National Academies Press: OpenBook

Improving the Safety of Older Road Users (2005)

Chapter: Chapter Five - Driver Licensing Initiatives

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Suggested Citation:"Chapter Five - Driver Licensing Initiatives." National Academies of Sciences, Engineering, and Medicine. 2005. Improving the Safety of Older Road Users. Washington, DC: The National Academies Press. doi: 10.17226/13546.
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Suggested Citation:"Chapter Five - Driver Licensing Initiatives." National Academies of Sciences, Engineering, and Medicine. 2005. Improving the Safety of Older Road Users. Washington, DC: The National Academies Press. doi: 10.17226/13546.
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Suggested Citation:"Chapter Five - Driver Licensing Initiatives." National Academies of Sciences, Engineering, and Medicine. 2005. Improving the Safety of Older Road Users. Washington, DC: The National Academies Press. doi: 10.17226/13546.
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Suggested Citation:"Chapter Five - Driver Licensing Initiatives." National Academies of Sciences, Engineering, and Medicine. 2005. Improving the Safety of Older Road Users. Washington, DC: The National Academies Press. doi: 10.17226/13546.
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Suggested Citation:"Chapter Five - Driver Licensing Initiatives." National Academies of Sciences, Engineering, and Medicine. 2005. Improving the Safety of Older Road Users. Washington, DC: The National Academies Press. doi: 10.17226/13546.
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Suggested Citation:"Chapter Five - Driver Licensing Initiatives." National Academies of Sciences, Engineering, and Medicine. 2005. Improving the Safety of Older Road Users. Washington, DC: The National Academies Press. doi: 10.17226/13546.
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Suggested Citation:"Chapter Five - Driver Licensing Initiatives." National Academies of Sciences, Engineering, and Medicine. 2005. Improving the Safety of Older Road Users. Washington, DC: The National Academies Press. doi: 10.17226/13546.
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Suggested Citation:"Chapter Five - Driver Licensing Initiatives." National Academies of Sciences, Engineering, and Medicine. 2005. Improving the Safety of Older Road Users. Washington, DC: The National Academies Press. doi: 10.17226/13546.
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31 The driver licensing process provides states with an oppor- tunity to periodically assess an individual’s driving compe- tency and can serve as a venue for distributing educational information and materials such as self-assessment guides, information on how aging can affect driving abilities, and alternative forms of transportation within the community. License examiners are also uniquely positioned to link older adults who are experiencing difficulties driving with more in-depth driver assessment and remediation resources within the community. A growing number of states impose some additional requirements for older adults wanting to renew their driver’s licenses, including more frequent renewals, vision screening, and/or in-person renewals. Some states have initiated special programs to identify at-risk drivers of any age. Others have focused on educating older adults to make responsible deci- sions about their own abilities to operate a motor vehicle safely. These efforts have frequently entailed forming part- nerships with other agencies and organizations in the public and private sectors. This chapter will highlight the many and varied driver licensing initiatives used across the country to improve older road user safety and mobility. FEDERAL GOVERNMENT INITIATIVES The recently published Model Driver Screening and Eval- uation Program: Guidelines for Motor Vehicle Administra- tors (Staplin et al. 2003) updates earlier NHTSA/AAMVA guidelines for identification of high-risk drivers (Petrucelli and Malinowski 1992). The new guidelines draw from the considerable research that had been carried out in the interim on how an individual’s functional abilities relate to driving performance, and reflect the results of a comprehensive research project carried out with the cooperation of the Maryland MVA. The guidelines also recognize the impor- tance of addressing mobility as well as safety considerations for the older driver. The key features of the recommended model program are summarized here (adapted from Staplin et al. 2003). Many of the state driver licensing initiatives described reflect elements of the model program. • A single unit within the DOT or DMV coordinates all activities to detect and intervene with functionally impaired drivers, ideally an MAB or its equivalent in each state. • Drivers enter the program both through external refer- rals and through internal (DMV) referrals resulting from periodic reevaluation of functional status. • All drivers are exposed to education and counseling activities appropriate to their health status—regardless of screening outcome—as part of a multi-tiered approach targeting driving health maintenance as well as crash reduction. • Program priorities are keeping drivers on the road as long as they are safe, through early identification and assessment, coupled with remediation, counseling, and restriction where needed. • Broad-based education of the driving public plus more focused training aimed at physicians and the medical community are essential before and during program operation, explaining the link between functional status and driving risk. • An advisory committee or consortium to help establish and periodically review program procedures should be formed under the auspices of the licensing authority, whose membership includes diverse public- and private- sector groups plus all agencies of the government con- cerned with transportation, public health, or aging. NHTSA also collaborated with AAMVA on the first com- prehensive review of MAB practices in the United States, including an identification of best practices (see Lococo 2003; Lococo and Staplin 2005). The review of practices report contains a state-by-state summary of procedures in place for determining an individual’s fitness to drive personal vehi- cles, including: • The organization of the medical program; • Mechanisms in place for identifying drivers with med- ical conditions and functional impairments; • Procedures and medical guidelines used to evaluate fit- ness to drive; • Evaluation outcomes, appeals process, and availability of counseling and educational materials; and • Employee training, driver tracking, and other adminis- trative issues and barriers to program implementation. The final project report (Lococo and Staplin 2005) con- tains specific recommendations for state driver licensing authorities with regard to licensing drivers with medical con- ditions and functional impairments. The recommendations address the role and function of a medical advisory or review CHAPTER FIVE DRIVER LICENSING INITIATIVES

board, legal requirements regarding physician reporting, education of law enforcement officers, requirements for license renewal, restricted licensing, referrals for driver reha- bilitation, and other important aspects of a driver medical review program. In addition, AAA has developed a list of Basic Best Practices for Medical Advisory/Review Boards based on the NHTSA study findings (see http://www. aaanewsroom.net/Files/seniorbestpractices.doc). OTHER NATIONAL INITIATIVES In addition to its collaborations with NHTSA on the afore- mentioned projects, AAMVA maintains a Driver Licensing and Control Committee that has helped guide its policies with respect to driver licensing. Of special regard to the older driver, AAMVA policy • Supports periodic reexamination of all drivers, at least once every 4 years, to include a visual screening test and, where appropriate, a written and/or driving test. • Recommends that drivers whose records show a pattern of either violations and/or crashes be given a diagnostic-type reexamination, as a means for con- firming a particular driving problem, as well as to pre- scribe driver improvement programming to ameliorate the problem. • Recommends that licensing agencies cooperate with the medical profession, state health agencies, and other entities to encourage reporting of physical and/or men- tal disabilities that might inhibit safe motor vehicle operation. A copy of AAMVA policy relevant to the screening and evaluation of drivers and driver license applicants is con- tained in Appendix D of Volume III of the Model Driver Screening and Evaluation Program: Guidelines for Motor Vehicle Administrators (Staplin et al. 2003). Provisions of the Uniform Vehicle Code affecting driver licensing are sum- marized in Appendix E of that report. AAMVA has also recently reconstituted its Driver Fitness Working Group. The goals and objectives of this group are: • To coordinate, conduct, and promote activities to better assess driver fitness, including medical conditions and older driver concerns; • To evaluate best practices for the screening and assess- ment of functionally impaired drivers; • To assist national and international projects whose activ- ities have impacts on DMVs; • To improve licensing renewal practices that may assist detection of functionally impaired drivers; and • To evaluate standards for ensuring drivers’ continued fitness to drive. 32 In the wake of the recent NHTSA report on state MAB practices, AAMVA’s Driver Fitness Working Group will be seeking to promote greater standardization of the driver med- ical review process across states. The AMA has also formulated policy with regard to the reporting of unsafe drivers. In 1999, the AMA Council on Ethical and Judicial Affairs adopted a policy outlining the responsibilities of physicians in reporting potentially unsafe drivers. The policy is available on the AMA website (see the end of this chapter for website address). The report outlines the following conditions for physician notification to the DMV: (1) the patient has identified and documented impair- ments clearly related to the ability to drive; (2) the patient poses a clear risk to public safety; (3) alternatives to report- ing, including remediation and training, driving restrictions, and patient and family counseling, are insufficient; and (4) the patient does not voluntarily comply with the physician’s rec- ommendation to discontinue driving. STATE INITIATIVES State Driver Licensing Requirements State-by-state driver licensing requirements are summarized in a number of reports, including the Model Driver Screening and Evaluation Program report (Volume III) (Staplin et al. 2003; see Appendix B) and the Physician’s Guide to Assess- ing and Counseling Older Drivers, produced by the AMA and NHTSA (Wang et al. 2003; see Chapter 8). However, because requirements can change over time, information of this nature is probably best obtained from a website that is regularly updated, such as that maintained by the Insurance Institute for Highway Safety, AAA, or the National Acad- emy on an Aging Society (see websites listed at the end of this chapter). At least 22 states have special requirements in place for older adults wanting to renew their driver licenses. Based on a combination of sources, Table 7 identifies states having addi- tional license renewal provisions affecting older adults. By far the most common requirement is an accelerated renewal, gen- Renewal Provision States with Added Requirements for Older Drivers More frequent renewals AZ, CO, HA, ID, IL, IN, IA, KS, ME, MO, MT, NM, RI, SC In-person renewals AK, AZ, CA, CO, CN, LA Vision testing AZ, DC, FL, ME, MD, MT, OR, SC, UT, VA Medical report DC, NVa Written test DCb Road test DC,b IL, NH, Other NC, TN a Medical report required only if renewing by mail. b May be required (i.e., not mandatory). TABLE 7 STATES WITH ADDITIONAL AGE-BASED LICENSE RENEWAL REQUIREMENTS FOR OLDER DRIVERS

33 erally ranging between 2 and 4 years, and sometimes short- ening with age. Thus, for example, the normal length of license renewal in Illinois is 4 years, but decreases to 2 years for drivers age 81 to 86 and to 1 year for drivers 87 and older. Fourteen states have an accelerated renewal provision in place, typically beginning at age 65 to 75. Ten states also have age-based requirements for vision testing. An example is Florida, which recently amended its law to require drivers over age 79 to pass a vision test at any office or, if renewing by mail, have a special form filed by an optometrist or licensed physician. Note that these are only states that have special requirements for older drivers. Excluded from the list are states that require vision testing for all license renewal applicants, without additional age- based provisions. A review of the state driver license require- ments posted on the National Academy of Aging website showed that 34 states require vision testing as part of their normal license renewal procedure. Six states require older adults to renew their licenses in person, generally starting at age 65 or 70. Again, these are states that otherwise allow license renewals by mail. Only two states, Illinois and New Hampshire, require older adults to pass a road test when renewing their license, both starting at age 75. The District of Columbia recently enacted legisla- tion specifying that a road test as well as written test may be required at age 75. The District of Columbia also requires a medical report for drivers after age 70, as does Nevada for drivers age 75 or older who choose to renew by mail. In a few instances, states have passed laws making it easier for older adults to renew their licenses. In Tennessee, licenses issued to people 65 and older do not expire, and license fees are reduced for drivers age 60 and older. In North Carolina, drivers age 60 and older who take the road test are not required to parallel park. Several states (Mary- land, Massachusetts, Minnesota, and Nevada) have passed laws specifying that age alone cannot be used as a basis for driver reexamination. State Programs and Initiatives The following program descriptions represent the types of activities underway at the state level with respect to driver licensing. Maryland Maryland was the site of the research activities for the devel- opment of the national Model Driver Screening and Evalua- tion Program, described earlier. Led by its MVA MAB and the Maryland Research Consortium, Maryland continues to provide a model driver licensing program that incorporates a multi-tiered driver screening and assessment process, cou- pled with a broad-based program of education, counseling, and training and remediation. MAB physicians review an average of 7,000 cases per year for medical fitness to drive. When evaluating an individual, the goal is always to recom- mend the least restrictive action that will enable that person to continue to provide for his or her own safe mobility. A team of trained nurse case managers facilitate the process. The MVA has also worked hard to develop resources within the state to assist older adults in maintaining their driving abilities. Three training courses have been developed for instructors at local driving schools: a low vision course, a course in adaptive vehicle equipment, and an “older driver tune-up.” Instructors successfully completing one or more courses are certified by the MVA, and the MVA and others then refer clients to them for assistance. The MVA is also working with the ADED to support increased opportunities for driver educators and other professionals to be trained as driving rehabilitation specialists. The philosophy underlying all of the Maryland MVA’s efforts is to assist older adults in remaining safely mobile for as long in life as possible. Oregon Oregon requires all drivers to respond to a series of medical questions on the driver license renewal application, and driv- ers over age 50 must also pass a vision test. Beginning in June 2003, the state began phasing in a new program of mandatory physician reporting. The Medically At-Risk Driver Program evolved from the recommendations of the state’s Older Driver Advisory Committee formed in 1999 (Report of the Older Driver Advisory Committee 2000). As a result of the committee’s report, legislation was enacted in 2001 stating that determination of an individual’s fitness to drive cannot be based solely on the diagnosis of a medical condition, but must be based on the “actual effect of a cog- nitive or functional impairment on the person’s ability to safely operate a motor vehicle.” Subsequently, a Medical Working Group was formed to identify those cognitive and functional impairments likely to affect driving safety and physicians responsible for reporting them. Work was also carried out to develop a training program for physicians, pro- cedures for managing license suspensions under the new pro- gram, procedures for reinstatement of licenses, and a public outreach campaign. The Medically At-Risk Driver Program was phased in over a one-year time frame, and since June 1, 2004, has been operational statewide. Along with increased reporting by physicians, Oregon has also encouraged greater reporting of at-risk drivers by fam- ily members and friends, making information available on its website. Individuals of any age who are referred by family members, physicians, law enforcement officers, or judges can be called in for reexamination. Currently, approximately 2,500 drivers each year undergo reexamination. The process begins with a meeting with a specially trained driver coun- selor, who determines which tests are required. The driver

then has 60 days to pass all tests to retain a valid driver’s license. Depending on the results of the testing, special restric- tions may be tailored to the individual driver. Oregon’s Medically At-Risk Driver Program is accompa- nied by extensive public information and education efforts carried out by the Oregon DMV and described in greater detail in chapter seven of this report. California The California DMV has been a leader in developing and evaluating programs for improving driver safety, with a spe- cial focus on identifying drivers of any age who have acquired visual, mental, or other functional impairments that might affect their driving ability. Still under development and testing is a three-tiered driver assessment system. In the first tier, all driver license renewal applicants (as well as drivers referred because of physical or medical conditions) are required to pass a written knowledge test, a cognitive screen, and tests of visual acuity (Snellen eye chart) and contrast sensitivity (the ability to distinguish varying shades of gray letters on a white background). Applicants are also observed for physical impair- ments that might affect driving ability. Drivers passing this first tier of testing are allowed to renew their license, whereas those who fail undergo a second tier of testing that includes a computer-based test of information processing ability. The third tier of testing, for those failing the first and sec- ond tiers, consists of the Supplemental Driving Performance Evaluation road test. This test was developed by the Califor- nia DMV and is already being used to evaluate drivers referred for reexaminations. Information about the road test is available on the California DMV website. DMV staff receives special training to conduct the tests that includes instruction in evalu- ating drivers with visual, mental, or physical limitations. The California DMV has also undertaken driver improvement and education programs that are described in later chapters of this report. Florida As noted in chapter two, the Florida Department of Highway Safety and Motor Vehicles (DHSMV) has led efforts in that state in addressing the safety and mobility of older road users. The department’s Transportation Lifetime Choices initiative has identified three primary goals: (1) extend years of safe driving by older motorists, (2) encourage positive education to influence drivers’ self-regulation, and (3) generate suitable alternatives to driving. An initial priority area for the DHSMV has been early recognition and assessment of potentially at- risk drivers through driver license issuance and renewal pro- cedures and through referrals to the department. With regard to the former, the department conducted research to evaluate several potential driver assessment tools in a tiered driver 34 licensing approach similar to that being taken in California and Maryland. Although no single tool was found to posi- tively predict crash risk, the combination of assessment meth- ods was shown to have promise for identifying high-risk drivers. The department also helped fund Florida Senior Safety Resource Centers, which provide more comprehen- sive voluntary assessments of driving ability. The Florida DHSMV has also conducted extensive cam- paigns to train law enforcement officials in identifying and reporting potentially at-risk drivers. It recently implemented a pilot program in Duval County (Jacksonville area) to edu- cate law enforcement, the judicial system, medical profes- sionals, social service providers, DHSMV employees, and the general public about how to recognize and report an unsafe driver. All forms for reporting an at-risk driver are readily available on the department’s website. The Florida Driver License Examiner’s Manual deals extensively with driver limitations, including visual observations to identify a potentially at-risk driver. Once an at-risk driver is identified, the Florida DHSMV has partnered with other agencies and with private-sector organizations to ensure that appropriate remediation options and/or transportation alternatives are communicated to the driver. These programs are described in later chapters of the report. Other State Initiatives In addition to these more comprehensive programs, a num- ber of other state DMVs have programs or policies in place to improve the safety of older drivers. Although certainly not comprehensive, the following list highlights some of these: • Iowa has a Senior Drivers Workbook available on its website that contains a practice driver license test for older drivers. • Illinois allows its seniors to renew their licenses in con- junction with a 2-h Rules of the Road class offered at senior centers and other sites statewide. • The Wisconsin DMV website contains extensive edu- cation and awareness information for older drivers, including information on aging or impaired drivers, driving with a disability, driving with a medical condi- tion, mature drivers, and medically impaired drivers. • Utah was one of the first states to restrict driver licenses based on defined levels of functional ability within med- ical condition categories (see Vernon et al. 2001). The program is described on the Utah Department of Public Safety, Driver License Division website. • In Pennsylvania, a campaign to increase physician reporting of older drivers resulted in a fourfold increase in the number of physician reports. Of those reported, 72% had impairments significant enough to merit tem- porary or permanent recall of their driving privileges (as reported in Staplin et al. 2003).

35 STATE DEPARTMENT OF MOTOR VEHICLE SURVEY RESULTS Given that information on licensing requirements was avail- able from other sources, the survey developed for distribution to state motor vehicle departments focused on services and programs offered to older drivers, license examiner training, and reevaluation of referred drivers. A copy of the survey and accompanying cover letter is contained in Appendix D. The survey was mailed to identified driver license contacts in each state using a list developed by the AAMVA. Responses were received from 34 U.S. jurisdictions. Detailed state-by-state responses to the survey are contained in Appendix E and summarized here. Information and Assistance to Older Drivers Fourteen of the 34 responding jurisdictions (41%) indicated that they made information on older road user safety available on their websites. Table 8 contains a listing of the reported sites provided by 12 of the states. Although all contain use- ful information, the Oregon, California, Florida, Virginia, and Wisconsin websites are especially informative. Just under half of the respondents (16; 47%) stated that they also provided educational materials for older road users (pamphlets, brochures, etc.) at their licensing offices. These were sometimes developed by the DMV, but often included a mix of DMV-developed materials and materials developed jointly with other agencies or organizations. For example: • California distributes brochures about its Mature Driver Improvement Course for drivers 55 or older; the AARP Driver Safety Program; its driver reexamination process and driver safety administrative hearing process; how to report a potentially unsafe driver; the ADA; and for family members, a brochure entitled Tips You Can Give to a Mature Driver. • Michigan distributes a brochure it developed, Driving for Life: A Guide for Older Drivers and their Families. • Missouri distributes the brochure, Driving & Dementia, which it developed in collaboration with the Alz- heimer’s Association. • Oregon distributes information on its Shifting Gears in Later Years program, including a brochure entitled How’s My Driving? and another entitled Retiring from Driving. It also has a colored poster encouraging older drivers to Protect Yourself and Other Drivers—Know Your Limits. Family members are encouraged, in a light-hearted manner, to talk with their parents about their driving: “Your parents had ‘the talk’ with you. Now it’s time to return the favor,” and also, “If you can talk to your kids about sex, you can talk to your parents about driving.” Approximately half of the responding DMVs also said that their agency provided guidance or assistance to older dri- vers or former drivers in accessing alternative forms of trans- portation. In some cases (e.g., in Florida and Alaska), this information was made available through the agency’s web- site. In Massachusetts, a 30-min Powerpoint presentation on the topic was developed as part of the Elder Outreach Pro- gram that is presented statewide. Several of the respondents noted that information on alternative transportation was available if requested by the renewal applicant, or to drivers who were undergoing reevaluations. Asked if their agency coordinated with other state agen- cies or with organizations in the private sector to make infor- mation or programs available to older road users and their families, 21 states (62%) responded that they did. Identified partners included state health departments, social services, State Website Alaska California District of Columbia Florida Illinois Massachusetts Michigan Oregon Pennsylvania Virginia Washington Wisconsin www.state.ak.us/dmv (click on “senior citizen information”) www.dmv.ca.gov (click on “senior driver information”) www.dmv.dc.gov (GrandDriver link to be added) www.hsmv.state.fl.us/ddl/tlc.html www.sos.state.il.us/home.html www.mass.gov/rmv (click on “medical affairs”) www.michigan.gov/sos (click on “older driver”) www.oregonsafemobility.org www.dmv.state.pa.us/pdotforms/misc/Pub_345.pdf www.dmv.state.pa.us/pdotforms/fact_sheets/fs-pasen.pdf www.dmvnow.com/webdoc/general/safety/maturedriver/index.asp www.dol.wa.gov/drivers.htm#senior www.dot.wisconsin.gov/drivers/drivers/aging/index.htm TABLE 8 STATE DMV WEBSITES PROVIDING INFORMATION TO OLDER DRIVERS AND/OR THEIR FAMILIES

and state offices on aging, along with AARP, AAA, National/ State Safety Council, Alzheimer’s Association, hospitals and driver rehabilitation centers, and other private-sector organi- zations. In some cases outreach was limited to providing information brochures or booklets; however, several states provided more comprehensive programs or services. Exam- ples include: • The Florida DHSMV, Division of Driver Licenses, has partnered with more than 40 state agencies, medical professionals, senior citizen advocacy groups, and pro- viders of services to senior citizens to address mature driver issues in the state. Sample initiatives include development of the Transportation Lifetime Choices program; sharing of booklets and brochures among part- ners; joint development of a comprehensive approach to licensing with assistance from the Florida At-Risk Driver Advisory Council; and pilot projects to test new approaches to assess driver capabilities, conduct med- ical referral training, educate DHSMV employees in aging sensitivity, etc. • In 1998, the Massachusetts Registry of Motor Vehicles began offering its Elder Outreach Program. Represen- tatives from the registry have presented the program at assisted living, hospital rehabilitation, AARP, and other settings across the state. The program includes a 30-min PowerPoint presentation followed by a question-and- answer period. • Michigan indicated that it networks with driver training instructors when dealing with special needs applicants and also partners with rehabilitation agencies to help drivers maintain their driving privileges. • Wisconsin coordinates with its Health and Family Ser- vices office, Department of Aging, and the Alzheimer’s Association, Epilepsy Foundation, Diabetes Association, and other health advocacy groups in providing informa- tion on state driving laws, how to report a medically impaired driver, restricted licenses, and a phone num- ber to call for further assistance. The DMVs were specifically asked if local driver license offices provided assistance to older adults or their families in the following four areas: • Identifying driver “refresher” courses (e.g., AARP or AAA courses) available locally, • Identifying local resources for more in-depth assess- ment of driving skills, • Identifying local resources for driver training or reme- diation, and • Identifying available transportation alternatives when driving is no longer an option. Table 9 summarizes results for the 34 responding juris- dictions. Twenty-one (62%) of respondents indicated that 36 local offices in their state provided information on driver refresher courses, and nearly as many (19; 56%) noted that at least some local offices offered information on driver training or remediation options in the area. One-half of the respon- dents (17) replied that local offices provided information on alternative transportation options in the area. The California Driver License Manual [December 2003 (Rev. 67)] specifi- cally encourages examiners to inform customers about trans- portation alternatives within the community. Alternative Transportation You should be knowledgeable about alternative transportation avail- able in the customer’s community. Even if your decision is to grant an area restriction, it is advisable to provide the customer with informa- tion on services available within the community. The Department of Aging has established a network of Area Agen- cies on Aging which administers programs for the elderly. Trans- portation service is included. • Give the customer the appropriate phone number for the Area Agency on Aging. • This list is also available on the Department of Aging website at www.aging.state.ca.us. Assistance with regard to driving assessments was less common, reported by just under one-third of the states (11). Several respondents noted that this type information was available on request, and one state (Florida) mentioned that local information could be accessed from the agency’s cen- tral website. The following states indicated that information was available locally in all four of these areas: Alaska, Florida, Iowa, Maryland, Massachusetts (through their med- ical affairs office), Montana, South Dakota, Vermont, Vir- ginia, and Wyoming. Driver License Examiner Training and Outreach One section of the DMV survey inquired about any special training provided to license examiners in areas of particular relevance for older drivers. These areas include observa- tional approaches for identifying potentially at-risk drivers, declines in visual or cognitive function that might affect driv- ing ability, medical conditions or medication use and driv- ing, and approaches for counseling older adults who must States Responding Yes Do Local Driver License Offices Assist in Identifying: No. Percenta Driver refresher courses 21 62 Resources for driving assessment 11 32 Resources for training or remediation 19 56 Available alternative transportation 17 50 aPercent of 34 responding states. TABLE 9 EXTENT LOCAL OFFICES OFFER ASSISTANCE TO OLDER DRIVERS AND THEIR FAMILIES

37 surrender their licenses. Respondents were asked to rate the level of training examiners received in each of these areas on a scale of 1 (no training) to 5 (comprehensive training). Responses to this set of questions were somewhat ambigu- ous, because (1) not all states have in-person driver license renewals, and (2) states vary in the extent to which they rely on local “line examiners” versus more specially trained assessment personnel to assume such responsibilities (as is the case in California and Maryland). The intent in asking these questions (and presumably the manner in which they were interpreted by the respondents) was with respect to training routinely provided to branch office examiners. With these caveats, Table 10 provides an average level of training with respect to each of the identified areas, and also lists states that self-rated themselves as either a 4 or a 5 in each area. States were most likely to give themselves high ratings with respect to observational approaches for identi- fying potentially at-risk drivers and medical conditions that might affect driving abilities. Close behind was training in age-related declines in visual function. States generally self- rated lower on training directed at cognitive declines, med- ications that can adversely affect driving ability, and coun- seling drivers who must surrender their licenses. States that self-rated themselves as either a 4 or 5 for all six topics included Alabama, Illinois, Montana, Nevada, Texas, and Vermont. Florida noted that it has developed training pro- grams for its employees and is planning statewide concen- trated training on aging sensitivity and the medical referral process to enhance current core examiner training. Respondents were also asked to self-rate their states with respect to the extent driver license examiners are present at local gatherings such as senior centers, health fairs, etc., concerning older road user safety issues and the extent that they engaged in other public education activities, such as host- ing booths at shopping malls or serving on community advi- sory panels. Response categories to both questions included “often,” “occasionally,” “rarely/not at all,” or “uncertain/do not know.” In general, license examiners were not reported to be very active in these areas. Approximately two-thirds of the respon- dents reported that their examiners were rarely or never pres- ent at local gatherings or engaged in other such educational activities. States reporting that their examiners often engaged in such activities included Florida, Illinois, Iowa, Massachu- setts, and Pennsylvania (with regard to presentations at local gatherings), and Florida, Illinois, and Iowa (with regard to other educational activities). Medical Referral Process A final topic area examined on the survey was referrals for reevaluation of fitness to drive. All but two states were able to provide an estimate (or in some cases the specific count) of the number of drivers referred annually for reevaluation. These numbers (detailed in Appendix E) ranged from a low of 149 in Vermont to a high of 29,185 in California. Approx- imately half of the states also maintained data on the age of reported drivers and were able to report (or estimate) the per- centage of referred drivers who were age 65 or older. These percentages ranged from a low of 36% in Virginia to a high of 95% in Nebraska (but may be affected by the particular subset of drivers being reported; e.g., nonalcohol referrals). On average, approximately two-thirds of the referred drivers were age 65 or older. States also provided information on the source of referrals for driver reevaluations (see Table 11). The large majority of referrals came from either law enforcement personnel (37% on average) or medical professionals (35% on average). Fam- ily or friends accounted for approximately 13% of the refer- rals, whereas the remaining categories tallied only small per- centages of the total. Area of Training Average Reported Level of Training on Scale of 1 to 5a States Self-Rating as a 4 or 5 Observational approaches for identifying potentially at-risk drivers applying for license renewal 3.0 AL, FL, GA, IA, KS, MO, MT, NV, ND, SD, TX, VA, WI, WY Age-related declines in visual function that may affect driving ability 2.8 AL, AR, FL, GA, IA, KS, MA, MT, NV, TX, VA Age-related declines in cognitive function that may affect driving ability 2.3 AL, GA, KS, MT, NV, TX, VA, Medical conditions that may affect driving ability 2.9 AL, FL, GA, IA, KS, MA, MT, NV, OH, TX, VA, WY Medications that may affect driving ability 2.3 AL, IA, KA, MA, MT, NV, OH, TX, VA Counseling older adults who must surrender their license 2.1 IA, KS, MT, NV, WY a1 = “no training” and 5 = “comprehensive training.” TABLE 10 TRAINING PROVIDED TO DRIVER LICENSE EXAMINERS

SUMMARY With support from AAMVA, AMA and others, NHTSA has led efforts to develop improved driver licensing programs that support its vision of safe mobility for life. A primary focus has been on developing effective procedures for assessing medical fitness to drive. Once again, however, indi- vidual states have needed to take the lead in developing and implementing programs and materials for their aging driver population. Driver education and awareness has been an important component of these programs. To accomplish their goals, DMVs have frequently collaborated with other state agencies, including departments of health and aging, and with AARP, AAA, and other private-sector organizations. States whose licensing programs were highlighted in this chapter were Maryland, Oregon, California, and Florida; however, many of the 34 states responding to the DMV survey pro- vided good examples of practices and materials that others might emulate. 38 Useful Web Resources Model Driver Screening and Evaluation Program (Staplin et al. 2003) [Online]. Available: http://www.nhtsa.dot.gov/ people/injury/olddrive/modeldriver. Summary of Medical Advisory Board Practices in the United States (Lococo 2003) [Online]. Available: http://www. aamva.org/Documents/drvSummaryOfMedicalAdvisory BoardPractices.pdf. AAA Basic Best Practices for Medical Advisory/Review Boards [Online]. Available: http://www.aaanewsroom.net/ Files/seniorbestpractices.doc. American Medical Association [Online]. Available: http:// www.ama-assn.org/ama/pub/category/5494.html or http:// www.ama-assn.org/ (search on “older drivers”). State driver licensing laws: http://www.agingsociety.org/agingsociety/links/driver License.html. http://www.hwysafety.org/safety_facts/state_laws/older_ drivers.htm. http://www.aaapublicaffairs.com/ (link from Mature Driver page). http://www.iihs.org/safety_facts/state_laws/older_drivers. htm. Iowa Senior Drivers Workbook [Online]. Available: http:// www.iamvd.com/ods/ (link to Senior Driver’s Informa- tion Guide). Oregon Safe Mobility Program [Online]. Available: http:// www.oregonsafemobility.org. Utah Medical Review Program [Online]. Available: http:// driverlicense.utah.gov/medical/index.html. Florida Transportation Lifetime Choices Program [Online]. Available: http://www.hsmv.state.fl.us/ddl/tlc.html. (See Table 9 for state DMV older road user websites.) Referral Source Average Percentage of All Referrals Law enforcement 36.9 Medical professionals 34.9 Family or friends 13.1 Crash/violation records 2.6 Self 2.4 Courts 2.0 Other 8.1 Total 100.0 TABLE 11 SOURCES OF REFERRAL TO STATE LICENSING AUTHORITIES FOR DRIVER REEVALUATIONS

Next: Chapter Six - Educational Approaches for Improving Older Road User Safety »
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TRB's National Cooperative Highway Research Program (NCHRP) Synthesis 348: Improving the Safety of Older Road Users examines programs and policies in place across the country to improve the safety and mobility of older road users. The report documents a range of strategies and related programs under way in roadway engineering, driver licensing, public information and education, and enforcement and adjudication.

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