Driver Screening and Evaluation Program
Volume III: Guidelines for Motor Vehicle Administrators
Each jurisdiction deciding to implement a screening and evaluation program will face unique challenges in program administration and in the delivery of services to its driver population. At the same time, it is possible to identify certain resources that will be required by most if not all jurisdictions, and to provide guidance for certain aspects of program operations that should uniformly enhance their efficiency and cost-effectiveness. Following a brief discussion of system capacity issues, the consideration of resource requirements in the Model Program will focus on personnel, training, and facilities and equipment needs.
The capacity of a screening and evaluation program, represented as the number of individuals screened annually in a State, is driven by the laws and policies governing eligibility. Jurisdictions in which people become eligible for screening for the functional abilities to drive safely only through referral to the DMV will have the lowest capacity. At the high end would be any jurisdiction where some type of screening, however limited, was implemented as a requirement for all drivers for initial licensure and for license renewal. Between these extremes are jurisdictions where screening for functional ability would be required in the case of valid referrals to the DMV, and also would be phased in for license renewal at a particular age threshold. The Model Program reflects this intermediate strategy, while recognizing that different jurisdictions will choose different age thresholds, for different reasons.
Estimating system capacity thus begins with a review of historical records showing the number of referrals by source to the DMV, plus current and projected age distributions of licensed drivers in a jurisdiction. Through education activities for the general public and for specific groups such as physicians and others in the health care profession that are recommended under the Model Program, it is expected that the volume of referrals will increase. In addition, changes in the laws which require--versus those which allow--physician reporting; the immunity provided in the case of such referrals; and the penalties and liabilities associated with failure-to-report all will impact referral volumes. The result of initiatives in this area can be dramatic: In Pennsylvania, following an information campaign reminding physicians of their mandate to report patients with conditions that could impair the ability to drive safely, the number of drivers referred to PennDOT increased from 10,000 in 1990 to over 40,000 in 1994.
Gauging system capacity in terms of the increase in the number of older persons in a given jurisdiction, which may be projected with reasonable accuracy from Census data, must also take into account the percentage of drivers in different age cohorts who retain their licenses. Research indicates that while the rate of licensure drops off significantly by about age 80 for females, and 85 for males, the percentages of all older men and older women with licenses are increasing and that gender differences are narrowing over time.8 If screening requirements for renewal are put in place, this trend may be offset to a small degree by voluntary cessation of driving. During pilot studies in Maryland it was observed that approximately 10% of drivers who were referred to the MVA for medical evaluation declined to keep their scheduled appointments for mandatory functional screening, instead choosing to relinquish their licenses.
After considering the factors outlined above and weighing their likely impact in a State, licensing authorities will be in a position to refine their projections of the number of drivers who would be screened, at particular age thresholds. A higher threshold will result in fewer drivers eligible for screening through the renewal process. For example, in Maryland in the year 2000 there were 452,591 drivers over age 65, or 12.7% of the driving population, but only 182,530 drivers or 5.1% of the driving population over age 75.
A final adjustment in estimating the annual numbers of drivers eligible for screening under the Model Program will reflect the renewal cycle in a given jurisdiction. Based on the Maryland example, where the renewal cycle is five years, the drivers eligible for screening under the Model Program would include referrals plus ~90,000 using an age threshold of 65, and referrals plus ~36,000 using an age threshold of 75. Of course, in future years these numbers would be expected to grow according to the demographic and behavioral trends noted earlier.
Thus far, the discussion of system capacity to perform driver screening has considered only first-tier assessments. As emphasized in these guidelines, these types of screening activities are designed primarily to determine whether and how urgently further evaluation may be required. And while screening may identify drivers with significant impairments who would otherwise go undetected, the functional measures recommended under the Model Program also hold the promise of reducing the number of drivers subject to more sophisticated and costly diagnostic assessments.
A case in point is drawn from the Maryland Pilot Older Driver Study conducted in cooperation with NHTSA. Relative to the period before a functional screening requirement was put in place for drivers referred to the MVA for medical evaluation, the percentage of people cleared to continue driving and the percentage for whom restrictions or cessation was recommended both increased; at the same time, the percentage of referrals for whom a recommendation was delayed pending a follow-up interview and/or a road test dropped sharply. A key benefit of the functional screening data was that it removed a substantial degree of uncertainty from the driver evaluation process, with dramatic gains in program efficiency. The official in charge of the pilot program in Maryland estimated that, in the future, screening could reduce the required number of road tests for referred drivers by up to 50 percent.9
Implementation of the full Model Program as recommended in these guidelines will involve the services of a diverse group of professionals to perform diagnostic assessments, education, counseling, mobility planning, and a host of remedial activities that are designed to help people keep driving safely longer. Medical and ophthalmological specialists, other health care professionals, and especially each driver's personal physician will play essential roles in a successful program. Occupational therapists and others qualified as Certified Driver Rehabilitation Specialists (CDRS) are likely to be in greatest demand; these individuals perform driver evaluations as well as prescribing adaptive/assistive equipment and training drivers in its use. Social service providers, at Senior Centers and elsewhere, are highly trusted resources for counseling and mobility planning when a transition from driving is under consideration.
However, while professionals such as these must be integrated into the operational plans for any driver screening and evaluation program that may evolve in a jurisdiction, they are external to the licensing agency, and their qualifications and training requirements are governed by certification bodies within their respective areas of specialization. In contrast, a professional who will serve as a Case Manager and those personnel charged with administering "first-tier" functional screening measures are more likely to include--though are not necessarily limited to--DMV employees.10 As indicated in the later discussion of Program operations, a nurse is viewed as the best-qualified person for the Case Manager role. Staffing and training requirements to perform first-tier screening are the present focus.
State civil service employees in positions ranging from line personnel to license examiners may successfully carry out screening activities, given appropriate experience and capabilities, and adequate training opportunities. It is recommended that a separate position and job description be developed, in accordance with each jurisdiction's guidelines, for staff who perform screening functions; this will reinforce the professional nature and responsibilities of conducting driver screening. Allowing personnel to conduct screening activities who are "borrowed" from their "regular" job within the agency is not recommended.
The personnel trained to carry out screening may be assigned permanently to a fixed site, or serve as roving teams that conduct screening at different sites on different days. Either way, experience in the Maryland Pilot Study indicates that these individuals should:
A suggested approach when initiating a driver screening and evaluation program is to select candidates for screening staff on the basis of the first attribute, with further evaluation of their suitability in terms of the second factor occurring during a training period, described below.
With limited training, candidates who have good "people" skills and demonstrate attention to detail can gain the knowledge and specific skills in test administration they need to effectively carry out driver screening activities. A combination of group and one-on-one training is recommended, for greatest efficiency. An extended practice interval with subsequent evaluation then yields a proficiency rating, using a structured checklist for scoring. If deficiencies are noted, re-training, practice, and re-evaluation should be provided. In all cases, once proficiency has initially been demonstrated, follow-up observations and re-evaluation will be necessary to ensure accuracy and consistency in test administration.
A mandatory, 3-day training period begins with a classroom group orientation to explain the purpose of the screening program, and the relationship between functional abilities and crash risk. Trainees must understand that the functionally impaired driver places his/her own health and safety at risk by continuing to drive, as well as the safety of others. The overall program goal of helping people drive safely longer should be clearly emphasized during the orientation period. An even number of trainees numbering no more than one dozen should be included in each group.
It is recommended that ½ day be devoted to orientation, combining presentations by the trainer with question-and-answer and group discussion. During the discussion, trainees may give examples from personal experience where they have had concerns about a loved one's fitness to drive safely. At the conclusion of the ½-day orientation session, trainees should be tested on their understanding and retention of the materials presented by the trainer before proceeding to a description of the screening procedures per se.
The second half of the first day of training is devoted to explanation and demonstration of the screening procedures. After an introduction to the range of measures they will learn how to conduct, it may be most useful for trainees to view a demonstration video showing the screening tests being carried out in a familiar setting. It is recommended that the trainer then review the video in short segments, stopping it as often as required during each test to emphasize aspects of the testing methods that are key to obtaining valid measures of functional status. Trainees are expected to take notes during the presentation of this material. At the end of the day, trainees should be tested on their understanding and retention of the materials presented by the trainer. As they leave the group training session on the first day each trainee is given written instructions, exactly as they are spoken to drivers during each screening procedure, to study before returning for the second day of training. A copy of the demonstration video should also be handed out to each trainee at this time.
The second day of training is devoted to one-on-one instruction by the trainer, with extended practice in test administration by pairs of trainees. A classroom setting may again be used, but it is recommended that movable partitions be set up to provide for as many semi-private areas as there are pairs of trainees. All equipment and supplies required to conduct screening must also be available, in sufficient quantity for all pairs of trainees to work concurrently.
To begin the second day, it is recommended that the trainer performs the screening tests on one trainee while the rest of the group watches. Each procedure--including instructions, equipment use, scoring, and feedback--will be explained by example. Questions by trainees should be encouraged. Again, those aspects of the testing methods that are key to obtaining valid measures of functional status must be emphasized by the trainer, who will also explain that these are the criteria according to which proficiency in test administration will be rated. During the remainder of the second day, pairs of trainees should practice on each other. The trainer should rotate among trainee pairs, providing criticism and correction as needed and answering additional questions as they arise. By the end of the second day, each trainee should have completed 6 to 8 repetitions of the entire battery of screening tests with his/her partner. At the end of the second day, each trainee will be given an appointment for a ½-hour time slot on the following day, when the trainer will formally rate their proficiency in test administration.
Proficiency ratings should be performed using a structured checklist that addresses all relevant details of test administration. The trainer will rate each trainee's proficiency on a private and individual basis, watching as he/she performs the various screening measures with a subject (not another trainee), then providing detailed feedback after all measures have been completed. The subject being screened during the proficiency rating may be a naïve driver, if feasible to recruit, or may be another agency employee who can effectively mimic this role as required to properly evaluate the trainee. What is most critical during this evaluation exercise is that the subject not evidence any pre-existing knowledge of what is expected of him/her during screening.
Feedback to trainees following their proficiency ratings will identify all instances where they have failed to accurately follow proper screening procedures. A tally of such instances will serve as the rating score, with zero (errors) as the best possible performance. The trainer will provide feedback immediately after test administration has been completed, for each trainee. Any trainees who do not pass the proficiency requirement established by a jurisdiction must return for repeated evaluation. Jurisdictions are strongly encouraged to adopt stringent proficiency requirements.
Trainees who successfully meet the proficiency requirement should subsequently be monitored, as unobtrusively as possible, either in person or via video recording methods, on a weekly basis for the first month he/she performs the responsibilities of the driver screener position. Bi-weekly observations should be made for the second month, and monthly observations every month thereafter. Inaccurate or inconsistent administration of test procedures invalidates the obtained measures of functional status. When problems are observed, remedial training should be provided. An individual who is repeatedly found to be administering screening procedures in an inaccurate or inconsistent manner should be reassigned to other duties.
Materials that will be useful to train screening personnel to perform measures recommended under the Model Program, include a trainer's manual, trainee's handbook, demonstration video, proficiency rating checklist, and all equipment and supplies involved in actual driver screening activities. Jurisdictions interested in implementing or standardizing their screening efforts may contact NHTSA for guidance in obtaining these resources.
The recommended first-tier functional screening measures require an indoor (office) area of approximately 3.6 by 2.4 m (12 by 8 ft) for test administration. The testing area does not necessarily have to be completely enclosed, but should be as removed as possible from noise, distractions or interruptions resulting from other, ongoing activities if screening is conducted at the DMV. If a separate office is not available, the use of 1.8-m (6-ft) high, movable partitions is recommended to create a wall that provides privacy when performing testing activities.
Equipment needs are limited to a small table and two chairs--one with a straight back--plus a PC running Windows 98 or higher, a 432-mm (17-in) or larger CRT monitor with a touch screen interface, and a standard Microsoft keyboard.
The guidelines presented in this section recognize that each jurisdiction engaged in driver screening and evaluation activities will face different challenges in delivering services that are both cost-effective and acceptable to the public, and will develop somewhat different solutions. At the same time, lessons learned in pilot implementation of the Model Program11 suggest a general framework for program organization and flow of program operations that should broadly benefit all jurisdictions in meeting common safety and mobility goals. Drawing upon this experience, a framework to guide and coordinate the activities of the key components comprising a driver screening and evaluation program is presented in figures 2 and 3.
From the very outset of an individual's Program involvement, it must be assumed that community and private sector organizations will play a major role in the identification of at-risk drivers--and that motor vehicle agencies will report back to external sources the status of referred drivers within legal bounds of privacy and confidentiality. Figure 2 lists the various external and internal referral sources discussed earlier in this report: DMV line personnel, most likely counter staff, who observe signs of functional impairment; law enforcement and the courts; physicians, occupational therapists, and other health-care providers; social service providers, including those who perform geriatric assessments; self-reports of medical conditions that drivers check off on license renewal forms; and family members, friends, and other citizens. As noted earlier, referrals from family, friends, and citizens are investigated by the Department of Motor Vehicles (DMV) to validate their legitimacy, before a driver is subject to functional screening and evaluation.
The box labeled "age-based policies for license renewal or review" is included in figure 2 as a direct referral source to indicate, tentatively, that this intake mechanism may be legislatively permitted or even mandated in an increasing number of jurisdictions in the future as the baby-boom generation reaches their mid- to late-70's. Currently, only a minority of jurisdictions conduct medical evaluations of drivers that renew their licenses--or treat drivers with a given number of sanction points on their records differently--depending upon their age.
A DMV (MAB) Case Manager, as shown in the program flow diagram, is central to the efficient conduct of program operations. This individual initiates paperwork and compiles a driver file containing all information that the MAB physician(s) require to perform a medical review. The Case Manager communicates with the MAB physicians regarding medical diagnoses and, as indicated in figure 3, is likely to be the individual who interacts with and counsels drivers about the outcome of their fitness-to-drive determinations by the MAB. To maximize the success of the screening and evaluation program, the Case Manager should have knowledge, skills, and abilities appropriate to this range of responsibilities--a nurse is an example of a professional who would possess the necessary qualifications.
For all valid referrals, a Case Manager sends a package of forms to the driver that must be completed by the driver and his or her physician(s), plus a release form for the driver to sign that allows the physician(s) to share information with the DMV/MAB (see appendix H for examples). The driver completes the health history questionnaire and signs the form authorizing the release of medical information, and then returns these forms to the Case Manager. The driver forwards the physician report forms to his or her physician for completion, and the physician in turn completes the forms and returns them to the Case Manager. Included in the packet of forms sent by the Case Manager to the driver is a notification of the requirement to undergo a "first-tier" functional screening battery at a local DMV office, or at another facility approved by the DMV to perform screening activities. As per previous discussion, the included tests will entail (manual or automated) procedures shown by current research to have the greatest utility for detecting impairments in the key functional abilities listed in table 3.
The Case Manager assembles a file containing the driver's crash and conviction data and forwards it, together with the completed medical history forms and the functional screening data, to the MAB (or equivalent body) for review by the physician(s) who will make the fitness-to-drive determination. The results of the functional tests, together with other information available for review by the DMV, lead to either a "clean bill of health" that clears the individual to continue driving without any new restrictions, or to further evaluation. If functional loss is detected, its extent dictates the type and the urgency of additional assessment procedures undertaken to determine fitness to drive.
The specific operations that may be entailed in this determination are shown in figure 3. As highlighted in this diagram, education and counseling are strongly recommended for all drivers, regardless of whether screening results lead to a determination of OK, OK with restriction, or not OK. Drivers who retain full privileges should receive materials describing strategies and tactics to help compensate for future loss of functionality (e.g., flexibility and strength-building exercises, walking, proper nutrition), together with techniques for self-testing to increase awareness of one's own declining abilities. In fact, it is recommended that these materials be developed, promoted and distributed to the general driving public, both in electronic form and in print, before implementing new or enhanced screening and evaluation activities within a jurisdiction. Such materials may be obtained from NHTSA.
For drivers who are determined to be not OK to retain even restricted privileges, counseling about how to meet their transportation needs is essential. This is an integral part of the Model Program. Individuals who no longer possess the functional abilities to safely operate a motor vehicle must be provided with information identifying alternative transportation options in their communities. They should also be connected with a "mobility manager"--either a DMV employee assigned to this task, or a knowledgeable individual or agency in the community who provides this service. As discussed earlier, offices of the Area Agency on Aging are particularly well-suited to meet this need. A mobility manager needs to be able to link the individual with alternative transportation programs and options for obtaining other needed supports. The importance of staying socially connected in one's community after giving up driving cannot be emphasized too strongly, both for the individual's sense of independence and dignity and for society as a whole--nursing home admissions are strongly predicted by loss of independent mobility. Alternative transportation spans not only public transportation and paratransit options, but also: shopping services for seniors; meals on wheels; adult day care; housekeeping services; social, cultural, and religious groups who provide transportation assistance to meetings and functions; and a broad range of private and volunteer providers preserving independent mobility for those who cannot or choose not to continue driving.12, 13
The program operations shown in figure 3 include a number of options for resolving cases where there is, upon first review, insufficient information for a determination of fitness to drive. One of the anticipated benefits to a DMV of performing functional screening is to reduce the number of cases where interviews or road tests are necessary to determine fitness to drive. In the Maryland pilot study, based solely on reviews of medical history reports and driver crash and violation data, MAB physicians judged 38 percent of referred drivers to be "OK" to drive and 22 percent to be "not OK" to drive, while 40 percent were put on "HOLD" status. When functional screening data were made available to the MAB physicians, those deemed "OK" to drive increased to 55 percent, those deemed "not OK" to drive increased to 29 percent, and the number of drivers put on "HOLD" status, pending more extensive assessment decreased to 15 percent of referrals. The pilot study thus demonstrated efficiencies resulting from functional screening whereby the number of drivers put on "HOLD" status was reduced by nearly 40 percent. This signifies a decrease both in the number of drivers needing an interview with an MAB physician and in the number of drivers needing a behind-the-wheel test to determine fitness to drive.
Nevertheless, certain individuals will remain on "HOLD" status after initial review of his/her case file by the MAB physician, and the recommended Model Program components provide for various avenues to resolve this need for more information. The driver may be required to come to the DMV for an in-person evaluation with a MAB physician, and/or, he or she may be required to take a road test. According to current practices, the costs associated with either/both of these information-gathering activities are borne by the DMV. In other cases, the MAB may request an outside evaluation by an occupational therapist (OT) or certified driver rehabilitation specialist (CDRS), or other medical specialists, including but not limited to cardiologists, neurologists, psychiatrists, endocrinologists, and ophthalmologists or optometrists. In some cases, an individual may be placed on "HOLD" status pending the results of a lab test or other diagnostic procedure needed for the reviewing physician to determine health status or the stability of a particular condition. Such lab tests could include measures of blood sugar, a cardiac stress test, blood pressure, renal function, etc. When this information is received, the "HOLD" may be released without any change in license status, a restriction may be recommended, or a need for further evaluation may be indicated.
The costs associated with the behind-the-wheel portion of an OT/CDRS evaluation are typically borne by the driver; that is, this cost is usually not reimbursable by health insurance. However, clinical/neuropsychological testing conducted as part of an OT/CDRS evaluation are commonly covered by insurance plans. Evaluations by vision specialists and subsequent visual corrections are similarly covered by health insurance providers, as are consultations with other medical specialists, and lab testing.
In some cases, an occupational therapist or other medical specialist will recommend driver skills re-training, adaptive equipment, or some other remedial treatment such as visual correction, physical therapy, or, in selected cases, perceptual skills (re-)training. The driver will then need to complete the remedial activity (often at his or her own expense), and provide evidence of completion to the Case Manager. Following discussion with the MAB physician, successful completion of the prescribed course of remediation may resolve the "HOLD." Or, further evidence of fitness as provided by, for example, a driving test, may still be required.
For those who are required to complete a driving test, several outcomes are possible. A recommendation may follow that the individual's license be unrestricted, or a need to restrict the driver to a certain geographic area, a time of day, a type of equipment (i.e., a vehicle with hand controls, a spinner knob, a left-foot accelerator or brake, etc.), or visual correction (glasses or contacts) may be identified. A driver who fails a driving exam may be provided with a limited number of opportunities to retake the driving test, depending on the reasons for the initial failure. For example, persons who demonstrate that they are a safety hazard to themselves and others by crashing or almost crashing during the road test, and who have been recommended for license suspension by other medical specialists, are not likely candidates for a retest. However, a person who has undergone remediation after a road-test failure, or a person who fails due to stress and nervousness who otherwise appears fit to drive should be given the opportunity to retake a road test. A maximum of three (3) attempts is recommended as a reasonable accommodation for these individuals.
If an OT/CDRS judges a person unfit to drive and recommends driving cessation, this feedback must be provided to the DMV, so that a licensing decision can formalized. In some jurisdictions, a failure on the road test given by the OT/CDRS may serve as due process, and in others, a DMV-administered road test may be required before suspending or revoking a person's driving privileges. In the latter case, it is recommended that the OT/CDRS report patient road test results to a licensing agency for further testing, because physically and mentally unfit license holders often continue to drive despite medical advice against driving. As noted earlier and highlighted in figure 3, all persons faced with driving cessation will receive counseling under the Model Program, and will be connected to a mobility manager.
Referral to a vision care specialist for a clinical assessment should follow when an acuity and/or contrast sensitivity screen has been failed at the "prevention threshold" (see earlier discussion in the section on Screening and Assessment Techniques). Failure at the "intervention threshold" indicates a gross impairment, with an immediate need for ophthalmologic evaluation to determine the underlying medical condition(s) and prospects for remediation. When a progressive disease or condition is detected as the result of such assessment--for example, macular degeneration--a reassessment should be scheduled at an interval determined by the vision specialist, with reporting to the DMV as per the guidelines presented earlier in this document. At the discretion of the DMV and/or upon the recommendation of the examining specialist, a road test to measure actual driving skills may also be required at this time and/or prior to license renewal.
In the case of drivers found through functional screening to suffer perceptual-cognitive impairment, a neurological evaluation may be recommended to more precisely determine the extent of an individual's limitations, and whether he or she is aware of them. A person who has suffered head trauma, or is the victim of stroke or dementia may be unaware of the resulting deficits in perception, cognition, or judgment. These individuals cannot compensate for their deficits, and the potential for remediation may be very small. An OT or neurologist would be the likely professional to make this determination.
There may be a special concern among licensing officials with regard to Alzheimer's Disease (AD). Current research and clinical judgment are divided regarding the ability of people to drive safely following the onset of AD. Overall, the crash rate for AD patients is only slightly higher than that for drivers of all ages in the United States, and remains well below that of young adults aged 16 to 24 during the early stages of the disease. In the year 2000, the American Academy of Neurology issued guidelines to help determine whether people with Alzheimer's disease should continue driving.14
The guidelines state that driving performance evaluations should be considered for people with slight cognitive impairment, or a Clinical Dementia Rating (CDR) of 0.5. This state is characterized by consistent slight forgetfulness that is "benign," or does not interfere with everyday activities. The guidelines recommend that these patients be reassessed every six months because of the likelihood that their level of dementia will increase to CDR 1 within a few years. At a CDR of 1, an individual experiences moderate memory loss that interferes with everyday activities, including moderate geographic disorientation, an inability to function independently in community affairs, and mild impairment in functioning at home. The judgment and problem-solving abilities of individuals with a CDR of 1 are moderately impaired. The American Academy of Neurology guidelines state that drivers with Alzheimer's Disease with a CDR of 1 or more should be advised not to drive. If a jurisdiction, through the MAB medical review process, grants restricted operating privileges on an individual-by-individual basis to drivers with a CDR of 1, this practice should reflect a successful road test result and require frequent follow-up evaluations to monitor the course of disease progression. With a CDR of 2, drivers pose a significant traffic safety risk and should not continue to operate a motor vehicle.
Finally, the Case Manager, after receiving the recommendation for licensing, treatment, and remediation from the medical specialists and others who evaluated the drivers placed on "HOLD" status confers with the MAB physicians to make a determination regarding their fitness to drive. This makes it imperative that the results of all evaluations performed by a driver's personal physician, other medical specialists, a physical or occupational therapist, or others be promptly reported to the Case Manager. If vehicle modifications for continuation of driving privileges are required, they must be identified.
The Model Program operations indicated in figures 2 and 3 should not be viewed as a rigid prescription for program implementation, and many details required to carry out program activities on a day-to-day basis have been omitted from this discussion. It is expected that each jurisdiction will tailor these guidelines to best suit their own needs. The related experience of NHTSA and jurisdictions to date suggests, however, that these operational components will be integral to an efficient and effective screening and evaluation program.
8 Source: NPTS 1983, 1990, 1995.
9 Dr. Robert Raleigh, Chief, Medical Advisory Board, Maryland Motor Vehicle Administration.
10 The Model Program allows for the possibility that screening could be conducted at a physician's office or other setting(s) within the community, as per specifications provided by the DMV.
11 Maryland Pilot Older Driver Study, 1998 - 2001.
12 Independent Transportation Network of Portland, ME, at www.ITNAmerica.org.
13 Supplemental Transportation Programs for Seniors, at www.aaafoundation.org.
14 Dubinsky, R.M., Stein, A.C., and Lyons, K. (2000). "Practice Parameter: Risk of Driving and Alzheimer's Disease (an Evidence-Based Review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000, June 27; 54(12): 2205-11.
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