A practical guide to working out which drivers are safe and which are not

Driving gives older adults autonomy and independence, but also carries enormous risks if they’re no longer fit for the road—and deciding when that time has come often weighs heavily on GPs.

While some signs are clear, there are some nuances that can help you make the decision—and ways to help your patients deal with the fact their driving days are done, experts say.

Memory loss alone does not necessarily make people unsafe

A decline in other key abilities is more likely to impact driving, says Professor Kaarin Anstey, Director of the UNSW Ageing Futures Institute and Conjoint Senior Principal Research Scientist at NeuRA, who has conducted extensive research into how ageing affects our ability to drive.

Good executive function is essential for making decisions when you’re faced with “a lot of complex information coming together, which is what a driving situation is,” she says.

“The most common type of crashes that older drivers have is the turning right crash. It’s that complex decision—it could be a set of traffic lights, it could be raining or it may not be, but you’ve got lots of information that has to be processed, and a judgment has to be made. And that’s very much linked to declining executive function.”

Cognitive slowing affects your ability to make decisions within a fixed amount of time. “For example, you have to judge traffic and decide when it’s safe to turn right or onto a roundabout. So if people can’t respond within a timeframe—if they’re too slow—that increases crash risk.”

Visual selective attention involves the ability to focus on key visual input, she explains.

“Think about a driving scene; there’s lots going on, it’s very busy visually. A driver has to be able to pick out the critical thing—a child running away from their parent or a dog running away. That’s where peripheral vision comes in as well.”

“What we have found is memory loss alone, if all these other things are going well, doesn’t make you as unsafe.”

Standard cognitive screens are poor predictors of unsafe driving

Occupational therapy driver assessor Laura Bosci, part-owner and manager at the Institute of Driver Health—a company that conducts OT driver assessments, education, and research—says that in isolation, traditional cognitive screens like the Mini Mental State Examination and Montreal Cognitive Assessment have “little to no correlation with driving performance on road.”

“There’s only a few tools out there with any significant research indicating they’re predictive of driving,” she says.

She uses Drive Safe, Drive Aware, an iPad-based test any health professional—including your practice nurse—can complete in as little as 10 minutes.

“It trichotomises patients into three areas: likely to fail an on-road assessment, needs further testing, or likely to pass an on-road assessment,” Ms Bosci explains. “It gives us that ability to make informed decisions about cognitive fitness to drive.”

Professor Anstey says part B of the Trail Making Test is quite sensitive, but assessments designed specifically to assess the skills needed for safe driving are better.

“Trail B is a test of executive function and it does predict unsafe driving—not the Trail A, that’s a bit too easy.”

Difficulty with a simple maze test is another predictor, she adds, but none of these tests are perfect or comprehensive and safety can be impacted by specific deficits.

Can they manage the admin of owning a car?

Trouble with administrative tasks often signals impaired executive function, Professor Anstey says.

“Being able to drive safely also involves being able to manage a car—keeping it registered, keeping it insured, etc. And if somebody can’t do that, then they may not be fit to drive either.”

Ms Bosci says it’s a red flag if other areas of a patient’s life, such as managing appointments, finances or shopping “start to fall apart.”

“Essentially, if there’s any doubt, further assessment is worthwhile.”

Hearing loss can point to other problems

While it’s not flagged in medical standards, hearing loss is still worth noting, Ms Bosci says.

“In my clinical experience, hearing loss doesn’t have a huge impact on driving in isolation. But it’s going to have an impact on your ability to hear emergency vehicles, for example.”

“So there needs to be strong other sensory inputs. They have to rely heavily on their visual input, for example,” she says.

“And we know that vision declines with normal ageing, but age also brings conditions like glaucoma, cataracts, macular degeneration, just to name a few, and all of them can obviously impact driving.”

It’s also important to consider conditions that co-occur with hearing loss, particularly cognitive impairment, she adds.

Professor Anstey points out that research shows hearing loss has only a small effect on safe driving, whereas eye disease has a much larger effect.

Physical issues that impact performance

Ms Bosci notes that driving requires adequate movement, strength, proprioception, sensation, and coordination in the upper and lower limbs, as well as trunk and neck motion for performing observation checks.

“Because obviously, operating driving controls, you need all those skills.”

Minor accidents

Professor Anstey says some people often “have lots of minor accidents if their driving is deteriorating, their perception is deteriorating. So we’ll notice their car’s got a number of dings on it.”

Ms Bosci adds that getting lost or losing their car frequently can signify problems.

Ask the family

Both experts agree concern from family members is significant.

A conditional licence may not be the answer

Simply “whacking a 15k restriction on someone because you’re a bit unsure isn’t going to be effective,” Ms Bosci stresses.

Instead, she advises considering conditions on a case-by-case basis. For example, local restrictions may be effective for someone experiencing cognitive fatigue, but not for someone with dementia.

“Unsafe driving in dementia is often related to momentary lapses in attention and they can happen anywhere, anytime. The majority of accidents happen close to home. So, restricting someone to local driving is not always going to be beneficial.”

That said, Professor Anstey notes most crashes happen close to home because that’s where most driving occurs, so exposure to risk is higher there—and this is true for all ages.

Lessons might get them over the line

Professor Anstey says driving lessons may help if patients or their family have concerns about their driving.

“Some drivers have developed bad habits over the years or not be aware of road rules, especially if they have moved interstate or to areas with different rules or road and traffic features. For example, many people are unsure of the rules relating to roundabouts,” she says. “Some people have a private assessment with an OT themselves too, to get frank feedback.”

Advice for telling patients their driving days are done

Ms Bosci suggests explaining you’ll need to start looking for medical and age-related issues that could impact driving well before patients need to hang up the car keys whenever possible.

If that time comes, sensitivity and assertiveness are crucial, she stresses, noting that in her clinical experience, loss of your licence “carries the same mental load and level of grief as loss of a loved one.”

“We want to communicate the need for driving cessation or concern around driving clearly, directly, but respectfully. We want to say what we mean, mean what we say—but don’t say it mean. A colleague of mine used to say be firm on the problem but soft on the person.”

Avoid framing it around skill loss, she advises.

“They particularly don’t like to be criticised about something they’ve been doing for 40, 50, 60 years and that they consider they’re good at.”

It’s important to validate their emotional response, she adds, suggesting you say something like “I know this is sad and doesn’t feel fair, but my priority is to keep you safe—and the only way to keep you safe is to stop.”

Professor Anstey suggests normalising the need to stop driving, given it happens to almost everyone.

She advises exploring ways patients can maintain independence and social connections, such as public transport, community transport, taxi vouchers and Ubers—which can cost a similar amount to running a car.

Further information and resources

Ageing Well On The Road | Advice and resources for clinicians and patients

Transport Victoria | Videos showing how cataracts, macular degeneration, and glaucoma affect driving

Occupational Therapy Australia | Find an OT driving assessor