• Selection and Training of Licensing Personnel;
• Identification and Referral of Deficient Drivers by Enforcement Personnel;
• Physician Reporting; and
• Functioning of Medical Advisory Boards.

SUPPORT PROCESSES

Selection and Training of Licensing Personnel by Douglas K. Tobin, Pennsylvania Department of Transportation

As American vehicles and roadways age, highway safety professionals design better vehicles and repair deteriorating roadways. American drivers, too, are aging, and licensing personnel must adjust to the special needs of this older population. According to Tobin, selection of licensing personnel is often governed by state civil service systems that prescribe candidate selection based on years of service rather than on training for the job. Therefore, licensing agencies train employees after they are hired. Many agencies use the American Association of Motor Vehicle Administrators' (AAMVA's) Certified Driver Examiner program. Using this program as a platform, agencies now need to incorporate training on the needs of older drivers. Tobin thought this training component would probably be combined with training to make accommodations for all special needs drivers, as required by the American Disabilities Act. No national program now meets this need; however, several state programs exist--notably Oregon's model older-driver program.

The need is for development of an effective, efficient, economical program to train licensing personnel in meeting the requirements of the elderly and other special-needs drivers. Personnel will need screening and evaluation tools to help decide which drivers require special licensing and guidelines on licensing actions appropriate for the varied needs of elderly drivers (e.g., denial of a license, license restrictions, and referral to further testing or retraining). The AAMVA is developing a non-commercial driving test that may be useful.

The training plan should provide for periodic retraining and focus on service- oriented aspects of working with elderly drivers. As Tobin wrote, "There is probably no good way to inform someone their driving days are over, but there are certainly many bad ways." In designing and conducting training programs, licensing agencies should take advantage of driver rehabilitation expertise available in hospitals and other organizations that work with the elderly. Finally, part of the training program must be continued re- evaluation to be certain efforts remain effective.

Improving the Ability of Law Enforcement to Identify and Refer Deficient Drivers by Raymond D. Cotton, Maryland State Police

Since their work nationally involves thousands of driver contacts each day, law enforcement is "the single largest source for referring deficient drivers to licensing agencies." However, law enforcement personnel often do not recognize physical and cognitive disabilities that make older drivers high-risk drivers, and they may not be trained to recognize deficient driving behaviors that result from the use of prescription drugs. Lacking guidelines for referring such drivers to licensing agencies and budget to make referral of deficient drivers a priority, enforcement personnel detect only a small portion of elderly drivers who should be referred to licensing agencies for evaluation.

Tobin mentioned five steps to improve law enforcement's ability to refer deficient older drivers:

1. Research effective policies and practices,
2. Respond by planning implementation of new training and enforcement strategies,
3. Re-educate personnel on the characteristics of deficient drivers and the processes for identifying and referring them,
4. Report to the public to increase awareness and garner help removing deficient drivers from the road, and
5. Refer deficient resident and nonresident drivers to appropriate agencies.

These steps will improve law enforcement's ability to identify and refer deficient older drivers. Once identification and referral procedures are developed and in place, they need to be integrated into routine patrol operations, and the information gathered should be included on crash reports. Of particular importance are tests to administer in the field that detect the presence of prescription drugs or physical and cognitive disabilities that affect driving. When law enforcement identifies deficient drivers, it is essential that the information reach licensing agencies quickly, especially for high-risk drivers. Moreover, referrals need to cross state lines when appropriate. By sharing methods and procedures and developing a national training program, law enforcement around the country can be proactive in preparing for the graying of the American driver.

Physician Reporting by Anne Long Morris, American Occupational Therapy Association

Citing a lack of public transportation in many suburban and rural areas, Morris called driving a necessary "activity of daily living (ADL)" for the elderly. Buying food, accessing medical services, and transacting government and private-sector business requires mobility. About 600 occupational therapists (OTs) are nationally registered and state-licensed to serve as driver rehabilitation specialists and help older people overcome visual, cognitive, and physical deterioration that may affect their ability to drive and, therefore, independently perform ADLs. OTs evaluate the needs of older drivers through in-depth interviews, testing, computer-simulated evaluations, and, if appropriate, behind-the-wheel observations of motor, sensory, and cognitive disabilities. Test results allow them to make recommendations regarding rehabilitation and/or licensing restrictions. Physicians who specialize in working with older patients help OTs assist older drivers by referring people whose medical problems put them in a high-risk category for driving. Holding physicians legally liable if one of their patients is involved in a crash, some states require them to refer seniors with certain medical conditions. Morris listed conditions that D. Reuben identified in 1993 as creating increased crash risk: "heart, circulatory, and lung diseases; diabetes; neurologic disorders, such as Alzheimer's and cognitive impairment, Parkinson's, and stroke; multiple medications; arthritis; and alcohol abuse."

While driver licensing agencies have ultimate responsibility for decisions to deny or restrict licenses, they rely on physicians and state medical advisory boards (MABs) for opinions. As of 1990, however, few MABs had occupational therapists or rehabilitation specialists on their panels and did not focus on the problems of older drivers. Moreover, as of 1992, many licensing agencies had only vague policies addressing the physical, cognitive, and visual disabilities that affect older drivers.

To address the need of physicians and therapists for improved assessment and referral procedures and the demand for effective rehabilitation programs, Morris recommended seven actions.

1. Promote awareness of rehabilitation programs among health and human services professionals,
2. Train more occupational therapists to teach driver rehabilitation programs,
3. Increase occupational therapist participation on MABs,
4. Continue distribution of the American Occupational Therapy Association's brochure, "Able Driving Is Safe Driving," to increase public awareness of driver retraining programs,
5. Foster cooperation between occupational therapists and driver licensing agencies to educate licensing staff about the needs of older drivers,
6. Improve systems for physicians to refer to licensing agencies and rehabilitation programs older patients with medical conditions that affect driving, and
7. Provide continuing education to those involved in identifying, referring, and retraining older drivers to keep them up on new screening and evaluation tools.

Functioning of Medical Advisory Boards and Physician Reporting by Jackie A. Anapolle, National Mobility Institute

By law or administrative authority, state Medical Advisory Boards (MABs) usually serve as advisors to driver licensing agencies on the medical aspects of driver deficiencies. Given a lack of adequate screening tools and insufficient public transportation for non-driving adults, identifying and restricting the driving privileges of high-risk older drivers is difficult. In addition, MABs are often made up of appointees who are neither trained nor motivated to make recommendations that may open them to legal liability. Anapolle reported that, at the time this article was written, 39 states had MABs, 37 of those boards helped design medical review processes, and 33 boards heard individual cases. However, some boards had no scheduled meetings and only a few active members. Therefore, it often falls to driver licensing agencies to make medical judgments on license restrictions for older drivers.

Referring to results of a survey by the Association for the Advancement of Automotive Medicine and information from the Massachusetts Registry of Motor Vehicles, Anapolle suggested changes in membership, function, legal protection, and board operation could benefit MABs.

Membership -- Boards should be made up of motivated members and a broad representation of medical specialties. A public health physician and members of the state medical society should serve on MABs. Alternate members (ex- members who would vote when needed) and associate members (non-voting specialists in fields related to highway safety) would complete the ideal board. Function -- In addition to advising licensing personnel on the relationship between medical conditions and licensure, MABs should help develop functional abilities' guidelines, train licensing examiners, design forms for physicians to use in referring patients to licensing agencies, educate medical professionals on the cause-and-effect relationships between medical conditions and traffic accidents, and gain support from the public in the identification and referral of older drivers with medical conditions that impair driving abilities.

Legal protection -- MABs need assurance that information used in medical evaluations of older drivers for licensure purposes will be confidential and used in court only in issues directly related to driving. In addition, members must be immune from legal liability for board decisions.

Board operation -- Boards need nationally developed uniform standards for license denial or restriction based on criteria related to cognitive, physical, and vision conditions. A team approach to using these standards should involve health professionals, driving educators, legal advisors, and others concerned with traffic safety for the older driver.