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I.B.1. DMV/Licensing Activities

With the sharp increase in the number and percentage of older drivers in the population that will occur in the years ahead, and the decline in a wide range of functional capabilities that is normally associated with aging, there will be an inevitable impact on highway safety unless the most at-risk individuals can be identified through screening procedures that are fair, accurate, and which can be administered cost-effectively by State/Provincial licensing agencies. The development and field testing of a Program which can meet these goals, while educating and counseling affected drivers about options to preserve (or even extend) their mobility are all key to success in this area.

A crucial first step is to evolve a framework to guide and coordinate the activities of the various external sources that may refer drivers into a screening Program, while seeking to standardize the reporting procedures and formalize lines of communication back and forth between these referral sources and a Motor Vehicle Agency. 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. It is recognized that external referral sources and referral mechanisms will need to be identified and described in detail prior to implementation of the Model Program.

Of course, at-risk drivers may also be identified through activities undertaken by an Agency itself. Applicants for renewal (and, optionally, original applicants), could be"pre-screened" through direct interactions with counter personnel, where candidates for functional screening are selected using standard and objective criteria. Screening might also be triggered by crash or violation experience; by age; or by a statistical sampling procedure (reflecting, for example, the relationship between age and crash rates). Self-selected populations, such as those applying for handicapped status, also could be required to undergo screening. Selection of candidates for testing will vary from one jurisdiction to another. But the Model Program will emphasize the need for drivers, once targeted for functional screening, to be assessed in terms of a common set of "first-tier" performance criteria.

The first-tier screening procedures focus on gross impairments (and, optionally, vision screening and/or road sign and knowledge tests). These tests are designed to catch those persons with the most serious physical or mental limitations using procedures that can be administered in a brief time (under five minutes), by current staff (with special training), in existing facilities, and without special equipment. Such persons would typically experience loss of licensure or restriction of term and/or privilege, allowing for due process. At the same time, the most capable--given a clean driving record--would be passed for license renewal without any further action.

Another outcome of the first-tier screening activities could be an administrative determination for additional testing. This might occur, for example, where an individual's standardized scores are marginal (i.e., a gross functional deficit is not demonstrated conclusively), but his/her driving record contains indicators of prior negligence. It is also possible that some individuals, depending upon their source of referral into the Program, could proceed directly to this "second tier" of assessment. Second-tier testing will likely address medical conditions, and/or attentional, perceptual, or cognitive functions, using tests that often require more sophisticated, costly, and lengthy procedures to assess reliably. While an Agency may wish to undertake such testing "in-house," the Model Program will certainly allow for physicians or other health care professionals or (certified) private sector entities to carry out these activities, given uniform reporting requirements.

Under the Model Program, after the requirement(s) for functional testing are completed for a given individual, any among a full range of licensing actions may follow (including no action). Specific actions relating to specific test outcomes or cutoff scores will be suggested but not mandated within the Model Program. States' practices with regard to options for restricting driving privileges will vary, as will drivers' rights to appeal restriction or removal of privilege, to demand retesting when diminished functional capability is indicated, or to demand a road test. In all cases, however, the Model Program will call for an Agency to provide individualized feedback on test performance and its consequences (i.e., prior to a licensing action). Education and counseling activities are also critical: Individuals should be provided with information identifying alternative transportation options in their communities; and, those who retain driving 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.

Pilot studies conducted in Maryland between Spring 1998 - Fall 1999 will evaluate components of the DMV model, with a focus on driver screening and assessment. The objectives of driver testing activities carried out in Maryland are to perform limited validations of Model Program components in a DMV setting, using a retrospective case-control study methodology which tests how well functional measures can discriminate between matched older driver groups who are and are not (a) crash-involved; (b) medically referred to the MVA for evaluation; and (c) who have and have not accumulated 3 or more points on their driving records. Thus, data collection and analyses resulting in the preliminary validation of screening instruments in terms of crash involvement, (multiple) violation involvement, and the (medical) referral status of older drivers are study goals. These data will support an assessment of the administrative feasibility of all included functional testing/screening techniques included in the pilot study and may assist with assignments of individual drivers to receive tailored road tests for selected conditions (e.g., visual, cognitive and/or physical problems).



I.B.2. Integrated Health, Social Service, and Community-Based Agency Activities

The most comprehensive solution to improved driver screening and evaluation is likely to incorporate a community-based approach where driving assessments and case management components are performed by entities outside of the DMV. Current examples of this approach are the "Getting in Gear" (GIG) program in Florida; Older Driver Evaluation Program of The Ohio State University Medical Center Office of Geriatrics and Gerontology (Franklin County); Michigan Area Agency on Aging "You Decide: Senior Driving Awareness Program" (Ann Arbor, Birmingham, and Romeo); Mature Driver Retraining Workshops (Oakland County, MI); the Older Driver Safety Project (DeGraff Memorial Hospital and Rochester Rehabilitation Center, New York), Howard County, Maryland's "Getting Around--Seniors Safely on the Go" Program; and The Senior Health Center at St. Mary's Hospital (Richmond, VA). The following discussion highlights components of these programs.

Community-based programs offer an opportunity to provide early detection of driving problems and a range of solutions--through referrals to remediation, retraining, and counseling about changes in driving habits and alternative transportation options--in convenient and non-threatening settings. With the availability of affordable and effective tools, applied consistently across settings, interventions in the community can address a range of older driver needs that fall outside of traditional procedures for license renewal. As diagrammed on the following page, the overview of an integrated approach to driver screening and evaluation assigns prominent and complementary roles to the DMV and to service providers in the community.

This approach relies heavily on coordination, cooperation, and communication between various agencies within a community, and while the basic mechanics will be similar across communities, the specific entities will likely vary with each program implementation. Community-based programs, including voluntary programs to assist aging drivers assess their skills and remain safe on the road include the following components: (1) assessment of competency to drive; (2) driver education and training; and (3) case management/agency referral.

External Referral Mechanisms: External (outside of the DMV) referral mechanisms include: self referral; referral by family, friends, and other caregivers; physicians, hospital discharge planners, Geriatric Evaluation Services (GES); occupational and physical therapists; individuals working in Area Agency on Aging facilities (e.g., senior centers); insurance agents; and law enforcement.

The Older Driver Evaluation Program in Ohio has a formal program with four municipal courts in the area, which allow the Judge or Mayor to give the older adult a choice to agree to undergo the evaluation either 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. However, in the GIG program in Florida, participation in the program is currently voluntary, and there are no consequences for not participating.

Regarding police referral, experience in Florida has indicated that although deputies supported the program and referred a total of 71 drivers during a test period, most of the drivers who were contacted by Program staff during a follow-up telephone call denied that they had diminished capabilities and needed the Program's service. Over 65 percent of those contacted stated they should not have been pulled over (e.g., "no one stops for that stop sign"). Eighty-five percent of those who were contacted declined to participate, once they learned that there were no consequences. Seven percent of those contacted did participate, and an additional 4 percent gave up their licenses on their own after being pulled over. The Program Director offered that this component "needs an incentive," to get law enforcement-referred drivers to participate. Such an incentive would include implementing a requirement for drivers stopped by law enforcement to participate in the GIG Program in lieu of ticketing, or to reduce the fine. But without this kind of incentive, drivers won't use the program.

[ Integrated Model Driver Screening and Evaluation Program Overview ]

For senior assessments at St. Mary's Hospital, patients must be referred to the center by their primary physician. A caregiver or family member with the patient's history must be present at every appointment. The comprehensive senior assessment is helpful for the following kinds of individuals: those with a decline in functional ability; those who may need a change in living situation; those who show increasing frailness; those who show a change in behavior or increased forgetfulness; those who have unsteady balance or have a history of falls; those who have a problem with incontinence; those who use multiple medications; and those with multiple active medical problems. The focus is on identifying remedial problems that, when addressed, can maximize independent functioning, and thereby improve a person's overall quality of life. Often, physicians refer clients for an assessment to avoid the unpleasant consequences of telling a patient that he or she should no longer be driving. Families often want an objective decision to back up their beliefs that a client should not be driving.

The three Area Agencies on Aging sites participating in the "You Decide: Senior Driving Awareness Program" in Michigan coordinate with state and local agencies, and public transportation authorities to identify older drivers who either (1) should no longer be driving; (2) want/need to determine if driving is still safe; or (3) want/need to plan for a future when driving may no longer be possible. These persons are targeted for participation in the Program.

Referral into the DeGraff program are made by primary care physicians, family members, individual older drivers, the Alzheimer's Association, and Allstate Insurance Company officials. In addition, the following community partners will refer older persons into the program: Offices for Aging, health professionals, AARP, the Department of Motor Vehicles, the American Automobile Association, NYS Office of Vocational Services for Individuals with Disabilities, and human service organizations.

Driver Assessment Component: Present assessment tools employed by various programs follow.

The GIG program includes the Mini-Mental State Examination (MMSE), the Automated Psychophysical Test (APT), the Useful Field of View (UFOV) test using the Visual Attention Analyzer, and an on-road driving test. Assessments performed by professionals in the Ohio Older Driver Evaluation Program include: a self-report questionnaire to obtain information regarding health status and behaviors, adaptive aids, driving habits, living arrangements, caregiving responsibilities, and much more; a pharmacological review; a hearing screening; MMSE; Trail-Making Parts A and B; vision screening (Optec 2000 Vision Screener); range of motion, balance, strength, and endurance; reaction time and threat recognition subtests of the Doron L225 Driving Simulator; and an on-the-road assessment, first in the parking lot and then in traffic. The Michigan Mature Driver Retraining Workshops (conducted by a AAA-certified instructor) include a 4-hour session using AAA's Safe Driving for Mature Operators course, supplemented with psychophysical tests to allow an individual to evaluate his/her own abilities (participation is voluntary and results are confidential). The tests include simple RT; visual acuity and depth perception; and visual attention (Visual Attention Analyzer/UFOV). An on-road driving evaluation is also given by a retired law enforcement officer who is AAA certified, on a course laid out by University of Michigan Traffic Engineering Department. The instructor indicates problems in driving behavior and offers suggestions for improvement. The on-road appraisal results are also confidential.

At the Senior Health Center at St. Mary's Hospital, driving history and fitness to drive are assessed as part of the health assessment. 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. A physician performs a review of the client's medical record, and other team members administer a battery of cognitive and functional tests. The cognitive tests include: the MMSE, a clock draw test, and the set test (which requires clients to name as many items in four categories as he or she can think of). A geriatric depression screen is also administered. 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. 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.

DeGraff Memorial Hospital and Rochester Rehabilitation Center are developing, implementing, and evaluating a replicable driver assessment, remediation, and referral program for older adults. The evaluation and assessment component includes visual acuity testing (day and night); reaction time testing; cognitive testing; and hearing tests, in addition to an assessment of rules of the road knowledge and an on-road driving assessment.

Driver Education and Training Component: Experienced (i.e., non-novice) drivers participating in the GIG program take the NSC Defensive Driving Course ("Coaching the Mature Driver"). This 6-hour course deals with the effects that aging has on driving ability. Drivers then receive a three-year auto insurance discount. Interestingly, according to the GIG program director, the people who choose to take the National Safety Council's defensive driving course are younger and more mobile than the people who want the driving assessment. Of the 200-300 people she taught over the past year, all have known someone else who should stop driving, but none think they have a problem with driving. The Program director noted that none of the Mature Driver class participants came to GIG for assessments or training. Preliminary findings of several research studies currently underway indicate that perceptual skills training to increase the size of the useful field of view (using the Visual Attention Analyzer) may reduce the crash risk of older drivers, and make it a tool for remediation of certain types of deficits [see Notebook Section IC3(a)ii]. The Getting in Gear Program has recently implemented UFOV testing and training.

The Mature Driver Retraining Workshops in Michigan include a 4-hour classroom review using AAA Workshop Materials. The workshop is conducted by certified instructors (AAA certified), who are retired enforcement officers (and therefore are age-peers of the participants).

The goals of the "You Decide: Senior Driving Awareness Program," conducted by the Michigan Area Agency on Aging through funds provided by the Michigan DOT Service Development and New Technology Funding Assistance Program, are to assist older persons and their families with driving safely for as long as possible, and to assist older adults with locating appropriate resources, alternatives, and support when safe driving is no longer possible. Educating older persons and providing input into the development of new or alternative/public transportation is also a goal of the Program. The "You Decide" model is based on the program "Driving Decisions for Seniors," developed by Ms. Ethel Villeneuve, in Eugene, Oregon (see Heckmann and Duke, 1997). Older persons will be trained to become volunteer peer-counselors to educate, support, guide, and assist older drivers in making appropriate mobility decisions. (Currently, project coordinators facilitate the groups, however, proper volunteer training is crucial to sustaining the project after the pilot period has ended. Project coordinators will recruit and train up to 10 volunteers to lead the program after the 2-year pilot program has expired). Senior Driving Awareness Program participants meet monthly at local senior centers for a two-part meeting. The first part offers information on a variety of topics including: how to improve or assess driving skills; when to consider restricting driving; how to cope with the emotional aspects of driving restriction or cessation; what public and alternative transportation options are available; how to participate in transportation planning efforts and public forums; and what to consider when planning for future mobility needs. Meeting topics to date have also included video presentation of AAA's "Older and Wiser Driver;" a discussion of the effects of medication and driving with a pharmacist, where attendees bring medications to the meeting for a one-on-one discussion with the pharmacist; and presentations by occupational therapists from the driving rehabilitation programs at several area hospitals. The second portion of the meeting is a support group where older persons and/or family members discuss issues of relevance to the older driver, such as lack of alternative transportation and geographic limitations, dealing with anxiety and feelings of separation associated with no longer driving, and problems with assisting family members who have dementia and other disabling conditions and continue to drive. Group trips are also arranged to help older persons who have never used or are uncomfortable using public or alternative transportation. Whenever possible, group trips are coordinated with travel training programs which are sponsored by local public transportation providers.

The Area Agency on Aging in Michigan publicizes the meetings through press releases, public service announcements, posters, flyers, and senior newsletters, distributed through local senior centers, libraries, YMCAs, and senior apartment buildings. The program has also been featured in at least one local newspaper. An evaluation report was produced by Special Program Evaluators and Consultants, Inc. (SPEC Associates) for the period January-March, 1998. A total of 111 individuals attended one or more sessions. Based on six meetings of the "You Decide: Senior Driving Awareness Program," the average number of participants per meeting has been 15; 72 percent are female and 28 percent are male. The average age of the participants is 75. Forty-eight percent of the participants are still driving with no restrictions and 37 percent are self-restricting their driving in some way. Sixteen percent reported having had a crash in the past two years. Focus group interviews were held with the participants; they dislike the name of the program because of the term "older driver." (Note: the program was begun under the name of "You Decide: Older Driver Program.") The participants agreed on a new name in April of 1998; the name of the Program has been changed to "You Decide: Senior Driving Awareness Program." The evaluation report states that the "Senior Driving Awareness Program helps participants to retain driving privileges for as long as safely possible by attracting a high-risk group of participants and providing for them a forum for discussing driving safety-related issues. The Program helps seniors cope with the emotional distress and life changes that accompany driving cessation by helping them to see that they are not alone in their experiences, and by teaching them how to cope with the substantial changes resulting from cessation of driving." A total of 433 individuals have attended meetings during the period of January 1998 to December 1998.

Case Management/Social Agency Referrals: If a driver decides to reduce or stop driving, or does poorly on the computer and road tests, professional case managers working in the GIG program help link the individual with available social programs such as alternative/public transportation, shopping, meals on wheels, adult day care, housekeeping, etc. Or, the case manager may refer a client to a physician for a physical exam or pharmaceutical review. The case worker works closely with the client's family regarding alternative transportation and dismantling/selling the client's car, if necessary.

In the Ohio Older Driver Evaluation Program, training may be prescribed or doctor visits recommended. A transportation resource guide has been developed to lead people to alternative transportation, if they must restrict or eliminate driving. The program works closely with the family, as the older driver issue is a family issue. The program can also help with alternative housing choices (to make alternative transportation/mobility easier) and other spin-offs of the older driver issue (e.g., nutrition). Program administrators have found that stopping driving can have a negative impact on health, and become involved in conversations with older adults and their families which illustrate these issues on a regular basis. Evaluation outcomes for the 400 drivers evaluated to date are as follows: 56 percent of the clients were found to be capable to drive safely at the time of the evaluation, or were capable with vehicle modifications; and 44 percent were determined to be incapable, which included those who are unsafe now, but may be safe after rehabilitation, surgery (cataracts), etc.

For Senior Health Center (St. Mary's Hospital) clients 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. If a family member becomes uncomfortable riding with a client, that is a danger signal that the person's competency may need to be reassessed. 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, such as ophthalmologists if the problem involves visual capability (e.g., for cataract removal) or to a physical therapist if the problem involves mobility/flexibility/strength. 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 counsels families of clients who are judged not fit to drive, about what to expect from the client (anger, depression, etc.). Tips are given regarding how to keep a cognitively impaired client from driving, who doesn't remember that he or she is not supposed to drive. Alternative transportation options are also explored, including public transportation, connections with volunteers, paid private drivers, as well as a consideration of moving to an assisted living community that provides transportation.

One of the products that will be produced by the "Senior Driving Awareness Program" will be an information and referral database to include a variety of mobility resources for older drivers including: current defensive or driver improvement courses; physician assistance and medical retraining/evaluation programs; secretary of state offices; counseling resources; public and alternative transportation resources; and peer-support programs including the "Senior Driving Awareness Program." This will fill a void--there is no local or regional source that older adults and families can turn to for comprehensive information and assistance with mobility decision-making and planning. Area Agency on Aging staff have reported making referrals for participants to defensive driving/educational programs, medical programs, local transit providers, and housing.

Possible interventions included in the DeGraff program are: referral to special vehicle modifiers; referral to driver specialist for on-road remediation; referral to medical personnel; referral to driver retraining programs (AAA or AARP); support group/counseling for driver (and family) who is advised to cease driving; and counseling on options/alternatives to driving.

The GIG Program manager indicated that several issues should be considered in future programs. First, some drivers who give up or lose their driving privileges may be physically isolated (no spouse, friends, grown children) and become emotionally isolated. They stop socializing, going to church, and doing proper (healthy) grocery shopping. They are at risk of clinical depression and can become suicidal. The GIG program manager recommends that a depression screen be part of any program, and be completed within 3 months following the decision/requirement to cease driving, so counseling can take place, if necessary. For those who choose to reduce driving, GIG recommends a re-test after 1 year, and during that year they suggest that the driver learn about and experience alternative forms of transportation. A recent study that highlights the importance of staying socially connected in one's community deserves mention. Researchers at Iowa State University in Ames, Iowa, and the University of Iowa College of Medicine in Iowa City concluded that extreme loneliness was a significant predictor of admission to a nursing home among rural older men and women. Study senior author Dr. Robert Wallace of the University of Iowa says, "interventions to prevent loneliness should be explored in order to keep older people independent." He and his colleagues believe that many of elderly living in rural areas need better access to transportation so that they can more easily stay in contact with relatives and friends. Community groups need to be encouraged as a means of bringing still-independent individuals together. Regular involvement in group activities seems to help ward off a dependence on nursing home care. For example, the investigators discovered that elderly churchgoers experienced much lower rates of nursing home admissions compared with those who did not regularly attend services.

Next, it was brought to the GIG program director's attention that a young/middle-aged female may not be the best choice for counseling older men to restrict or eliminate driving. Older men are proud and independent and see the car and driving as part of themselves. In homes where there is a wife, there is often domestic abuse; oftentimes, the wife is silent about encouraging the husband to reduce or stop driving. The director suggests having older men mentor older men, possibly through the employment of retired police officers who would go to a driver's home to help him make decisions about stopping/reducing driving, what to do about a car (e.g., how to sell it), and going with the older person to show him how to use alternative transportation.

On the other hand, older women who have never driven but find themselves faced with no transportation after the death of a spouse, may start or resume driving, with little skill. Older women may benefit from referral to a driver education program, as well as information about alternative transportation in the area. Additionally, assertiveness training may be recommended, because it was noted that many women will not ask for help from providers of transportation (stepping up on a bus) and will just not use the alternative transportation option.

Diversity of Practices Regarding Interactions with DMVs: Currently in Florida, only with the client's consent can GIG staff provide feedback regarding poor performance to the Department of Driver Licensing (DDL), and to the family, the physician, and other care providers, for that matter. Otherwise, test results are confidential, and GIG believes referral to the DDL without permission is a breech of confidence that would be a detriment to the success of the program. However, if a client decides to voluntarily surrender his or her license after counseling by GIG staff regarding computer and road testing performance, a voluntary surrender form, developed by the DDL can be signed, and a GIG case manager can forward the form to the DDL. The DDL will update the driver history and send the driver a letter of appreciation. If a driver voluntarily surrenders his or her license directly to the DDL, the DDL will contact GIG, if there seems to be a need for counseling and social services link up (regardless of age).

Although not currently in place in Florida, if a driver fails a DDL mandated re-examination (e.g., can not pass the road test after 5 tries), he or she will be given the choice of immediately having the license suspended or having a 45-day suspension with the opportunity to participate in the GIG program. The driver will need to successfully complete the DDL re-examination to keep his or her license. DDL and GIG procedures act independently of one another, such that a road test given by GIG does not count as a test given/passed/failed by DDL. If the driver does not contact GIG and re-take the DDL re-examination or does not voluntarily surrender the license, the Florida 5-day process will continue (the re-exam must occur in 5 days, or the license will be immediately suspended). One point the program director at GIG made was that some proportion of drivers whose licenses are suspended continue to drive. GIG wants to analyze some of the DL records this year. Also, if a person with dementia has his or her license suspended, who follows up to make sure the individual isn't driving? Who helps the person with selling the car?

The results of the assessment conducted by Older Driver Evaluation Program staff (Ohio) are provided in written consult form to the older adult's physician, with a copy sent to the older adult to facilitate communication and compliance with recommendations. Of particular interest, is that a consultation letter is not sent to the Bureau of Motor Vehicles. The evaluation is a health care referral program, and is handled within the health care boundaries between program staff, the older adult, and his or her physician. It is the physician's responsibility (moral obligation more so than a legal obligation) to ensure that an unsafe driver doesn't drive, and the evaluators work closely with the referring physicians to identify liability and other legal issues related to the driving decisions of their patients.

Participation in the Michigan Mature Driver Retraining Workshops is voluntary. No psychophysical test scores are maintained, and the results of the on-road evaluation are confidential. The Workshop results have no bearing on driver licensing.

Getting Around--Seniors Safely on the Go. Another, noteworthy attempt to implement and evaluate an integrated, community-based model for driver screening, counseling and referral activities is being carried out as part of the Maryland Pilot Study, in Howard County, MD, through the Area Agency on Aging and its affiliated Senior Centers in the county. An overview of key elements in this project is presented in the diagram on the following page.

The Howard County, MD project is funded initially to run from March through December, 1999, beginning with two and expanding to four Senior Centers. Its stated goals are to: (1) Keep older drivers safely on the road as long as possible; (2) Provide effective intervention for unsafe older drivers; and (3) Ensure that older adults who no longer drive are provided with appropriate and adequate alternative transportation in order to remain connected with their communities.

In its 9-month pilot phase, the Howard County effort will help explain how well functional abilities for safe driving--as measured by a quick, simple, and low-cost screening tool (GRIMPS)--relates to seniors' driving experience. Analysis of the data for a projected sample of 650 seniors may contribute to a preliminary validation of the screening tool. By performing the screening in Senior Centers, it may also be determined if the national Area Agency Network can be utilized to engage seniors in maintaining safe mobility--by driving as long as they can safely do so and then choosing the best transportation alternatives to sustain a high quality of life--through accurate screening, counseling, and referral services. Follow-up information for all seniors taking the screening will be collected for up to five years by telephone and/or mail surveys. This includes changes in health, driving habits, use of transportation alternatives, and driving incidents and crashes.

Project activities are carried out by older volunteers trained as "peer screeners," Occupational Therapists (OTs), and staff of the Senior Centers themselves. Senior volunteers are trained to administer GRIMPS, but provide feedback to older drivers only to the extent of sorting performance into two categories: "below average" versus "average or above," based on "cut points" for each test procedure provided through NHTSA's "Model Driver Screening and Evaluation Program" contract. Further feedback, interpretations of screening results, referrals, etc., is provided by an OT who has completed in-service training in driver evaluation by a Certified Driver Rehabilitation Specialist (CDRS). Screening and counseling is done on an appointment basis only.

[ Pilot Study Elements Conducted Through the Area Agency on Aging ]

The OT reviews and discusses the screening results with the driver. This health professional provides feedback to the driver in one or more of the following areas depending on whether the focus is skill maintenance and/or long-range mobility planning for those who score average or above average on all GRIMPS measures. For drivers with below average scores, the OT's recommendations may be in the direction of follow-up assessments, remediation/treatment activities, and/or changes in driving habits. These include:

• Recommendation to see an eye-care specialist, either through the older person's primary care physician, or an eye-care specialist covered under the driver's medical insurance;

• Recommendation for a physical exam or pharmacological review by the driver's primary care physician;

• Recommendation for examination by a neuropsychologist/psychologist (by referral through the primary care physician) if dementia or other cognitive impairment is suspected or evident;

• Recommendation for consultation with an Occupational Therapist or Physical Therapist for remediation;

• Referral to a senior center, community wellness center, or other exercise program for health maintenance activities;

• Referral to a certified driving rehabilitation specialist (CDRS) if the driver has recently suffered a stroke, head trauma, appears unfit to drive, or could benefit from adapted driving equipment;

• Referral to a driving school is the person is fit to drive but lacks confidence; or

• Referral to a mature driver retraining class (such as AARP's 55-Alive) if general information is needed such as visual, cognitive, and physical changes with age; effects of medication and fatigue; review of signs, signals, pavement markings, driving in adverse weather; trip planning, etc.

After the older driver has been screened, but before he or she is seen by the OT, written material is provided. This material can be perused by the driver while waiting for counseling, and may be referred to during the counseling session. The older driver is given material on alternative transportation in Howard County, senior resources, and material related to safe driving and aging. For access to public transportation, the driver may be referred by the OT (which can be reinforced by the Senior Center staff) to the Senior Information and Assistance staff who can certify older adults over the phone and will discuss other types of community-based transportation depending on the individual needs of the older person.

At the end of the screening and counseling session, participants are given written information describing reporting procedures and review practices of the Maryland Medical Advisory Board (MAB). While the Howard County Office on Aging will not directly report any program participants to the Motor Vehicle Administration, it is appropriate to reinforce knowledge of existing laws and procedures regarding medical competence to drive.

The Howard County Office on Aging promotes the screening and counseling program through:

• Publicizing in the Howard County Office on Aging Senior Connection newspaper;

• Local cable coverage through regular senior shows and special taping of screening and counseling activities with willing older drivers;

• Direct promotion through all Howard County Senior Centers;

• Direct mailing to approximately 10,000 seniors on Office on Aging mailing list;

• Interviews of volunteers and/or participating older drivers with local and regional newspapers;

• Press releases to newspapers in Baltimore-Washington area;

• Promotion to local churches, senior groups, and other appropriate organizations;

• Purchase of advertising in local newspapers;

• Promotion to groups consisting of adult children;

• Posting information on the Howard County Office on Aging web site;

• Promotion of project through other community publications such as Howard County General Hospitals "Wellness Matters" mailed to all Howard County households; and

• Publicizing through Howard County government internal newsletters (such as The Daily Grind for Howard County employees, and the Police Department's paper).

In addition, word-of-mouth promotion is very effective in the senior community. The use of senior volunteers in the screening is considered part of the promotion process, with an aim of conveying the feeling that this activity is "safe" and part of the valuable actions which seniors can take to make themselves and the community safe for driving. Program promotion also includes medical professionals chosen because of the nature of their speciality or if they have a practice consisting of large numbers of older patients. Physicians are educated by the Maryland Medical Advisory Board on functional abilities needed for safe driving, the nature of remediation for older drivers to promote safe driving, and alternative transportation resources in the community for patients choosing to self-restrict or cease driving. The Howard County Police Department has expressed interest in the project, and will design appropriate linkages with the Office on Aging to promote and support the activities. To complement these activities, the Howard County Office on Aging will make available materials providing guidance to law enforcement officers in identifying older drivers at high risk.


I.B.3. Information and Educational Support for Safe Mobility Choices by Public Agencies, Private Professionals/Organizations, and Concerned Individuals


In a recent study investigating high-risk older driver state reporting requirements and practices, as well as information outreach programs, Aizenberg and Anapolle (1996) examined over 75 documents and other materials. They found that less than 15 percent of the materials collected for the review provided counseling tips for assisting older drivers with problems or for assessing driver competency (e.g., self-assessment questions, warning signs). About one-third of the publications discussed licensing issues; and only a very few addressed reporting unsafe drivers to authorities. In addition, less than one-half of the publications mentioned the possibility of driving cessation and about one-third specifically advised or made reference to using alternative transportation. The reviewers concluded that most of the materials dealt with the issue of older driver safety on a very general level. Few publications dealt with specific problem groups or with interventions that may be especially effective or justified with different subpopulations.

Decina, Staplin, and Lococo (1997) identified several dozen safety publications in their information search, 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. However, a small percentage of materials targeted caregivers, including family members. These publications 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.

The American Association of Motor Vehicle Administrators (AAMVA) Public Affairs and Consumer Education (PACE) Committee compiled a catalog of written and audio visual materials pertaining to older drivers, in its member jurisdictions (US States and Canadian provinces). The most widely available pamphlets are in the self-help category, directed at older drivers. AAMVA states that few pamphlets are available that provide advice to older drivers' families, friends, and caregivers. (The Malfetti and Winter report is helpful in this area). AAMVA also identified gaps in the topics of medical community responsibility, and alternative transportation.

The success of Model Program activities will rely on effective informational and educational (I & E) materials, using a variety of appropriate media, which:

• Facilitate self-regulation by sensitizing older drivers to the types of functional declines they may experience, and their consequences for safe driving.

• Provide advice and identifying resources to aid friends and family in problem identification and support for driving reduction/cessation.

• List and describe alternative transportation options specific to a community/county.

• Inform physicians of the driving risks associated with identified functional deficits, and describe feasible and standardized techniques for functional screening.

• Describe behavioral cues that police officers can use to identify at-risk older drivers, and procedures for referring suspect motorists for screening (in lieu of citation or other punitive actions).

• Provide easy-to-use tools for health care and social services field personnel to identify gross impairments, guidelines for referrals for follow-on tests and/or remedial programs, and advice on issues of confidentiality and reporting to licensing authorities.

The Maryland pilot study will include the Public Information and Education (PI&E) goals of promoting: (1) a broad social awareness that driving while (functionally) impaired is a serious public health issue; and (2) a broad social awareness that loss of mobility is a serious health and quality of life issue for older people. After a review of the available materials (listed above), a working group within the Maryland Research Consortium (MRC) will: develop Public Relations (PR) materials which illustrate how safe mobility lowers costs to society while improving quality of life for seniors; develop PR materials which illustrate how maintaining safe mobility is central to maintaining physical and mental health in old age; identify a spokesperson(s) to deliver the message; identify available PI&E resources and determine additional needs to attain the goal; and create the campaign content, implementation strategy, and evaluation plan.

An educational brochure created for distribution to seniors who participate in the screening activities conducted at several Senior Centers and Motor Vehicle Administration offices in Maryland during the pilot study is presented ot the end of this section. It will be a 2-sided, 3-fold brochure, and will be enlarged to measure 11 inches by 17 inches, to increase its legibility.


•AAMVA (1997)

•Staplin and Lococo (1997)

•Aizenberg and Anapolle (1996)

•Decina, Staplin, and Lococo (1997)


• USAA. (1990). Adaptive Driving: Safe At Any Age.
• Brenton, Myron (1986). The Older Person's Guide to Safe Driving. Public Affairs Committee, Inc,
• PennDOT. Drive Smart and Drive Longer: Tips for the Older Driver.
• PA Dept. of Aging. Getting Older...And Going Places: Benefits for Older Drivers and Older Riders
• USAA. (1992).Helpful Tips to Reduce Your Risks While Driving.
• Maryland Motor Vehicle Administration. Maryland's Guide for Drivers Over 55.
• South Carolina Dept. of Highways and Public Transportation, SC Commission on Aging. Mature Driving: Some Serious Thoughts for Older Drivers.
• AAA Foundation for Traffic Safety. (1997). Older and Wiser Driver.
• AARP. (1992). Older Driver Skill Assessment and Resource Guide.
• Platt, Fletcher N. (1996). Going on 80: Tune up your Driving Skills.
• AAA. (1992). Straight Talk for Older Drivers: Good Vision...Vital to Good Driving.
• AAA. (1993). Straight Talk for Older Drivers: Maintaining your Vehicle.
• AAA. (1992). Straight Talk for Older Drivers: Meeting the Challenge.
• AAA. (1992). Straight Talk for Older Drivers: Rx for Safe Driving.
• Nevada Office of Traffic Safety. Tips to Help Older Drivers Ease on Down the Road: Alcohol and Medications.
• Nevada Office of Traffic Safety. Tips to Help Older Drivers Ease on Down the Road: Safety Belts.
• Nevada Office of Traffic Safety. Tips to Help Older Drivers Ease on Down the Road: Vision.


• Texas Medical Association/Texas DOT. (1991). The Physician, the Older Patient, and Driving Safety: A Physician's Guide.


• Malfetti, J.L. and Winter, D. J. (1987). Safe and Unsafe Performance of Older Drivers: A Descriptive Study.
• McKnight, A.J. and Urquijo, J. I. (1993), "Signs of Deficiency Among Elderly Drivers."

• Transportation Research Record, 1405.

• Zimmerer, L. Florida Highway Safety Patrol Questionnaire


• Malfetti, J.L., and Winter, D.J. (1991). Concerned About an Older Driver? A Guide for Families and Friends; AAA Foundation for Traffic Safety
• PennDOT. Talking with Older Drivers: A Guide for Family and Friends; PA Dept. of Aging, PA Dept. of Transportation.
• CALDMV. Tips you Can Give to a Mature Driver

[ How is Your Driving Health? ]

[ How is Your Driving Health (part 2) ]

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