The applicant further stated that the process employs segregative criteria including intrusive and over-broad application forms and information requirements. The voluntary hospitalization for a psychiatric condition, according to the applicant, is immaterial to the driver licensing process and would constitute an invasion of his privacy if such information were disclosed.

In 1995, the claims of the plaintiff were dismissed by the US District Court for the Middle District of Alabama; however, general provisions required (1) the adoption of standards for the licensing of drivers with medical conditions; (2) development of procedures for administrative review of driver license denials, suspensions, revocations and cancellations for drivers with medical conditions; (3) implementation of a restricted driver license; (4) the employment of a Registered Nurse on a 2-year contract to assist in administering the program regarding medical requirements for drivers; (5) the attempt to pass legislation increasing the number of physicians on its MAB; (6) the attempt to pass legislation amending the state statute prohibiting the issuance of licenses to certain persons; (7) allowance of all persons who have previously been denied a driver license for medical reasons to reapply under the standards and procedures as set out in the decree; and (8) institution of a program of training for driver license examiners.

The Alabama Driver License Application was revised 9/95; a chapter on Medical Standards for Driver Licensing was rewritten and enacted 3/11/96. The medical information on the new form asks: "Within the last 2 years, have you experienced an episode of altered consciousness or loss of body control, or had any medical condition that may affect your ability to drive safely? Conditions that may affect your ability to drive safely include: brain or head injury; insulin controlled diabetes; heart; lung; mental; muscle or nerve; seizure disorder; stroke; addiction to alcohol or drugs." Also included for "yes" answers are: date of last episode, whether driver is presently being treated or has been recommended treatment within the past 2 years, and the physician's name.

Conclusions/Preliminary Recommendations:

The inclusion of questions on license application and renewal forms regarding medical conditions/symptoms and medications that affect driving performance may help the licensing agency identify drivers who are at increased crash risk, particularly in jurisdictions where reporting by physicians is not mandatory. Because many conditions that were previously linked to increased crash risk are controllable through medical technological advances and because research studies show mixed results for many conditions, follow up with the treating physician for individuals who report conditions is a necessary step before any licensing action is undertaken. Also, because drivers may not consider their particular health condition as one that may affect their driving performance or may not recognize it in a list of body systems (e.g., "cardiovascular"), the wording of medical conditions should be non-technical and easily understood by the general public (e.g., "heart"), and should include examples of conditions and symptoms (e.g., irregular heart beat, heart attack, heart surgery, high blood pressure).

A form that includes the following questions is thus recommended. The conditions were obtained from Maryland (old version) and Utah's application forms, and from the data presented in section IA1 (a through m) and IA2(a) of this Notebook. Definitions and or symptoms should be included for each medical condition, as shown on the Utah form.

References:

• Alabama DMV
• Janke and Hersch (1997)
• Maryland MVA
• NHTSA (1992)
• Ohio DMV
• Utah (Abbreviated Health Questionnaire)
• Wisconsin DOT

[ Alabama Driver License Application: front / back ]

[ Maryland Driver License Application front / back ]

[ Utah Abbreviated Health Questionnaire ]

[ Wisconsin Operator License Application front / back ]

IC1(a)iii. Contact Based on Driving Record

The use of a single point system for all ages assumes that the relationship between points and crash risk is the same at each age level. The purpose of the analysis performed by Gebers and Peck (1992) was to determine if there is a quantitative justification for intervening against older drivers on the basis of fewer traffic conviction and/or crash points, in light of the hypothesis that older drivers who accumulate traffic convictions and crashes may represent atypical individuals who are not completely compensating for declining skill level. They calculated the expected number of predicted crashes per 1,000 drivers based on the negligent operator point total for all drivers in general, and for drivers in the 60-69 age group and 70+ age group. This was for the expected number of crashes in a subsequent 3-year period and number of negligent-operator points in the prior 3 years. At the lower point levels (0, 1, 2), the older drivers were equal to or better than all drivers in terms of the expected number of crashes for a given number of points. At the 3-point level and above, there is a slightly steeper increase in the number of predicted crashes for drivers age 70+, relative to what would be expected among the total population. A similar trend was found for drivers ages 60-69 who had more than 5 points in a 3-year period. Among the group who accumulated 6 points in 3 years, there is an expected rate of 437 crashes per 1,000 drivers in the next 3 years for the general population, 441 crashes among drivers ages 60-69, and 512 crashes for drivers age 70+. An analysis of covariance of crashes and convictions occurring over the same 6-year period demonstrated that drivers ages 60-69 or 70+ begin to exceed the number of crashes among the general population when they have reached the point of accumulating two or more convictions.

In Iowa, the Department may require a special reexamination when a licensee has been involved in two crashes within a 3-year period, and the investigating officer's report of each crash lists one of the following "driver/vehicle related contributing circumstances: ran traffic signal; ran stop sign; passing, interfered with other vehicle; left of center, not passing; failure to yield right-of-way at uncontrolled intersection; failure to yield right-of-way from stop sign; failure to yield right-of-way from yield sign; failure to yield right-of-way making left turn; failure to yield right-of-way to pedestrian; failure to have control." The Department may require a special reexamination when a licensee who is age 65+ has been involved in a crash, and information in the investigating officer's or the person's own report of the crash indicates the need for a reexamination. A circumstance that may indicate a need for reexamination includes (but is not limited to) any of the following actions by the licensee: left turn resulting in the crash; failure to yield the right-of-way at a stop sign, yield sign, uncontrolled intersection, at a traffic control signal; the licensee's vision may be a contributing factor to a nighttime crash; the licensee has a physical disability-related license restriction other than "corrective lenses" and the crash involved one of the above-listed circumstances.

Conclusions/Preliminary Recommendations:

Gebers and Peck conclude that an age-mediated point system in which driver control actions are initiated at a lower threshold for drivers above age 60 or 70 would serve as an early warning system for detecting functionally impaired older drivers, but interventions should not be unduly obtrusive or punitive at the first level of intervention (e.g., a self-assessment brochure would be appropriate).

References:

• Gebers and Peck (1992)
• Iowa Code

Ic1(a)iv. Contact Based on Age at Renewal

(includes random and stratified sampling selection procedures)

Petrucelli and Malinowski (1992) stated that while chronological age is a poor predictor of functional capability, it is used as a screening tool. A subset of States and Provinces require a medical report/

examination or vision screening after a certain age at the time of renewal, as shown in the table below (data from Alcee, Jernigan, and Stoke, 1990; Fields and Valtinson, 1998; Janke, 1994; and Petrucelli and Malinowski, 1992).

Pennsylvania's "Older Driver Reexamination Program" is a mechanism for identifying medically incompetent drivers. Each month, 1,650 drivers over the age of 45 are selected for retesting at the time of license renewal. Driver selection is weighted heavily toward the oldest drivers, and results in (almost) every driver over the age of 85 being selected. Each selected driver is required to undergo both vision and physical examinations. The medical evaluation may be conducted by any licensed physician. The vision screening may be completed by a physician, or, at a Driver License Center at no charge. As a result of this program, 28 percent of the drivers selected for reexamination do not have their licenses renewed. This number includes drivers who have already stopped driving while retaining a license and drivers who voluntarily surrender their license in lieu of completing the exams. Less than one percent actually fail the medical or vision exams. An additional 26 percent of the drivers selected have restrictions placed on their driving privileges. Ninety-nine percent of these restrictions are related to vision or hearing problems. If warranted by the results of the medical examination, the selected drivers are required to successfully complete an on-road driving examination. PennDOT has found that the driver's examination is warranted for less than 1 percent of the drivers. Freedman, Decina, and Knoebel (1986) found that the reexamination program is effective in discovering medical and visual conditions that require remediation, restrictions on driving, or withdrawal of operating privileges, especially among drivers age 60 and older. They stated that based on the data on new restrictions, failures, and other reasons for loss of license, as well as crash data, very little is gained by requiring drivers under age 60 to undergo reexamination.

In four states under study, McKnight and Lange (1996) found that in states requiring age-based on-road driving tests for renewal (Indiana and Illinois), tested drivers evidenced significantly lower (7%) relative involvement in crashes than their counterparts in the comparison states (Ohio and Michigan). However, while age-based testing appeared to lower the rate of crashes for older drivers, it did not lower the proportion of single-vehicle crashes. The authors note that testing may serve to induce drivers to drive less frequently rather than to remove unsafe drivers from the road. They concluded that age-based road testing as a means of selectively removing unsafe drivers from the road, or even reducing the amount of their driving, receives no support from the comparisons made in their study. Rock (1998) noted that McKnight and Lange's non-tested group (age 70-74) in one of the testing states (Illinois) had just come off of a testing requirement, which may have had a lingering effect, potentially affecting their study findings. Rock explored the changes made to Illinois' revised renewal requirements for older drivers and found that eliminating the road test for those ages 69-74 had no negative impact on crashes. In addition, shortening the renewal term to 2 years (from 4 years) for drivers ages 81-86 did not appear to have any benefit.

A discussion of attitudes toward the testing of older drivers for relicensing is useful. Although AARP believes that age-based testing is discriminatory and arbitrary, they support "a combination of driver education, improved testing methods, and the availability of alternative transportation for those who are unable to drive" for drivers of all ages (AARP, 1995). In addition, AARP believes that "states should achieve greater consistency in licensing programs and procedures, such as graduated licensing and testing procedures, and should develop educational materials to educate older drivers, their families and caregivers, and the general public about the effects of functional age on driving, the availability of specialized licenses, the procedures involved in the re-examination process, and alternatives to driving." Older drivers' attitudes toward age-based testing are presented next.

Gutman and Milstein (1998) asked 162 focus group participants ages 56 to 76+ the following question: "If older drivers were required to be retested before their license was renewed, at what age should this happen?" Twenty-eight percent of the total sample were against retesting on the basis of age without an additional reason; 44 percent of the drivers age 76 and older were against testing on the basis of age, compared to 22 percent of those ages 56-65 and 30 percent of those ages 66-75. The most frequent age specified by those who indicated that age-based testing was appropriate was 70 (by 41 percent of all respondents), followed by age 65 (by 31 percent of the group). When asked, "Does retesting of older drivers discriminate against them," 70 percent replied "no," 25 percent replied "yes," and 5 percent did not respond. When asked what kinds of tests drivers would be required to pass for license renewal, 55 percent of the participants stated an eyesight exam, 54 percent stated a medical checkup, 51 percent a road test, 41 percent a fitness test, and 36 percent a written test (multiple responses were permitted). Drivers age 76 and older were approximately half as likely as those in the two younger age groups to indicate criteria for license renewal. However, drivers age 76 and older were more than twice as likely as the two younger groups to state that all tests should be required for all renewals, regardless of age. When asked, "Who should decide when you should stop driving," the most frequent response was the doctor (45%), followed by self (36%), scores on an unbiased test (33%), the licensing department (22%), the person's family (15%), and a panel of experts (7%). In the oldest driver group, self determination was reported more frequently (56%) than physician (48%).

In a survey of 384 older driver ages 68 to 88 (mean age=75.7) conducted in Salisbury, MD for the NHTSA "Model Driver Screening and Evaluation Program" project, the present Notebook authors found that 61 percent responded in the affirmative when asked whether there should be mandatory retesting of drivers based on age. Of those older drivers who believe that mandatory age-based testing should be implemented, 23 percent indicated that testing should begin at age 80, 20 percent stated at age 75, 17 percent at age 65, 14 percent at age 70, 13 percent at age 85, and 10 percent at age 60. A further question asked who should pay for mandatory retesting for license renewal, with the following options provided: (1) Self--you pay full cost; (2) co-pay--self shares cost with State or with insurance company; (3) State pays full cost; and (4) Insurance pays full cost. The majority (37%) indicated the State; 25 percent indicated "self;" 21 percent indicated "co-pay;" and 15 percent indicated "insurance." When asked what kind of professional would be qualified to administer testing (from a list that included doctor, other health-care professional, police, Department of Motor Vehicles, occupational/physical therapist, and community service worker), the vast majority (84%) indicated doctor, followed by DMV (64%). Twenty-seven percent of the subjects indicated that the police would be qualified to administer tests, 22 percent identified other health-care professionals, 18 percent identified occupational/physical therapists, and 13 percent indicated community service workers. The final question asked who should hold the ultimate responsibility for deciding whether and how much an individual should drive (from a list that included DMV, doctor, family/friends, self and other). Eighty-five percent the subjects indicated "self," 49 percent indicated doctor, 40 percent indicated DMV, and 29 percent indicated family/friends.

In a smaller survey of 26 older drivers ages 57 to 86 (mean age=71) sampled by the present Notebook authors while conducting Pennsylvania Department of Transportation (PennDOT) project number 96-13, "Driver Safety Public Information and Education (P.I.&E) Campaign," 69 percent responded "yes," i.e., there some age at which all drivers should be retested on their fitness to drive. The ages provided by this sample and the number of subjects indicating each age are as follows: age 16 (n=1); age 55 (n=2); age 60 (n=3); age 61 (n=1); age 70 (n=2); age 75 (n=3); age 80 (n=3); and age 85 (n=3). Drivers in this survey were asked to provide a rank ordering of their preference for the type of individual who should administer license renewal testing. The list included eight agencies/professionals; (1) the Department of Motor Vehicles; (2) the police; (3) family doctor; (4) health care professional other than a physician (e.g., nurse, medical technician); (5) volunteer service provider (e.g., community/senior center activities director); (6) Government agency case worker (e.g., Department of health, social services, area agency on aging); (7) occupational or physical therapist; and (8) local AARP chapter. The agency/individual ranked as first preference by the largest percentage of subjects was the DMV (by 34.6%), followed by doctor (30.8%) and AARP (19.2%). The most frequent second-choice agency/individual chosen by subjects was health care professional other than physician (by 34.6%). The agency/individual most frequently chosen as the least-preferred (ranked 8th) for administering testing for license renewal was the police (by 38.5% of the subjects) followed by a Government agency case worker (by 23%).

Stutts, Wilkins, and Schatz (submitted) reported that the majority of the older drivers who participated in their focus groups believe that older drivers should be more carefully evaluated than they are now, with more rigorous and more frequent testing. Participants could not agree on an age when testing should begin; however, most indicated that it should be "sooner rather than later" so that seniors could get comfortable with the idea.

Conclusions/Preliminary Recommendations:

Age-based medical and visual testing upon license renewal are common among many jurisdictions, and have been shown to be a good means of identifying drivers with age-related functional impairments that may affect safe driving performance. It appears that age-based reexaminations are not appropriate for drivers under the age of 60. A road-test requirement for all renewals over a certain age does not appear to add any additional information about a driver's ability to safely carry out the driving task, and may be best reserved for drivers who are referred to a DMV by family, friends, police etc., for observed unsafe driving performance; drivers who have been referred by physicians for specific medical disorders (e.g., dementia); or drivers who have been involved in point violations or crashes between renewal periods.

There is some support by older drivers for age-based testing upon license renewal. Older drivers have identified physicians and the DMV as most appropriate for administering testing, and police among the least-appropriate individuals for conducting license renewal testing.

References:

• Alcee, Jernigan, and Stoke (1990)
• Decina, Staplin, and Lococo (1998)
• Fields and Valtinson (1998)
• Freedman, Decina, and Knoebel (1986)
• Gutman and Milstein (1988)
• Janke (1994)
• Lange and McKnight (1996)
• McEwan (1997)
• Petrucelli and Malinowski (1992)
• Rock (1998)
• Stutts, Wilkins, and Schatz (submitted)

IC1(b)i. Family/Friend Referral

Fifty-four of 60 Driver License Administrators surveyed in 60 U.S. States and Canadian Provinces indicated that it would be feasible in their jurisdictions to have family or friends refer drivers they believe to be impaired (Staplin and Lococo, 1998). Many States already have this referral process in place. The Pennsylvania Department of Transportation (PennDOT), for example receives approximately 500 signed letters from family members each year. Sixty-five percent of these drivers ultimately lose driving privileges. Family members account for 5 percent of requests for reexamination by the DMV in Iowa, and 10 percent of the requests in Michigan. Five percent of the "Behavior Reports" submitted to the Wisconsin DMV in 1996 were from citizens. Wisconsin's "Driver Condition or Behavior Report" (Form MV3141) is presented at the end of this section. Wisconsin's Guidelines (Section 235, Evaluating Medical Conditions or Disabilities) state that "persons volunteering information about other licensed drivers should be told that the information will be available to the driver they are reporting under Wisconsin's Open Records Law. This includes unsolicited reports from physicians and other health care specialists. A pledge of confidentiality cannot be given after an individual has provided information to the department. Pledges of confidentiality are not given routinely."

The Ohio Bureau of Motor Vehicles accepts referrals from anyone (friends, family, police, court, physician), but the individual must be willing to be named as the source of information (Staplin and Lococo, 1998). When family and friends report an individual, the Bureau conducts a pre-investigation before requiring a re-test, to make sure the report is legitimate. Police officers who observe unsafe driving performance can submit a "re-examination or re-certification" and a judge who is trying a case (e.g., for a traffic violation) can also submit for re-exam or re-cert, if he or she suspects that the person has some medical problem that could increase crash risk (e.g., Alzheimer's Disease). In the case of police, the court, and physician reporting, the Department does not do a pre-investigation. Age is not used as a basis for re-exam; however, a large proportion of the drivers who are "requested for re-exam or re-cert" are older. According to the Director of the Ohio State University's Office of Geriatrics and Gerontology, family members appear to be a good referral source and friends (in general) are not (pers. comm., B. Kantor, 1/98).

Family members were identified in Oregon as a likely source of information about older drivers with medical impairments (Janke and Hersch, 1997). Families have the ability to observe these drivers over longer periods of time, and therefore may be aware of conditions or behaviors not observed by physicians or licencing agencies.

Information about the status of this issue in Illinois was obtained from a 1990 report, entitled "Report of the Driver Safety Advisory Committee," which was submitted to the Secretary of State, Jim Edgar (Illinois Retired Teachers Association, Inc. ,1990). In this report, it states that the Driver's License Act of 1953 provided the Secretary of State with the discretionary authority to examine a driver if there was good cause to believe the person holding the driver's license or permit was incompetent or otherwise unqualified to operate a motor vehicle. However, in 1974, the office of the Illinois Secretary of State determined that family members and insurance companies would no longer be considered an authorized source for requesting a citation for re-examination. In 1990, a panel of traffic safety experts, medical professionals, members of senior citizen organizations, and law enforcement officials were appointed to review a Cite for Re-examination proposal, which would allow family members to request a re-examination for drivers who show deteriorating driving skills. The panel, named the Driver Safety Advisory Committee, concluded that the proposed amendment did not discriminate against any driver. It was further recommended that family requests for re-exam not be held confidential, as a deterrent to fraudulent reports. This amendment, dubbed the "tattletale plan" by the media, was withdrawn from consideration as a result of criticism from opponents running for Governor against the current Secretary of State, who first proposed the legislation. Only doctors, police officers, judges, and secretary of state employees are authorized to make such reports.

Approximately two-thirds of 50 participants in focus groups (family members concerned about an older driver) indicated that they would report a family member who was a problem older driver (Sterns, Sterns, Aizenberg, and Anapolle, 1997). The characteristics and patterns of unsafe driving they describe are many of those that are listed in section IA2(g) of this Notebook: forgetfulness; confusion; bad judgment; new dents and dings on the vehicle; reports to family members about an unsafe older relative, from police, neighbors, other family members; driving too slow on the expressway; driving too fast/close to the car in front; weaves in and out of lanes; slowing/stopping for green lights; ignoring red lights; not looking when backing; not using mirrors; and couldn't find brake/accelerator. All family members and friends indicated that they were able to recognize unsafe driving behavior among the elderly of their concern. Several had attempted to report such drivers to their State DMV, or to physicians. Only a few had the support of a physician, and none had the support of law enforcement or the DMV.

The New York State Office for the Aging conducted a survey of family and caregivers concerned about the safety of an older driver (see Lepore, 1998). Respondents included 123 individuals who voluntarily completed a questionnaire that requested detailed information about the driver, family concerns, and the types of help they would like to have. The majority of respondents (79%) were female family members who lived no more than 30 minutes from the driver, and most had jobs or other caregiver responsibilities. Most notably, over 70 percent of the respondents reported that they had been concerned for more than 1 year about the driving safety of the older family member, and that their first indications of a safety problem came from watching the driver (slow reactions in traffic, slow driving, and inattention to other road users and hazards). Of the drivers identified as unsafe, 85 percent were age 75 and older; over 90 percent lived in their own home or apartment, and almost 75 percent lived alone. Despite having serious concerns about an older family member's driving safety, 60 percent of the respondents reported that they were unable to discuss the problem with the driver, or to intervene. The most common reason (provided by 80 percent of those who could not intervene) centered on concerns about taking away the driver's independence. These individuals stated that alternative transportation options, plus the support of a physician to prescribe "no driving" and/or refer the older driver to the DMV, would be helpful. Over three-quarters of the surveyed family members voiced support for a DMV driving test. A second survey is currently underway, to learn about how family members and friends successfully resolved an unsafe older driver situation, or helped an older person to return to driving safely. This survey can be downloaded from the internet at http://aging.state.ny.us/nysofa. The information will be used to develop a handbook for families, caregivers and others concerned about the safety of an older driver, entitled "When You are Concerned: A handbook for those concerned about the safety of an aging driver." The planned publication date of the handbook is Fall of 1999; it will be available from the New York State Office for the Aging. The handbook will include the following information: resources-- what to expect in the way of assistance; monitoring an aging driver, even when you don't live nearby; solutions for when an aging driver is at-risk, including discussions and interventions; transportation when driving is not an option; strategies for helping the aging driver cope with the loss of a license and overcoming the guilt of intervention; and strategies for keeping an aging driver safe on the road.

In another survey that included 119 health care and rehabilitation specialists, 30 percent responded that they had reported an older person to State authorities (Sterns, Sterns, Aizenberg, and Anapolle, 1997). Of particular significance was the fact that for two-thirds of the respondents who had reporting experiences, their report was initiated by concerned family or friends.

Conclusions/Preliminary Recommendations:

Referrals from families or friends about impaired older drivers are an important source of information for licencing agencies. Family members have more of an opportunity to observe these drivers on a daily basis. Family and friends also have the strongest concern for older drivers, and therefore are motivated to keep them safe. Steps need to be taken to facilitate this process, however. These steps may include distribution of information to the public detailing if, when, and how one should refer an impaired driver. In addition, since physicians are the most frequent contact, and are often reluctant to get involved with families and issues of driving cessation, social marketing campaigns must include and target health care personnel. Family and friends require the support of physicians, law enforcement personnel, and the DMV for reporting and retesting.

References:

• Illinois Retired Teachers Association, Inc. (1990)

• Staplin and Lococo (1998)

• Janke and Hersch (1997)

• Lepore (1998)

• Sterns, Sterns, Aizenberg, and Anapolle (1997)

• Wisconsin DMV

[ Wisconsin Driver Condition or Behavior Report page 1 / page 2 ]

IC1(b)ii. Law Enforcement Referral

Evidence of unsafe behaviors by older drivers is provided in a study by McKnight and Urquijo (1993), who examined the criteria that law enforcement personnel use when referring older drivers for reexamination, following their observations of signs of incompetence when an older driver is stopped for a violation or is involved in a crash. The data consisted of 1,000 police referral forms from the motor vehicle departments of California, Maryland, Massachusetts, Michigan, and Oregon. Referrals were classified on the basis of initial contact, as well as the behaviors leading to the contact and the deficiencies that served as the basis of referral. Initial contact could result from one of four conditions: a crash; a violation; police observation of aberrant behavior; or referral by an outside source such as friends, relatives, or physicians. The specific behaviors contributing to the contact between the aging driver and the police officer included: driving the wrong way or on the wrong side of the street; driving off the road; rear-ending a vehicle; failing to yield the right-of-way or come to a complete stop at a stop sign; infringing on the rights of a pedestrian or cyclist; turning across the path of oncoming vehicles; crossing lane markings; operating at low speed; backing improperly; and other behaviors.

Results of the data analysis showed that older driver crashes were the leading source of referrals (48 percent), followed by violations (44 percent). Observed behavior accounted for 7 percent of the referrals and outside referrals accounted for only 1 percent. The primary behaviors that brought these drivers to the attention of police were: driving the wrong way on a one-way street or on the wrong side of a two-way street, which contributed to many violations (149), but few crashes (29) and accounted for 19 percent of the referrals; driving off the paved surface, which contributed to many crashes (176) but few violations (8) and accounted for 19 percent of the referrals; and failing to stop or yield to other traffic, which contributed to significant numbers of crashes (74) and violations (114), and accounted for 18 percent of the referrals. Making unsafe turns in front of other traffic was half as frequent as the three aforementioned behaviors, but is a mistake in which older drivers are generally overrepresented; turning across traffic contributed to 46 crashes and 43 violations, or approximately 9 percent of the referrals. Other contributing behaviors, in decreasing frequency, included: driving very slowly; rear-ending another vehicle; backing improperly; failing to observe lane markings; and not yielding to pedestrians and bicyclists.

After being pulled over, officers reported a number of deficiencies that served as the basis for referral for reexam. These included: aberrant behavior (taking too long to pull over, difficulty producing identification, etc.); attentional deficit (admission of being generally unaware of other vehicles, traffic control, what they had done that resulted in violation or crash); cognitive deficit (lack of recall, inability to comprehend, failure to know rules of the road, etc.); medical problems (blacking out, diabetes, Alzheimer's, fainting/dizziness, Parkinson's disease, seizure, epilepsy, stroke, etc.); mental problems (confused, disoriented, lost, senile, drowsy or fatigued, etc.); motor problems (slow reflexes, inappropriate manipulation of controls, such as brake and accelerator, generally poor coordination, observed difficulty walking, shaking or tremors, physical disability, general weakness, extremely short stature); and apparent sensory deficits (impaired vision or hearing, poor depth perception, degraded night vision, recent eye surgery or cataracts).

The Pennsylvania Department of Transportation (PennDOT) annually receives about 2,000 police reports and 500 crash reports concerning potentially impaired drivers of all ages. Approximately 50 percent of the drivers who are reported lose driving privileges following a medical or driving exam. Data from Wisconsin DOT indicates that in 1996, two-thirds of reports concerning impaired drivers of all ages in the State came from law enforcement officials.

A survey of driver licencing agencies in nine states (CA, CT, FL, MA, MI, OH, OR, TX, and WI) indicated that 24 percent of older driver referrals were submitted by law enforcement officials (Aizenberg and Anapolle, 1996). In Oregon, law enforcement is a significant reporting source of older drivers, accounting for 24 percent of reports for older drivers compared to 17 percent of all reports. However, information from Oregon indicates that police officers tend to be responsible for many unnecessary reexaminations and medical referrals (Janke and Hersch, 1997). Michigan receives approximately 5,000 referrals annually; physicians and law enforcement are the two primary reporting sources, followed by family members (Aizenberg and Anapolle, 1996).

An external referral program in the State of Florida with participation from two police agencies resulted in the referral of 71 impaired older drivers to an education/training program. Only 7 percent of the drivers identified decided to participate in a driver education program, with another 4 percent voluntarily surrendering their driving privileges. Most of the drivers contacted by the older driver program administrator denied that they had diminished capabilities and needed retraining. Over 65 percent of those contacted stated that they should not have been pulled over by law enforcement officers.

An elderly driver special referral form developed for use by the Florida Highway Safety Patrol (Zimmerer, undated) is presented on the next page. A draft paper has been developed by Zimmerer/NHTSA (in press) describing cues for possible impairment that law enforcement should observe when encountering older drivers. These include observations of the driver's awareness and cognitive status (e.g., does he or she know time of day, day of week, month of year, the origin and destination of the trip; does the person stumble over words or ramble); appearance (e.g., does the person exhibit poor hygiene or inappropriate clothing); and physical status (does the person take a long time to walk a short distance, stumble/fall, shake, seem uncoordinated). The purpose of the observations are for constructive intervention (e.g., referral for remediation) and to assist the older driver in self assessment.

Conclusions/Preliminary Recommendations:

Law enforcement agencies have the ability to identify and refer impaired older drivers. Officers are not qualified to make medical judgments, but can be provided with guidelines and support materials, and can be trained to recognize behavioral indicators of age-related impairments. This approach is expected to cut down on unnecessary referrals. In addition, the participation of potentially-impaired drivers in education or remediation programs should be mandatory (e.g., once stopped for unsafe driving behavior, an older person may choose re-training or receive a traffic ticket with points); a majority of drivers will not participate otherwise.

References:

• Aizenberg and Anapolle (1996)

• Florida: Law Enforcement Component of "Getting in Gear" Program

• Janke and Hersch (1997)

• McKnight and Urquijo (1993)

• PennDOT (1997): Information Distributed at Pennsylvania Governor's Highway Safety Conference

• Wisconsin: 1996 Behavior Report Statistics

• Zimmerer (in press) police form

[ Zimmerer police form ]

IC1(b)iii. Court Referral

The Ohio State University Medical Center "Older Driver Evaluation Program" has an agreement with municipal courts allowing judges to give the older adult a choice to agree to undergo the evaluation as an alternative to formal charges for a motor vehicle violation, as a means of identifying deficits that might threaten future successful driving and independence, or as a means of determining current function and potentially lessening license suspension time frame. Referred drivers complete a medical profile, undergo tests of perceptual, cognitive, and psychomotor skills, and on-road driving tests. The outcome of the evaluation may involve a recommendation for or against independent driving, or remedial training. One judge stated that sentencing is a very subjective procedure; the OSU program takes a lot of the subjectivity out (Mader, 1994). There are two scenarios for referral (Ottolenghi-Barga, 1993). In the first, an officer stops a driver, determines that he or she is at risk on the road, and orders a court appearance and retesting by the Bureau of Motor Vehicles (BMV). In the second scenario, the court recognizes a driver's pattern of minor or major crashes and infractions, and suggests that the driver participate in the Older Driver Evaluation Program (ODEP). Under either scenario, a driver who agrees to go through ODEP may not be charged with the violation and may not receive points. The traffic case is continued pending completion of the program, and the BMV may or may not be requested to retest, based on the ODEP results. A driver is not forced to participate, but if he or she refuses to do so, the ramifications of refusal may include mandatory retesting and conviction on the driving infractions. Points resulting from the conviction may lead to insurance premium increases or cancellation.

Conclusions/Preliminary Recommendations:

The effectiveness of this program has yet to be evaluated, however, court-mandated testing of older drivers who have come before the courts as a result of a traffic violation or crash represents a potentially successful mechanism for identifying impaired older drivers. Retesting and referral into a training/remediation program that is presented by the judicial system to the older driver as an alternative to legal action will result in a higher rate of participation than a purely voluntary initiative.

References:

• Mader (1994)

• Ottolenghi-Barga (1993)

IC1(b)iv. Occupational/Physical Therapist Referral

Occupational therapists provide a variety of services geared toward assisting the older driver. Their goals are to keep people independent. As such, driving programs have two goals: (1) to provide objective evidence of who would be dangerous on the road; and (2) to prolong the mobility of those who have the potential to be safe drivers. Generally, occupational therapists have 5 parts to their evaluation: (1) an interview to determine why the person came to them and to see if the person has insight as to why the doctor or family wanted the evaluation; (2) physical assessment of strength, range of motion, and sitting balance; (3) cognitive evaluation to determine the ability to organize and react to traffic information; (4) sensory evaluation to determine the ability of the person to perceive his/her environment; and (5) simulation to evaluate driving performance (Hunt, 1990).

Drivers come to the attention of OTs through various mechanisms, including physician referral, hospital point of discharge (e.g., after a stroke, a patient may enter a rehab program), court referral, clergy referral, and through concerned family members and friends. Occupational therapists help older drivers cope with age-related changing abilities by developing programs designed to retrain older drivers. They also retrain drivers who have had amputations, strokes, and chronic arthritic disease to use adaptive equipment (hand controls, spinner knobs, grip attachments, seat height adjustors, pedal extenders, signal switchers, blind spot mirrors) to maintain safe mobility. OTs provide objective assessments that help to guide decisions regarding continued mobility or driving cessation. Conducting driving evaluations thus requires an understanding of the impairments associated with normal aging, as well as the interactions of age effects with effects of disease, and how these factors influence on-road driving performance. Because OT practitioners are trained to look at physical and cognitive issues, they are in a good position to evaluate and retrain disabled or elderly drivers (OT Week, 1998; Hunt, 1996; Ranney and Hunt, 1997; American Occupational Therapy Association Brochure). Descriptions of several programs follow.

Ohio State University Medical Center's Older Driver Evaluation Program is physician-driven; a physician oversees the program, which is staffed by an occupational therapist, a geriatric clinical nurse specialist, and an on-the-road evaluator. The assessment is conducted in two parts. The first part consists of cognitive, vision, and mobility tests. The second part consists of simulator and on-road driving tests. Also included in the evaluation is a pharmacological review. Results of these tests are forwarded to the driver's physician and to the driver, but never to the Bureau of Motor Vehicles. Evaluation outcomes for the 400 drivers who have been evaluated thus far, are as follows: 56 percent were deemed capable with training or vehicle modifications; and 44 percent were deemed incapable to continue driving. Those deemed incapable are sorted into two categories: incapable to drive now and in the future; and incapable now, but may be capable in the future with remediation (e.g., cataract removal). Evaluations last 3 hours, require 2 visits, and cost $330.00. According to the program administrators, this program is not meeting the need of all the older drivers in the state, based on cost and time to administer the evaluation. The program developers are working to create a short screening tool to be administered in physician's offices. They have followed the mammography model regarding desired sensitivity and specificity, in that they cannot tolerate sending a poor driver out on the road; therefore they err on the side of conducting full assessments on drivers whose driving ability is not compromised (pers. comm., Bonnie Kantor and Linda Mauger, 1/20/98).

Penn State offers a comprehensive, three-phase driver rehabilitation program. Drivers are first evaluated on visual and perceptual skills, reaction time, cognition, attention, dexterity, and judgment. Remediation is provided in areas found to be weak. An instructor accompanies the driver to the State licencing exam. Counseling regarding alternative transportation services is provided to those judged unfit to drive (Geisinger/Penn State Medical Program: Support Services Brochure).

Bryn Mawr Rehabilitation's Adapted Driver Education Program provides an in-depth examination of driving ability. Their assessment includes tests of vision, divided attention, reaction time and cognition, as well as an on-road driving evaluation. Results of the exam are forwarded to patient's physician, who has the responsibility to report to the DMV. Driver training and equipment prescriptions are part of the program (Bryn Mawr Rehabilitation Hospital Adapted Driver Education Program Brochure).

DeGraff Memorial Hospital and Rochester Rehab Center have proposed a driver assessment, remediation, and referral program for older adults. Components will include: (1) evaluation and assessment (vision, reaction time, cognition, hearing, rules of the road, safety features, on-road assessment); (2) reporting (a written analysis of findings and recommendations for enhanced safety); and (3) interventions (referral to vehicle modifiers, driver remediation, counseling on driving alternatives, and support groups). The total cost per person assessed is estimated at $253.00 for 4 hours and 40 minutes (DeGraff Memorial Hospital: Older Driver Safety Project Executive Summary, Dr. Gary Brice).

Kim White of Sinai Rehab Hospital (Baltimore, MD) highlighted several issues important to the discussion of OTs and driving evaluations. First, driving rehabilitation/training is not a covered service (not covered by Blue Cross/Shield, Medicare, or Medicaid); insurance companies do not consider driving a medically necessary activity. Second, many people do not know how to go about getting the question answered regarding whether they are (or a family member is) a safe driver. There are very few OTs involved in driving evaluations. More certified driving instructors are needed and more information needs to be disseminated to the public describing driving evaluation. Finally, regarding reporting to the Motor Vehicle Administration, Sinai uses an informed consent approach: if a driver fails an evaluation, Sinai reports the results to the MAB. This has resulted in only a few drivers not participating in an evaluation. However, she states that it is often difficult to collect payment for the evaluation from drivers who fail.

Conclusions/Preliminary Recommendations:

Some occupational therapists/hospital rehabilitation programs already have comprehensive driver assessment, counseling, and remediation programs in place. These programs can be used to identify impaired drivers, and to determine whether the impairments can be remediated through training or adaptive equipment. There is a need for more driving assessment/rehabilitation professionals, and a need to educate the public about the existence of these programs. At issue is who will pay for these services, and whether results will be confidential or will be reported to a DMV. In many cases, the results of these assessments are only made available to the driver, or occasionally to the driver's physician. In addition, it is currently the case that a driver who passes a driving evaluation by an OT must also pass the State exam, if an exam is required in a jurisdiction for renewal, or reinstatement after suspension for medical reasons.

References:

• American Occupational Therapy Association (AOTA) Brochure: "Able Driving is Safe Driving: How Occupational Therapy Can Assist the Older Driver"

• Bryn Mawr Rehabilitation Hospital Adapted Driver Education Program Brochure

• DeGraff Memorial Hospital: Older Driver Safety Project Executive Summary (Dr. Gary Brice)

• Geisinger/Penn State Medical Program: Support Services Brochure

• Hunt (1990)

• Hunt (1996)

• Ohio State University Medical Center Older Driver Evaluation Program Evaluation (pers. comm., Bonnie Kantor and Linda Mauger, 1/20/98)

• OT Week (1998)

• Ranney and Hunt (1997)

• Review of Sinai Hospital Driver Rehabilitation Program at Maryland Research Consortium Meeting (Presentation by K. White 3/98)

IC1(b)v. Referrals from Social Service Providers

Maryland Geriatric Evaluation Services (GES) undertakes comprehensive evaluations of older individuals referred by family, friends, clergy, etc. who are at risk of losing their independence (to a nursing home admission) because of health, social, or environmental problems. The assessment helps to determine the person's functional status and what an individual's needs are to maintain community living for as long as possible. The 1.5 hour, in-home evaluation consists of medical, psychosocial, environmental, psychiatric, and economic assessments (performed by licensed certified social workers and nurses, in addition to consulting physicians and psychiatrists). After the evaluation is complete, a plan of care is prepared that provides recommendations for resources. The evaluation is free; however, case management services are charged to the client on a sliding scale basis. Results are kept confidential, but occasionally a letter is sent to DMV indicating that a person should not be driving. This letter does not mention specific information about diagnosis; instead, behavior is described to avoid patient confidentiality issues.

Genesis ElderCare is an organization that provides health care services through a network of people, places, and programs. They were established in 1985 and are working in 12 States on the east coast. Services include: family counseling and care coordination; adult day health programs; physician services; nutrition management services; pharmaceutical care and medical supply services; home care support services; respite programs; rehabilitation services; assisted living and retirement communities; and long-term care centers. A "Full Life Counselor" conducts a 2-hour, in-home assessment that includes health status, behavior, ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs), social interaction, emotional and intellectual well-being, and living situation and financial situation. The assessment includes the Mini-Mental Status Examination (MMSE). The assessment costs $225.00 and includes a "full life plan," which is a three-section written course of action for the elder and caregiver based on the assessment. The first section is a summary of the information collected in the assessment as well as the counselor's observations during the assessment. The second section is a summary that indicates how well the customer functions in each of the six areas critical to maintaining a full, independent life (sensory perception, mobility, continence, nutrition, medication management, and behavioral health). The third section is the counselor's recommendations to help the customer achieve the goals for independent living. A client or family may purchase on-going care coordination for $65.00/month. This is used for problem-solving of situations as they occur and for consultations with the customer to monitor the customer's satisfaction with the plan. A full life counselor may help to coordinate service for nearly any request. For example, one customer called them when a toilet overflowed, and Genesis arranged for plumber service. According to Abby Weintraub (a Full Life Counselor in Kennett Square, PA), driving and transportation are a big issue; the counselor asks whether the client drives, wears a seat belt, and should be driving. Genesis has an ambulance service, and is working to develop a transportation company (Genesis ElderCare Brochures; pers. comm., Abby Weintraub, Full Life Counselor, Kennett Square, PA, 4/98).

A service organization named "National Eldercare Services Company" is an independent company that has been created to utilize existing Employee Assistance Programs (EAPs) in companies to help employees (typically the adult children) deal with problems related to the care of an older parent. Employers who purchase this service can use existing EAP counselors working in a company's benefits administration or human resources department to troubleshoot problems an older parent may have staying independent in his or her own home. A Preliminary Eldercare Profile (PEP) computer program has been designed to "red-flag" problem areas such as lack of a social network, safety of the immediate environment, health status of the elder parent, what benefits can be coordinated between the parent and child, etc. This level of service (Level 1, similar to a triage) is the minimum level/least expensive option to the employer that Eldercare contracts out to the employer, and the PEP is free to employees who utilize the service. Problems and concerns that the employee identifies about the older parent's driving will be "red-flagged" during the PEP.

The second through fourth levels of service provided by National Eldercare can be capitated as an employer-paid benefit; otherwise, the service is available on an elective basis and is paid out of the employee's pocket. Level 2 is a Home Evaluation Profile (HEP), conducted under the auspices of National Eldercare, and provides National eldercare the opportunity to see what is going on in the home and with the health of the older person. Interventions can be accommodated at this time to correct immediate health and safety problems that the PEP identified. Specifically, the HEP covers: (a) an assessment of the older person's health and physical ability; (b) a comprehensive drug review that examines the self-medication patterns, warns against potential drug interactions, and suggests improvements; (c) assessment of the older person's mental health and neighborhood ties; (d) notes on how to modify the residential structure and its amenities to make it more "elder-friendly"; and (e) notes on access to neighborhood facilities and the available transportation options.

Level 3 is a Review Panel and Preparation of the Eldercare Action Plan. The National Eldercare Review Panel is a group of 5 professionals who represent the five divisions of service delivery being organized in the company's preferred provider network. These five divisions are: (1) Health and Allied Services, including Wellness programs; (2) Home and Personal Services, including home safety, home modification, custodial care services, transportation, etc.; (3) Elderlaw, including estate planning; (4) Financial Planning and Asset Management; and (5) Case Management/Quality Assurance and Utilization Review. An action plan is developed that prioritizes the steps that need to be taken to help keep the older person living safely in his or her own home; recommends providers within the closed-panel network of eldercare specialists, including estimated costs and fees; evaluates insurances and entitlements; and attempts to maximize third-party reimbursement.

The fourth level is Resource Management and Core Management Services. A Resource Manager, supported by the National Eldercare's database operations, is called upon to be an advocate for the family and the well-being of the older person in his or her own community and home setting. The Resource Manager recommends core management services (typically elective and paid for on a fee-for services-basis) may include drug utilization review; personal emergency response system; wellness regimen/preventative care and participation in outside activities by the older person; home maintenance; etc. In a basic core management services contract between National eldercare and the family, a fixed monthly amount is determined and billed on a monthly cycle. Other episodic or one-time charges are incurred as needed and as agreed to by the family.

Notwithstanding the usefulness of programs such as Genesis ElderCare and National Eldercare, similar networks of professionals already exist at the State-level, provided through the Older Americans Act. The Older Americans Act of 1965 is the major categorical grants program provided in federal law to advance the interests and needs of older persons relative to the provision of social and health-related services. It provides a central focus for a broad range of constituent activity on the part of various public and private sector organizations, institutions, agencies, and individuals seeking to improve the aged's actual status in society. It provides an integral stimulus--through a partnership of federal government with state and local governments, the private sector, and older persons themselves--for promoting the allocation and/or redistribution of resources on behalf of the elderly beyond those granted by the federal government. The Older Americans Act has, for the past 30 years, played a crucial role in bringing national resources to bear in addressing older persons needs. The overall design of the Act is anchored on the premise that decentralization of authority and the use of local control over policy and program decisions are necessary ingredients for creating a more responsive supportive service system at the local level.

When first enacted in 1965, the Older Americans Act established a federal Administration on Aging responsible for overseeing the creation of a more responsive service system at the community level specifically designed to meet the social and human service needs of the elderly. Today, AoA is the principal agency in federal government responsible for building strong inter-governmental partnerships to address the concerns and problems of older Americans. AoA has defined its mission in terms of two major goals. These are: (1) To promote opportunities for older persons to secure and maintain independence and self-sufficiency; and (2) To ensure, to the extent possible, that services or other appropriate assistance are available to those older persons in the greatest social or economic need. In pursuit of these goals, AoA has sought to (1) serve as a federal focal point for addressing issues affecting older persons; and to (2) assist states and localities to promote the development of coordinated, community-based service systems for those older persons in need.

The State Office on Aging is the statewide leader in the planning, coordination and delivery of programs and services for older adults to promote their health and well-being. These services are provided at the local level, through Area Agencies on Aging. Title III is the principal service title under the Older Americans Act. It is predominantly through the programs and structures of Title III

that the Older Americans Act touches older people. Title III is organized into several parts. The main parts that are currently funded include: general provisions (part A); supportive services and senior centers (part B); congregate nutrition service (part C-1); home-delivered nutrition service (part C-2); in-home services for frail older individuals (part D); and, disease prevention and health promotion services (part F).

Definitions used by the Older Americans Act to describe Title III-B services are provided below.

Adult Day Care: a program of therapeutic social and health activities and services provided to adults who have functional impairments, in a protective environment that provides as noninstitutional an environment as possible.

Advocacy: action taken on behalf of an older person to secure his/her rights or benefits. Includes receiving, investigating and working to resolve disputes or complaints informally. Does not include

services provided by an attorney or person under the supervision of an attorney.

Chore: performance of house or yard tasks including such jobs as seasonal cleaning, essential errands, yard work lifting and moving, simple household repairs, pest control, and household maintenance for eligible persons who are unable to do these tasks for themselves because of frailty or other disabling conditions.

Case Management: begins with initial client intake and continues through the application process, assessment of need, service planning for a client, provision or arranging for provision of services, review and reassessment of client need, and revision of service plans as appropriate.

Counseling: the exploration of a client's interests and skills, problem solving, emotional support and guidance and encouragement for adopting new behaviors, and setting of realistic goals. It also may

include diagnosis and structured treatment of psychological and psychosocial problems. The counseling takes place on a one on one basis and may include family members.

Companionship: visiting a client who is socially and/or geographically isolated, for the purpose

of relieving loneliness and providing continuing social contact with the community by casual conversation, providing assistance with reading, writing letters, or entertaining games.

Discount: a reduction made on goods or services from a regular or list price.

Education/Training: providing formal or informal opportunities for individuals to acquire knowledge, experience, or skills.

Emergency alert/response service: a community based electronic surveillance service which monitors the frail homebound elderly by means of an electronic communication link with a response center.

Employment: assisting an individual to secure appropriate paid employment. This may include part time, full time, or temporary employment.

Escort: personal accompaniment of individuals to or from service providers. Escorts may also provide language interpretation to people who have hearing/speech impairments or speak a foreign language.

Home Health Aide: the provision of medically oriented personal health care services by a trained home health aide employed by a licensed home health agency to an individual in the home under the supervision of a health professional.

Homemaker Service: the accomplishment of specific home management duties including housekeeping, meal planning and preparation, shopping assistance, and routine household activities by a trained homemaker.

Housing Improvement: providing home repairs or alterations for an eligible person or assistance in obtaining needed repairs or alterations for the client's home; arranging for home improvement grants or loans; providing assistance to obtain adequate housing; securing fuel and utilities, and provision of pest exterminating services. Housing Improvement is distinguished from Chore in that Housing Improvement and Emergency Home Repair may encompass repairs requiring a permit for accomplishment while Chore may not.

Health Support: activities to assist persons to secure and utilize necessary medical treatment as well as preventive, emergency and health maintenance services. Examples of Health Support services include obtaining appointments for treatment; locating health and medical facilities; obtaining therapy; and obtaining clinic cards for clients.

Information: responding to an inquiry from a person, or on behalf of a person, regarding resources and available services.

Interpreting/Translating: explaining the meaning of oral and/or written communication to non-English speaking and/or handicapped persons unable to perform the functions.

Legal Assistance: broadly defined in the Older Americans Act as meaning "legal advise and representation by an attorney (including, to the extent feasible, counseling or other appropriate assistance by a paralegal or law student under the supervision of an attorney), and includes counseling or representation by a non-lawyer when permitted by law, to older individuals with economic or social need." Legal Assistance for program delivery purposes is defined as services to assist clients to become aware of and protect their civil/legal rights through activities or direct intervention by attorneys or legal paraprofessionals.

Letter Writing/Reading: reading and/or writing business or personal correspondence.

Material Aid: aid in the form of goods or food such as the direct distribution of commodities, surplus food, the distribution of clothing, smoke detectors, eyeglasses, security devices, etc.

Medical Therapeutic Services: corrective or rehabilitative services which are prescribed by a physician or other appropriate health care professional. Such therapies may include occupational therapy, physical therapy, respiratory therapy, and services for individuals with speech, hearing and language disorders.

Outreach: making active efforts to reach target group individuals, either in a community setting or in a neighborhood with large numbers of low income minority elderly, making one-to-one contact, identifying their service need, and encouraging their use of available resources.

Personal Care: services to assist the functionally impaired elderly with bathing, dressing, ambulation, housekeeping, supervision, emotional security, eating and assistance with securing health care from appropriate sources.

Placement: assisting a person in obtaining a suitable place or situation such as housing or an institution such as a nursing home.

Recreation: participation in or attendance at planned leisure events such as, games, sports, arts and crafts, theater, trips and other relaxing social activities.

Referral: an activity wherein information is obtained on a person's needs and the person is directed to a particular resource; contact with the resource is made for the person as needed; follow-up is conducted with the referred person and/or resource to determine the outcome of the referral. Agencies making referrals will usually obtain intake information from the client to be used as part of the referral process.

Respite Care: relief or rest from the constant/continued supervision, companionship, therapeutic and/or personal care, of a functionally impaired older person for a specified period of time.

Shopping Assistance: assisting a client in getting to and from stores and in the proper selection of items. An individual Shopping Aide may assist more than one client during a shopping trip.

Screening and Assessment: is defined as administering an assessment test or other eligibility instrument to determine new applicant's eligibility for services or ongoing eligibility for services for current clients.

Supervision: overseeing actions and/or behavior of a client to safeguard his rights and interest for the purpose of protection against harm to self or others.

Telephone Reassurance: communicating with designated clients by telephone on a mutually agreed schedule to determine their safety and to provide psychological reassurance, or to implement special or emergency assistance.

Transportation: travel to or from service providers or community resources.

One Area Agency on Aging that has a very active senior transportation component is the Central Plains Area Agency on Aging (CPAAA) in Kansas. The CPAAA in Wichita, KS developed a model to improve senior transportation services in a tri-county area (Sedgwick, Butler, and Harvey Counties) populated by 80,000 seniors (one-third of whom are age 75+). A two-year demonstration grant was awarded to the CPAAA by the Administration on Aging (9/93 to 9/95). One objective of this project was to "establish linkages between the Area Agency on Aging, local law enforcement, and driver's license offices to connect the elderly who may be at-risk of losing accessibility through their automobile with information on alternative transportation resources" (Central Plains Area Agency on Aging, 1996). This model has three main components: (1) planning for retirement from driving; (2) learning how to drive safely longer; and (3) peer counseling to help ease the transition. Planning allows time to obtain knowledge about alternative transportation resources. Learning how to drive safely longer allows a driver to take action such as self assessment, exercise or physical therapy, and refresher courses such as 55 Alive. Peer counseling addresses a need for counseling to seniors experiencing problems dealing with the transition from driver to retired driver. This proactive approach was hypothesized to lead to voluntary retirement from driving, as opposed to involuntary retirement/loss of license due to DMV action or traffic violations/crashes.

The CPAAA developed a partnership with the Helping Our Own People (HOOP) program, which is a volunteer peer counseling program. CPAAA also developed Older Drivers in Crisis: A Handbook for Peer Counselors, as a supplement to training required of counselors participating in the local HOOP volunteer peer counseling program. The five goals of peer counseling for older drivers are: (1) to show empathy, respect, and genuine caring to help an older driver in crisis; (2) to help the older driver by listening to his or her individual situation and then help solve the problem; (3) to use the counselor's awareness of issues involved in retiring from driving and communicate those to the older driver in crisis; (4) to use the counselor's knowledge of the aging process to counsel older adults; and (5) to familiarize the counselor with local transportation resources and increase access to those resources for older adults.

CPAAA created a brochure entitled, "Planning for the Day You Retire From Driving." The brochure targets seniors who are still driving, but advocates planning ahead for the day they retire from driving since that day could come unexpectedly, as a result of a crash or sudden illness. It contains several yes/no questions to get drivers thinking about their health, driving habits, and trip planning, and provides simple tips in these areas to help drivers drive safely longer (e.g., annual vision checks, exercise programs, schedule trips during non-rush periods). Because one of the objectives of the CPAAA's Senior Transportation Project was to link seniors who lose their drivers licenses to information on transportation alternatives, seniors are also encouraged to use the Wichita Metropolitan Transit Authority's "Senior Transportation Hotline" for specific information about transit resources in their area. The brochure encourages seniors to contact the CPAAA for peer counseling to help those already in transition from driving. The brochure is distributed to local senior centers, social service agencies, driver's license offices, rural law enforcement offices, AARP's "55 Alive" program administrators, health care providers, and other agencies.

Another brochure was developed in conjunction with the CPAAA and Rehability (a national rehabilitation corporation specializing in physical therapy) called "Helping You Drive Safely Longer." It contains a (self) driving assessment (17 yes/no questions) of hearing, vision, head/neck flexibility, and problems with arms and hands, and legs and feet. It also provides tips related to these areas, as well as simple exercises for helping seniors drive safely longer. A 20-minute video was also produced with this title. It contains testimonials of two seniors who took the driving assessment and underwent approximately six weeks of exercise recommended by rehability. Simple exercises are demonstrated that seniors can do at home to improve problem areas or weaknesses which affect their driving ability. Driving assessment clinics and exercise demonstrations were a part of this program so that groups of seniors at senior centers and nutrition sites could view the video, assess their driving ability using the tool in the accompanying brochure, and be shown personalized exercise routines by a physical therapist facilitating the clinic.

An evaluation of the brochures and clinic was conducted and is described in the CPAAA Final Report (CPAAA, 1996); the lessons learned are summarized next.

The "Planning for the Day You Retire from Driving" brochure was completed long before the "Helping You Drive Safely Longer" package was produced. The "Planning" brochures were distributed to 67 agencies in the tri-county area to test reactions and experiment with distribution methods. One-thousand brochures were sent to: 3 driver's license examining stations; 3 city police departments in small towns; the Kansas Highway Patrol; Kansas Safety Belt Education Office; the Kansas Traffic Safety for Older Adults Private and Public Agency Working Group; 41 senior centers; 4 social service agencies; 13 health care providers; Wichita Metropolitan Transit Authority; a Life Enrichment Program at a community college; and 1 church. A short survey was conducted to determine seniors' reactions to the brochures; 39 agencies responded to the survey. Some agencies displayed the brochures, but most chose to either personally hand them out or to combine a display with a hand-out. Of the agencies who discussed the brochure with seniors, most said the topic received a negative reaction. Only 12 percent of the 39 agencies stated that the information was well received. The distributing agencies were in agreement that the brochure was a good idea, however, since this is a sensitive subject, they indicated that a different distribution method should be evaluated that would be less offensive to seniors. A second distribution method involved a well-known and respected Community Liaison law enforcement officer who spoke at a Senior Center about issues surrounding retiring from driving to a group of 25 seniors. He spoke about the effects of aging and driving, and alternative transportation options. Brochures were handed out to the participants. Seniors were receptive to the topic and accepted this type of information dissemination.

Next, the "driving safely longer" package (brochure and video) was provided to 41 senior centers in the tri-county area, selected health care providers (hospitals, home health agencies, and private physicians), public libraries, and three grocery stores that have video departments. The materials were also incorporated into the AARP 55-Alive defensive driving courses delivered throughout Kansas, the Kansas Department on Aging, and the University of Kansas Transportation Center Lending Library. Rehability conducted six driver screening clinics in the Spring of 1996, that were attended by a total of 140 seniors. The attending physical therapist from Rehability conducted a short presentation. Then the majority of the participants were assessed by the therapist, and were provided with written examples and demonstrations of simple exercises, tailored to their particular needs.

In addressing the problem of seniors who are unsafe behind the wheel, but continue to drive, CPAAA found that seniors reacted most positively to presentations that included a showing of the "Helping You Drive Safely Longer" video and distribution of the accompanying brochure and the "Planning For The Day You Retire From Driving" brochure, or driving assessment clinics in which the video is shown, brochures are distributed, and exercises are demonstrated. CPAAA states that because the seniors responded positively to these methods, they will be more likely to give up driving when they can no longer drive safely. The "Planning For the Day" brochure distributed alone, on the other hand, even though written with a positive tone was threatening.

One point of interest, is that the clinics ceased to be administered when the funding for the pilot study was no longer available (at the end of the project). A contract had been drawn with a regional medical center rehabilitation department to have a physical therapist perform the assessments, at no cost to the consumers. When the pilot study ended, the Area Agency on Aging did not renew the contract with Rehability. This points to the need to develop alternative funding sources for assessments and training that can be performed through Area Agencies on Aging, such as corporate sponsors or insurance companies.

Conclusions/Preliminary Recommendations:

Area Agencies on Aging are well-positioned to provide education, training, assessment, counseling, and referral services to older drivers. These social service providers (and potentially, volunteers they would need to recruit) could be a significant source of information for and about impaired older drivers, however, few of these agencies presently advertise services specifically related to safe driving, or appear to even communicate with DMVs. What the commercial and Government services have in common are services to assess needs for remaining independent, links to resources to help maintain independence, and support when independent living is not safe. They (including Genesis and National Eldercare) all have the potential to be incorporated into a Model Driver Screening and Evaluation Program, as they include assessment of functional capability. What is not known is what kinds of confidentiality issues there are to overcome, and what the impact of reporting to a DMV would be for individuals requesting assistance. Since GES is part of the State Health Department, the confidentiality issue may be able to be resolved, and possible negative impact on requests for assistance may be reduced. The benefits of providing drivers with information about self-assessment, alternative transportation, and peer counseling by AAA volunteers may be enough to enable drivers to make responsible driving decisions; referral to the DMV may only be necessary when drivers refuse to drive responsibly and need the hand of authority and license revocation before admitting that they are no longer safe to drive. For those drivers where this is the case, peer counseling may become an appreciated component. It is recommended that a position (or two) be funded at each local area Agency on Aging to develop and coordinate a program geared to assisting older drivers in assessing their ability to drive safely, counseling older drivers about how to remain safely mobile longer, and about how to use alternative transportation when needed.

References:

• Central Plains, KS: Area Agency on Aging (1996)

• Genesis ElderCare Brochures; pers. comm., Abby Weintraub, Full Life Counselor, Kennett Square, PA, 4/98

• Maryland Geriatric Evaluation Services (GES) Brochure; pers. comm., L. Dersch, Harford County, MD, 1/98; pers. comm., B. Fleming, Baltimore, MD, 1/98

• National Eldercare (President: Richard J. Lank), Box 12364, Silver Spring, MD 20908. Website: www.natleldr@bellatlantic.net

• Older Americans Act; Title III

IC1(b)vi. Hospital Plan of Discharge/Care Referral Plan

No specific mention was made of assessing transportation needs or driving fitness or referral of patients to the DMV; however, Sonia Coleman, formerly an OT at National Rehab Hospital wrote that elderly drivers learn about driver rehab services provided by OTs and PTs when they are hospitalized for a condition that results in impaired driving ability (Coleman, 1994). According to Coleman, driver rehabilitation is available from occupational therapists (OTs), physical therapists, vocational counselors, speech therapists, optometrists, and psychologists. It is the OT's role to help a person be as independent as possible. OTs teach older drivers compensatory strategies for slowed reaction times. OTs and physical therapists help older drivers improve arm and leg strength so they can safely drive a car; they also train drivers to use adaptive equipment to continue driving with a physical disability. In addition, they guide elderly drivers to choose the best time of day to drive safely and to use public transportation. Vocational counselors help older drivers who work or are involved in volunteer activities to find positions that are close to home and do not require night driving. Other health professionals train elderly drivers to improve decision-making skills or offer vision training, eye exercises, and corrective lenses to improve eyesight.

Coleman goes on to say that unfortunately, healthy elderly drivers are seldom aware of these services, and evaluations to qualify drivers to receive services from medical professionals are expensive and not covered by medical insurance. When older drivers turn to less costly commercial driving schools, they often find they do not get the kind of help they need. Coleman suggested that meeting the rehabilitation needs of older drivers should begin with standardized driver education training for all health professionals. These trained health professionals would receive referrals from licensing agencies and evaluate each older driver's needs. Health professionals could recommend rehabilitation through specific health service providers, through an educational program like "55 Alive," or through a commercial driving school. Coleman believes that instructors at commercial schools should also be trained in the special needs of older drivers. Finally, Coleman called for insurance companies to cover the cost of driver rehabilitation programs. Coleman concluded that driver licensing agencies, health professionals, and commercial driving schools could work together to create an effective, affordable rehabilitation program for older drivers.

An example of how health professionals are participating in assessments of fitness to drive and referrals was provided by Debbie Perkins, a geriatric nurse practitioner at St. Mary's Hospital Senior Center in Richmond, VA. A detailed description of the activities conducted at this clinic was presented in Section IB2 of this Notebook. At this Center, a community-based team of professionals performs detailed comprehensive senior health assessments that focus on age-related factors that influence an older person's health and well being. The team includes a physician, nurse practitioner, pharmacist, and social worker; all have expertise in caring for older persons. Other professionals (e.g., occupational therapists, physical therapists, dieticians, audiologists, and other physician subspecialists) are consulted as necessary. The team's findings are used to develop recommendations and a care plan for patients, their families, and physicians. The goal of the center is to provide detailed information that is incorporated into regular primary medical care. Functional tests include a review of activities of daily living, and tests of mobility, gait and coordination. Clients may be referred to a neuropsychologist for more in-depth testing, including reaction time.

Driving history and fitness to drive are assessed as part of the health assessment at St. Mary's Hospital Senior Center. The client's previous driving record is reviewed, the family is asked if they have observed unsafe driving behavior, and questions are asked of the client and family about whether the patient gets lost while driving. The assessment outcomes are categorized as follows: (1) clearly safe to drive; (2) clearly unsafe to drive; and (3) possibly safe with intervention/needs more testing. For those who are deemed clearly safe to drive, a recommendation is made to the client's family to ride with the driver frequently to keep track of the client's performance, and to notice cognitive changes over time. For those who are deemed clearly unfit to drive, a "no driving prescription" is written and the client is reported to the DMV; the DMV will revoke a license. For those who need intervention, a referral is made to additional disciplines (e.g., ophthalmologists, physical therapists). There are two private pay driver evaluation programs in Richmond, VA that provide additional testing and restorative therapy. For drivers who need more testing, referrals also are made to the DMV for knowledge testing, on-road testing, or both (at no charge to the client). The Health Center does not perform driving evaluations. The Center is reimbursed by Medicare, and if a client has supplementary insurance (Blue Cross/Shield) the entire cost is usually reimbursed.

Conclusions/Preliminary Recommendations:

It is currently unknown what percentage of hospitals address fitness to drive when preparing a discharge plan of care; it may be that only hospitals with a driving rehab facility consider the issue of driving. It is also unknown to what extent hospitals provide information to the DMV/Medical Advisory Board. There may be patient information confidentially issues that need to be resolved before hospitals could make reports to a DMV. However, besides referring patients for remediation of driving skills or advising against driving, hospitals discharge planners could be a source of referrals to the DMV. The information could become part of the driver licensing file, to assist in future decisions regarding license renewal testing, renewal periods, restrictions, etc.

References:

• Coleman (1994)

• Internet search of geriatric discharge planning

• pers. comm., Debbie Perkins, Geriatric Nurse Practitioner, St. Mary's Hospital Senior Health Center, Richmond, VA, 4/98

IC1(b)vii. Assessments Performed at Special Events/Wellness Fairs

Recently, the Philadelphia Corporation for Aging sponsored an "Age Expo" at the Philadelphia Convention Center. This event was for "fun and information" for people age 50 and older, and included over 300 exhibits, plus health screenings. The Expo offered 20 different health screenings on site, that were free with admission. Information about fitness and nutrition were also presented as separate events.

[ PCA Age Expo Schedule ]

IC1(b)viii. Referral From Vision Specialists

In New Brunswick, a program is currently in place for mandatory reporting by optometrists (Staplin and Lococo ,1998). According to the Ontario Highway Traffic Act, all physicians and optometrists are required to report to the Registrar of Motor Vehicles, any person over age 16 who has a condition that could impair the safe operation of a motor vehicle. The physician's report is confidential and the physician is immune from legal action. Also, Yukon Territory requires physicians and optometrists to report conditions to the Department (Petrucelli and Malinowski, 1992).

Conclusions/Preliminary Recommendations

Vision specialists should counsel their patients regarding the effects of eye disease and reduced visual function on the driving task. Indeed, older adults participating in a focus group study pointed to ophthalmologists as the group of physicians most likely to discuss driving with them.(Persson, 1993). States that do not require a vision test for license renewal would benefit from information that eye care specialists could provide, if reporting were mandated. Many visual impairments are remediable, so any license actions (restrictions) would need to be reviewed following visual correction or remediation.

References:

• Petrucelli and Malinowski (1992)

• Persson (1993)

• Staplin and Lococo (1998)

IC1(b)ix. Physician Reporting/Mandatory

Fourteen States/Provinces [California, Delaware (epilepsy), Georgia, Nevada (epilepsy), New Jersey, Oregon, Pennsylvania, Manitoba, New Brunswick, Northwest Territories, Ontario, Prince Edward Island, Saskatchewan, and Yukon Territory] currently require physicians to report medical conditions hazardous to driving to licencing agencies. All of these grant the physician immunity from legal action by the driver (Petrucelli and Malinowski, 1992).

The Pennsylvania Vehicle Code (Section 1518), mandates physician reporting; this has been in effect since the 1960's. Reporting is done on the basis of any condition that may impair the ability to drive safely for anyone over the age of 15. The medical conditions are formulated by the Medical Advisory Board. Physicians have immunity from civil and criminal liability, since reporting is mandatory. Failure to report can result in a physician's being held responsible as a proximate cause of a crash resulting in death, injury, or property loss caused by his or her patient. Also, physicians who do not comply with their legal requirements to report may be convicted of a summary criminal offense. Physician reports are held confidential, and may be used only for licensing decisions. Reporting has increased steadily (approximately 500+ percent), until 1990, when there were 10,000 referrals. In 1992, PennDOT conducted an information campaign to 46,000 physicians; this resulted in 40,000 reports in 1994. This number of referrals is by far the largest of any State, and increases by approximately 2,000 each year. When a report is made, restrictions to the person's driving privilege may be added or deleted, the person's license may be recalled or restored, the person may be required to provide more specific medical information or to complete a driver's examination, or no action may be taken. The PennDOT Physician Reporting Fact sheet states that approximately 72 percent of individuals who are referred have medical impairments significant enough to merit temporary or permanent recall of their driving privilege. Fifty-one percent of the recalls are due to seizure disorders, and 16 percent to other neurological disorders. An additional 9 percent of physician reports result in restrictions placed on the individual's driving privilege; 60 percent of these restrictions involve special equipment needs. This sheet also states that these reports cross the age spectrum, with 51 percent involving drivers under 45 years of age.

Aizenberg and Anapolle (1996) reported that in Oregon, 31 percent of reports to the DMV on older drivers come from health providers. This is greater than the percentage of reports from self-referral (29%), law enforcement (24%), family and friends (10%), and DMV personnel (4%).

According to Janke and Hersch (1997), at the time of their report, California was the only State that mandated reporting of dementia to the licencing agency.

In Saskatchewan, crash data were examined for 226,864 drivers for the period between 1980 and 1989 (Medgyesi and Koch, 1994). Of these, 2,448 were participants in the Province's Medical Review Program. Another 63,398 were identified who had not been reported to the Province, but were diagnosed with a medical condition. Drivers with a diagnosis of alcohol/drug dependence, cardiovascular disease, stroke, coordination/muscular control diseases, diabetes, seizure disorders or visual disorders showed consistently higher rates of at-fault involvement compared to controls matched on age, gender, place of residence, license class, and period of driving. Diagnosed drivers in the Medical Review Program (those drivers with alcohol/drug dependence; cardiovascular disease; cerebrovascular disease; diabetes; visual disorders; essential hypertension; and commercial class drivers with seizure disorders) demonstrated a lower incidence of at-fault crashes than those diagnosed drivers not in the program, suggesting that the program is effective in reducing driving risk. Program effects were not observed for coordination and muscular control disorders, which the authors state may reflect the ineffectiveness of the medical review program to improve the performance of drivers which are less impacted by better self management.

NHTSA (1992) guidelines state that physicians must be granted immunity from legal action arising out of reporting, whether reporting is compulsory or on a voluntary basis.

Conclusions/Preliminary Recommendations:

Mandatory physician reporting is an effective means of identifying potentially at-risk drivers. The data collected in Saskatchewan suggests that under-reporting of potentially dangerous (diagnosed) conditions continues to be a problem. This study also demonstrates how effective a medical review program can be at reducing the risk of crashes for drivers with medical problems.

References:

• Aizenberg and Anapolle (1996)

• Janke and Hersch (1997)

• Medgyesi and Koch (1994)

• NHTSA (1992)

• Petrucelli and Malinowski (1992)

• Staplin and Lococo (1998)

IC1(b)x. Physician Referral/Voluntary

As of 1992, ten States and three Canadian Provinces (Connecticut, Florida, Illinois, Maryland, Minnesota, North Dakota, Ohio, Oklahoma, Rhode Island, Utah, Alberta, British Columbia, and Nova Scotia) permitted physicians to report potentially impaired drivers to the licencing agency. Of these, only North Dakota, Ohio, and Alberta do not grant immunity from litigation to physicians making these reports. Other jurisdictions allow the physician to report hazardous conditions to the licencing agencies, but only after the patient refuses to report himself or herself (Petrucelli and Malinowski, 1992; McEwan, 1997).

In Wisconsin, approximately 22 percent of the drivers referred to the DMV were referred by physicians, despite the fact that the State does not mandate such reports (Sterns, Sterns, Aizenberg, and Anapolle, 1997).

Conclusions/Preliminary Recommendations:

Reports from physicians, either on a mandatory or a voluntary basis, are an important source for identifying impaired drivers. Information must be provided to physicians about specific signs and symptoms. Furthermore, immunity from prosecution must be provided to physicians to encourage referrals of drivers whose impairments could compromise safe driving performance.

References:

• McEwan (1997)

• Petrucelli and Malinowski (1992)

• Sterns, Sterns, Aizenberg, and Anapolle (1997)

IC1(c)i. Distribution of Self-Evaluation Materials

Dobbs (in press) provides a review of the literature highlighting the fact that many older drivers compensate for age-related declines in capabilities by reducing their annual mileage, as well as regulating when and where they drive. Drivers who correctly perceive that there is a change in competence can appropriately modify their driving behavior, by restricting or ceasing driving (depending on the level of decline), and seek remediation for abilities that can be retrained or compensated for by adaptive equipment.

The purpose of a Self Evaluation Guide under development for PennDOT (Decina et al., in press) is to raise older drivers' self-awareness about their driving habits, their physical and mental well-being, and to address concerns about specific driving difficulties that they may have. The Guide also provides ways for older drivers to test their abilities to make sure they are "up to par" in aspects of vision, attention, and motor coordination related to safe driving. Several of the GRoss IMPairments Screening (GRIMPS) tests [see Notebook section IC2a(i)] are included (arm reach, rapid-pace walk, foot tap test, head/neck flexibility), in addition to a contrast sensitivity test. The Guide offers strategies that may help older drivers compensate for the problems they experience as they age.

Janke (1994) reported that California plans to develop an older driver self-assessment kit as a means of making drivers more aware of the need to compensate/self restrict. The kits would include a questionnaire and a scoring key that would indicate to drivers what self restrictions might benefit them. She proposes that kits be sent to some subjects randomly selected from a sample of elderly drivers, whose subsequent driving records would be compared in a prospective study with those of subjects not receiving kits. Surveys could be made before and after mailing the kits to determine driving habits and practices, mileage, and (for the treatment group) the reported influence the kits had on their driving behavior. The proposed activity has not been implemented. California is, however, trying to implement an age-mediated point system in which drivers age 70+ who have 2 or more crash or violation points in a year would be sent the AARP Skill and Assessment Guide and would be asked to take the self tests included therein. No evaluation of the effect is planned (pers. comm., M. Janke, 7/98).

Conclusions/Preliminary Recommendations:

Older drivers who do not suffer from cognitive impairment have the ability to assess their own capabilities, and choose strategies to remain safe on the road, or to know when to stop driving. A resource that provides advice about which capabilities are important to driving safely, how to test these abilities, what the score means, and where they can go and what they can do if they don't perform well (e.g., get pedal extenders or other adapted driving equipment from an occupational therapist; go to a physician or geriatric nurse practitioner to check number/interaction of medications; increase flexibility/endurance through exercise; contact local Area Agency on Aging for alternative transportation, wellness programs, educational programs, etc), is an important resource that serves the same function as a first-tier screen (i.e., GRIMPS) in a DMV or other institutional setting.

References:

• Decina, Staplin, Lococo, and Hughlett (in press)

• Dobbs (in press)

• Janke (1994)

IC1(c)ii. Automated Testing in Public Venues (e.g., Kiosks)

Current innovative electronic technology provides feasible applications for providing information and education to the public (Decina, Staplin, Gish, and Kirchner, 1996). Recent innovative technology to communicate traffic safety issues to the public has been demonstrated by U.S. DOT agencies.

The National Highway Traffic Safety Administration (NHTSA) has determined that there is strong potential for using electronic media to facilitate learning of safe driving skills (Smith, 1994). NHTSA sponsored the development of an interactive traffic safety education program, "The Traffic Safety Box (TSB)," created for pre-drivers and drivers, which uses interactive technology and multimedia presentations. The program was originally developed for a kiosk, but then redirected to reach youth as a program accessible through CD-ROM technology. The TSB has an educational format with four learning modules: students take an informal pre-test, get repeated reinforcement of important messages, and take a post-test to measure what they learned in the exercise. The TSB can be incorporated into a week's lesson in driver education classes or used at a special events which focus on safety issues (NHTSA, 1998).

The Federal Highway Administration (FHWA) is using a computer-based, interactive touch screen kiosk which uses a full complement of multimedia to bring attention to the public traffic safety issues in a way that is more engaging than traditional publications or videotapes. The "Moving Safely Across America" kiosk provides users the ability to interact with and experience various aspects of highway safety, as well as test their understanding of these topics. The kiosk consists of three separate modules: Road Trip, which provides a virtual journey where users encounter four different situations where they must make decisions about highway safety; Road Challenge, which provides a fast-paced game where users must answer questions about highway safety in order to earn safety miles; and Safety Stops, which is a database of facts (FHWA, 1997).

Conclusions/Preliminary Recommendations:

Similar applications to help the older driver (e.g., self-assessment, safe driving tips, local mobility options) are quite feasible. Venues for kiosks can include malls and shopping centers, license renewal centers, and community centers. Venues for CD-ROM and other software applications can be accessible through PCs, as well as at libraries, academic institutions, and in the home.

References:

• Decina, Staplin, Gish, and Kirchner (1996)

• Federal Highway Administration (1997)

• National Highway Traffic Safety Administration (1998)

• Smith (1994)

IC1(c)iii. Outreach by Professional Associations (AAA, AARP, "Wellness Fair")

Decina, Staplin, and Lococo (1997) identified several dozen safety publications, which are currently available to the public from state licensing agencies and other organizations (predominantly the American Association of Retired Persons (AARP), American Automobile Association (AAA), and AAA Foundation for Traffic Safety to help older drivers and their concerned family and friends. The material collected ranged from booklets and pamphlets, to less common items such as flyers, reference cards, newsletters, and even some videos. Most of the publications targeted older drivers themselves, and covered a wide range of topics, including: older driver safety; vehicle design and adaption measures; vehicle maintenance; environmental/road design and adaptions; driver improvement and rehabilitation; behavior change; occupant protection; aging and health; specific medical problems (i.e., vision, dementia); professional referral sources; licensing issues and procedures; transportation options; driving cessation; assessment tips; and counseling tips. Aging and health issues were common topics mentioned in the publications. These issues covered information on demographic trends, morbidity and health characteristics of the older population, and cognitive and physical changes that accompany the aging process. Other common topics were references to professional resources (i.e., physicians, optometrists); driver improvement and rehabilitation; and behavioral changes and safe driving practices to reduce collision risk.

Wellness fairs are a venue where people can learn safety techniques and practice skills. Organizations such as AARP and AAA could participate in wellness fairs, providing stations where older drivers could test their capabilities and obtain information about danger signs, safe mobility, and alternative transportation. Recently, the opportunity for older drivers to find out whether their driving "needed a tune up" was provided at the annual meeting of the American Occupational Therapy Association, in Baltimore, MD (4/98). The assessment was advertised in several local newspapers and was free to drivers. It was reported by Kim White of Sinai Rehab, that only 2 or 3 older drivers took advantage of this assessment opportunity. Driving is a touchy issue for many older persons, and they may not want to participate in an assessment for several reasons. They may not be ready to face the possibility that they are no longer safe; or they may not want anyone in the medical community to know their functional status for fear of referral to the DMV.

Doylestown Hospital (Doylestown, PA) mails a Health and Wellness Directory to area residents on a yearly basis that lists the Hospital's programs and community services. The information contained in the guide is compiled by the Community Relations Department at Doylestown Hospital, and includes services and programs for older adults, teens, health and fitness for maternity patients, support groups, etc. Senior programs include 55 Alive/Mature Driving classes, senior wellness/aerobics programs, adult day care, yoga, and foot care facts. A page from this Directory is presented at the end of this section. Another program, the AgeWell Center, is a joint program of Presbyterian Homes, Inc. and St. Luke's Hospital (also in Pennsylvania). A listing of special programs for older adults that were presented at an area mall is also provided. Many of the programs have special relevance to driving, but it is unknown whether the relationships between driving safety and health, exercise, medication use are highlighted for the participants, other than what would be presented in the 55- Alive Class. Health professionals need education about their specialties and driving risk, so that this information can be incorporated into their community program activities.

The Central Plains Area Agency on Aging in conjunction with Rehability (a national rehabilitation corporation specializing in physical therapy) developed a brochure called "Helping You Drive Safely Longer." A 20-minute video was also produced with this title [see Notebook section IC1(b)v]. Driving assessment clinics and exercise demonstrations were a part of this program so that groups of seniors at senior centers and nutrition sites could view the video, assess their driving ability using the tool in the accompanying brochure, and be shown personalized exercise routines by a physical therapist facilitating the clinic.

Conclusions/Preliminary Recommendations:

Older drivers must trust that their performance during professional-sponsored clinics and wellness fairs will be held confidential. Special care needs to be taken to determine where the clinic should be held for the best attendance and participation; and the approach should be seen as positive (e.g., aimed at helping seniors drive safely longer, as opposed to trying to determine who should not be driving). In addition, a successful outreach program and clinic must provide more than just tests to assess driving ability. The clinic should provide information about what to do when someone doesn't perform well, such as referral information for further testing/remediation of specific disabilities; how to compensate for diminished capability; exercises for improving performance; and information about local alternative transportation and peer support groups. Counseling is a necessary component to assessment activities performed in clinics and wellness fairs held in community settings.

References:

• Notebook section IB3

• Decina, Staplin, and Lococo (1997)

• pers. comm., K. White, Sinai Hospital, Dept. of Rehab., Balto. MD, 4/20/98

• Central Plains Area Agency on Aging (1996)

• AgeWell Center; Bucks County Wellness Partnership (Doylestown, PA)

• AAMVA (1997) Communications Resource Guide

[ Doylestown Hospital Directory From: Doylestown Hospital's 1998 Dialog: Health and Wellness Directory- A Guide to Doylestown Hospital's Programs and Community Services.. ]

[ Program Listing for AgeWell Center ]

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