Driving rules and assessment for older people

A medical assessment is required for licence renewal in people aged over 75 years. However older drivers should be frequently assessed for fitness to drive, especially when their medical conditions or medications change.

It is often difficult to address the topic of driving fitness. If there is a danger of destroying a therapeutic relationship, a GP may consider referring the patient to another medical practitioner for assessment. If a patient is generally medically fit but there is still concern about their driving ability due to frailty, possible cognitive decline or a specific medical condition, they may be referred to a specially trained occupational therapist for a driving assessment. This recommendation can also be indicated on the driver’s medical certificate if the patient is renewing their driver licence.

The specific type of driving assessment is dependent on the patient’s medical condition. As a rule an occupational therapy driving assessment is only required, where there is a medical problem which impacts on the patient’s physical or cognitive function, related to driving.

GP tip: Discussing driving fitness is often forgotten during complex consultations. Make this part of your “safety net” checklist at the end of each consultation. This is especially important in the case of an acute illness where the diagnosis has not been confirmed and when a new drug has been prescribed. Don’t forget to record driving advice in the patient notes.

Signs that may indicate decline in an older person’s driving abilities

GPs and practice nurses should be alert to signs which may indicate that an older person is having difficulty with driving. The patient themselves, or their family members, may comment on the following:

• Driving at inappropriate speeds – too fast or too slow
• Asking passengers to help check if it is clear to pass or turn
• Responding slowly to or not noticing pedestrians, cyclists or other drivers
• Ignoring, disobeying or misinterpreting road signs and traffic lights
• Failing to give way to other vehicles or pedestrians that have the right of way
• Failing to judge distance between cars correctly
• Becoming easily frustrated and angry
• Appearing drowsy, confused or frightened
• Having one or more near accidents
• Drifting across lanes or bumping into curbs
• Forgetting to turn on headlights after dusk
• Difficulty with glare from oncoming headlights, streetlights etc
• Difficulty turning head, neck, shoulders or body when driving or parking
• Ignoring signs of mechanical problems with the car
• Having too little strength to turn the wheel quickly to avoid hazards
• Becoming lost in familiar areas or routes which would not have previously confused them
• Confusion when stopping or changing lanes
• Not making sound judgements about what is happening on the road

GP assessment of fitness to drive

When considering a patient’s fitness to drive, the following factors should be taken into account:

• Do the patient’s signs and symptoms of their individual condition affect their ability to drive?
• Does the patient have a condition in which sudden loss of vision or sudden impairment of driving ability may occur?
• Does the patient have a medical history of previous episodes of dizziness, vertigo, angina, visual disturbances or TIA?
• What are the effects of any medications that the patient is currently taking? Is the patient compliant with taking their medications?
• Does the patient have more than one medical condition that may affect driving fitness?
• What type of licence is held by the patient and what type of driving do they undertake? (e.g. passenger vehicle, heavy transport vehicle?)
• What is the patient’s motor vehicle accident history? Has the patient had a previous accident related to a medical condition?

Clinical examination should include assessment of:

• Cardiovascular system - especially poorly controlled hypertension, arrhythmias or significant ischaemic disease
• Central nervous system - especially coordination and sensory loss, post-stroke effects, Parkinsonism, TIAs
• Musculoskeletal system - general mobility and strength, especially in relation to arthritis and other degenerative conditions
• Cognitive or mental health issues - orientation in time and place, recent memory, coordination, appropriateness of behaviour and responses, inattention, confusion, ability to communicate
• Sensory - vision and hearing
• Other significant conditions such as severe respiratory illness or malignant disease

Refer to the New Zealand Transport Agency “Medical aspects of fitness to drive” guide (supplied to all GPs) for specific requirements and standards for testing.

Quick driving assessment

Consider if a new medical condition, change in medical condition, new medication or change in dose has the potential to compromise driving performance.

Does the change affect any of the following:

• Physical - weakness, slow or limited movement?
• Sensory - visual loss, limited feeling in limbs?
• Cognitive/perceptual - slowed thinking, decreased attention?
• Emotional - anxiety, panic reactions?

Questions to consider asking include: Is anyone concerned about your driving? Do you feel less confident about driving? Have you restricted your driving habits? Do you think you are a safe driver?

Simply observing the patient during the consultation may make it unnecessary to assess some of these functions, but consider examination of cognition, vision, motor skills and sensation.

Discussing being unfit to drive

Prepare patients early for the possibility that they may become unfit to drive at some point in the future. Allow the patient time to consider other transport alternatives that they may need to adopt. Changes could be made prior to a complete cessation of driving, including reducing the amount of time driving, avoiding peak traffic periods, avoiding highways and busy roads or avoiding driving at night time. Patients are usually open to suggestions of ways they can remain safe drivers.

If a patient has been deemed unfit to drive, discuss the reasons for this and when the decision may be reviewed (if at all). It is often a good idea to have this discussion in the presence of a supportive family member or friend. Consider putting the decision in writing for the patient, especially if long-term cessation of driving is advised.

If the patient agrees that they will not drive or will only drive under specified conditions, no further action is required. If the patient does not accept the advice and is likely to continue to drive, the New Zealand Transport Agency should be advised (see sidebar “Legal obligations”).

In general, men find it more difficult than women to adjust to life without driving. Being without a driver licence is more of a threat to older men’s independence and self-image. Be aware of these gender differences, and how the loss of a driver licence can affect others, that rely on that person for transport.

Driving restrictions for medical conditions common in older people

Table 1 contains a summary of driving restrictions applicable to medical conditions commonly seen in older people. For a full list of conditions and restrictions, refer to “Medical aspects of fitness to drive” guide.

Medications and alcohol may have an enhanced negative effect on driving in older people

Medications that cause drowsiness or distraction can have a significant impact on driving ability. Age-related changes in drug metabolism can enhance the effect of these medications in older people.

When starting any new medication in an older patient, consider what affect it may have on their driving ability. Adverse effects are often worse in the first few days of a new medication. Consider advising the patient to avoid driving until they know how a medicine will affect them.

Benzodiazepine use is most often associated with an increased risk of injury causing accident among older drivers. Other medications that may affect driving ability include opiates, antidepressants, antipsychotics, some antihistamines and some cold and flu preparations.

The effects of alcohol may also be enhanced in older people. This should be explained to older patients and recommended to them that they have minimal or no alcohol intake prior to driving.

Mobility scooters and power chairs

Mobility scooters and power chairs (motorised wheelchairs) may be a suitable option for older people who are no longer able to drive a motor vehicle, have limited distance mobility outside the home and who are sufficiently cognitively capable. A driver licence is not required to operate these devices.

A mobility scooter costs approximately $2000 - $7000 to purchase. Second-hand scooters are available privately and from some retailers. Approximately 250 Lottery Grants are awarded each year for the purchase of a scooter. Some areas offer schemes (e.g. Wellington City Mobility) which provide a number of free scooters for short-term use.

Many local councils run training courses for using mobility scooters or power chairs. Contact the Road Safety Coordinator at the nearest council.

N.B. Lottery grants are also available for funding vehicle modifications for individuals with physical disabilities to drive or travel as a passenger.

Total Mobility taxi scheme

The Total Mobility taxi scheme offers subsidised transport for people with disabilities (mobility, sensory, psychiatric or intellectual) who have difficulty using public transport. After assessment for eligibility, a person will receive up to 50% discount on door-to-door transport (usually a taxi).

This scheme may not be available in all areas (e.g. rural) and there are local variations on the amount of discount applied. Contact the nearest local or regional council or Age Concern office.

Free off-peak public transport

SuperGold Card holders may be eligible for free off-peak public transport (9am to 3pm, after 6pm, weekends and public holidays). There are local variations to the definition of off-peak travel and types of transport available therefore contact local councils for information.

Mobility Parking permit

The Mobility Parking permit allows users to park in accessible marked parks. Permit holders may also use standard car parks and metered spaces for longer than the stated times. The scheme is run by CCS Disability Action in partnership with local councils. To be eligible, a person must rely on mobility aids such as crutches, walking sticks or a walking frame, or be unable to walk for more than 200 meters unaided due to their condition. Permits cost $45 for five years or $30 for a temporary 12 month permit. GPs must certify applications.

For more information contact: CCS Disability Action - 0800 227 2255

National travel assistance scheme

DHBs provide funding for travel assistance to enable people to attend specialist health and disability support services i.e. if a specialist refers a patient to another publicly funded specialist, transport costs of getting there (and accommodation if applicable) may be covered. This does not apply to General Practice visits.