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DriveWise: An Interdisciplinary Hospital-Based Driving
Assessment Program
Article in Gerontology & Geriatrics  ·Education February 2008

DOI: 10.1080/02701960802497894 · Source: PubMed
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Gerontology & Geriatrics Education, Vol. 29(4) 2008
© 2008 by The Haworth Press. All rights reserved.
doi:10.1080/02701960802497894 351
WGGE 0270-1960 1545-3847 Gerontology & Geriatrics Education, Vol. 29, No. 4, October 2008: pp. 1–18 DriveWise: An Interdisciplinary
Hospital-Based Driving
Assessment Program
O’Connor, Kapust, and Hollis GERONTOLOGY & GERIATRICS EDUCATION Margaret G. O’Connor, PhD
Lissa R. Kapust, LICSW
Ann M. Hollis, OTR/L
ABSTRACT. Health care professionals working with the elderly have
opportunities through research and clinical practice to shape public policy
affecting the older driver. This article describes DriveWise, an interdisciplinary hospital-based driving assessment program developed in response
to clinical concerns about the driving safety of individuals with medical conditions. DriveWise clinicians use evidence-based, functional assessments to
determine driving competence. In addition, the program was designed to
meet the emotional needs of individuals whose driving safety has been called
into question. To date, approximately 380 participants have been assessed
through DriveWise. The following report details the DriveWise mission,
DriveWise team members, and road test results. We continue to refine the
assessment process to promote safety and support the dignity and independence of all participants. The DriveWise interdisciplinary approach to
practice is a concrete example of how gerontological education across professions can have direct benefits to the older adult.
Margaret G. O’Connor, Associate Professor of Neurology, Harvard Medical
School; Director of Neuropsychology, Beth Israel Deaconess Medical Center,
Boston, MA.
Lissa R. Kapust, Director, DriveWise; Senior Program Manager, Beth Israel
Deaconess Medical Center, Boston, MA.
Ann M. Hollis, DriveWise Occupational Therapist, Beth Israel Deaconess
Medical Center, Boston, MA.
Address correspondence to: Margaret G. O’Connor, Psychiatry Department,
Harvard Medical School, Boston, MA 02215 (E-mail: [email protected]).
352 GERONTOLOGY & GERIATRICS EDUCATION
KEYWORDS. Driving safety, road test, DriveWise, dementia
INTRODUCTION
Drivers older than age 80 years have higher crash rates per mile driven
than any other age group except teenage drivers (Insurance Institute for
Highway Safety, 2006). As the proportion of older drivers increases, there
is growing public concern about the safety of the older driver, particularly
those with cognitive problems. The older driver may drive too slowly,
may drive unpredictably, may fail to use turn signals, and straddle
between lanes. These types of errors increase the chance of an accident,
and the older driver is more likely to be involved in a fatal car collision
because they are physically fragile (Li, Braver, & Chen, 2003).
There are many factors that compromise the driving competence of the
older driver. These include visual problems such as a decline in visual
fields, decreased visual acuity, and decreased glare resistance. Other
factors such as diminished auditory acuity may interfere with driving. In
addition, the aging process is accompanied by a decline in musculoskeletal
abilities such as strength, flexibility, coordination, and dexterity. Importantly, age-related medical conditions (e.g., stroke, diabetes) and medication side effects (Wang, Kosinski, Schwartzberg, & Shanklin, 2003)
might affect cognitive and physical functions critical for driving safety.
Age may be accompanied by a decline in cognitive abilities. In some
cases these changes proceed gradually and are rather subtle. In other
instances there are more insidious cognitive declines that may evolve into
dementia.
Aging does not adversely affect all of the cognitive processes involved
in driving. For instance, one’s procedural memory (e.g., memory for how
to operate a car) is not affected by age. However, reaction time, capacity
for multitasking, and speed of visual processing often decline with age,
and problems in these areas present challenges for the older driver
(Owsley et al., 1998). Most older drivers are aware of these difficulties
and make adjustments to their driving routines to mitigate the effects of
subtle cognitive problems on driving. However, some individuals, particularly those who suffer from dementia, are not aware of the effects of
diminished cognitive efficiency on driving competence (Dobbs, Carr, &
Morris, 2002).
Many older people in the United States suffer from dementia. A recent
epidemiological study indicated that the prevalence of dementia among
O’Connor, Kapust, and Hollis 353
individuals age 71 years and older was 14% (Plassman et al., 2007).
However, there is no consensus regarding whether people with mild
dementia should continue to drive. There has been considerable debate
among professionals working with dementia patients regarding whether
driving privileges should be automatically terminated in conjunction with
the initial diagnosis of dementia. This issue is complicated by the fact that
dementia patients present with a heterogeneous array of cognitive and
perceptual deficits. Because driving is a procedurally based skill and
because procedural memory is often preserved in dementia, driving safety
may not be compromised for a subgroup of patients. However, other
patients present with deficits on tasks that are considered critical in the
driving situation (i.e., visual integration, selective attention, processing
speed.)
Recommendations from the American Academy of Neurology (Dubinsky,
Stein, & Lyons, 2000) suggest that persons with very mild dementia are
not at greater risk for a crash than are new drivers whereas those with
more advanced disease have significantly reduced driving competence.
Screening instruments geared toward rating level of dementia are a
starting point in the identification of the impaired driver; however, these
ratings alone do not tell the whole story regarding each person’s driving
skills.
Identification of the impaired driver is difficult but even more challenging is the initiation of a discussion about driving competence.
American culture celebrates the car in film, music, and literature; and
driving is integral to one’s sense of freedom, independence, and ultimately self-esteem. It is no wonder that the elderly, amid other losses
associated with aging, cling to their licenses and driving. Because driving
is so integral to the core of one’s self-esteem and independence it has
been referred to as the “asphalt identikit” (Eisenhandler, 1990). Discussions regarding driving competence are emotionally charged and have the
potential for causing tremendous conflicts in families and doctor/patient
relationships. No one wants to be the bad guy when it comes to making
decisions about a person’s future driving. A survey of 106 physicians, 146
police officers, and 52 community members (Silverstein & Murtha, 2001)
revealed that none of the stakeholder groups wanted responsibility for the
determination of driving competence. Some physicians reported that they
were not comfortable making decisions regarding driving for their
patients because they lacked the time and knowledge base to address this
complex issue. Across stakeholder groups there was inconsistent agreement regarding the type of assessment needed to determine driving
354 GERONTOLOGY & GERIATRICS EDUCATION
competence (Silverstein & Murtha, 2001). Educational and practice initiatives are needed to address knowledge and skills gaps among the professions and the public to increase understanding related to fitness to drive.
THE DRIVEWISE PROGRAM
The DriveWise program was developed 12 years ago by a group of
hospital-based clinicians (neurologists, neuropsychologists, occupational
therapists, and social workers) who were asked to make decisions regarding the driving competence of elders with dementia. Over the course of
the last 12 years, DriveWise has provided multifaceted evaluations of
driving safety for people of all ages, including those with neurological,
psychological, and/or physical impairments. DriveWise provides a comprehensive overview of the transportation needs and emotional well-being
of each participant in addition to obtaining information regarding their
actual driving skills during a road test. Importantly, because DriveWise is
a hospital-based program, the underlying complexities of the medical
condition are always considered in terms of decisions and recommendations for each person. Perhaps the most unique aspect of DriveWise is that
information from a variety of critical sources is weighed carefully in the
assessment and in the final written recommendations. The DriveWise
program has helped almost 400 persons and their family members
confront the issue of driving safety in a manner that is compassionate and
evidence based.
DriveWise Participants
DriveWise referrals come from physicians, family members, community
agencies, the Department of Motor Vehicles and occasionally from a driver
who has concerns about his or her own driving competence. Most individuals referred to DriveWise have demonstrated vulnerabilities in the driving
situation. Some have had actual crashes. In other instances, individuals are
referred after family members observe subtle warning signs (e.g., new dents
in the vehicle, missing side view mirrors) or a pattern of getting lost when
driving on familiar routes. Elderly driving mishaps are often featured
prominently in the news. Heightened media attention may prompt worried
family members to refer their loved one for a driving evaluation.
The majority of individuals referred to DriveWise have been diagnosed
with medical conditions that present concerns for continued driving.
O’Connor, Kapust, and Hollis 355
Many who undergo DriveWise evaluations suffer from mild dementia.
Others have been referred following a stroke, traumatic brain injury, or in
the context of diagnosis of Parkinson’s disease. Psychiatric illnesses,
including depression and schizophrenia, prompted referral for some
patients. A small group of DriveWise participants were referred without a
clear diagnosis but simply on the basis of advanced age and/or driving
problems in everyday life.
DriveWise Assessment Process
DriveWise team members include professionals who specialize in clinical social work, neuropsychology, occupational therapy, and a certified
driving rehabilitation specialist. Each team member plays a unique and
pivotal role in the driving assessment process and in crafting the individually tailored recommendations used during the feedback session. The
interdisciplinary office based assessment takes 2½ hours. A 1-hour
standardized road test follows the office interviews. The person returns
2 weeks later for a 1-hour feedback session with the social worker. The
cost of the hospital-based assessment is $331.00. The road test costs an
additional $120.00. The DriveWise program is private pay and is not currently covered by Medicare or other health care insurance. Although driving is defined by the American Occupational Therapy Association
(AOTA, 2002) as an instrumental activity of daily living within the
domain of occupational therapy, Medicare does not recognize the medical
necessity of formal driving evaluation.
The clinical social worker plays a key role in the assessment. Each
participant meets with the social worker at the beginning and end of the
program. DriveWise social workers have specialized training in the area
of gerontology and are familiar with state driving regulations as well as
clinical research studies regarding driving safety. The social worker
explores the role of driving for each DriveWise participant. It is important
to consider other relevant losses experienced by the person and his or her
psychological state in relation to the extremely important decision about
driving. Family members and DriveWise participants often do not see eye
to eye on the assessment and potential outcomes. Although the family
member’s report on the perceived safety issues for the DriveWise participant are important, family members may over- or underreport the true
extent of problems. For example, the spouse who does not drive may
underreport the problems of the husband or wife, because cessation of
driving will dramatically affect transportation options. In other cases, an
356 GERONTOLOGY & GERIATRICS EDUCATION
overly concerned adult child may exaggerate the driving problems of a
parent. Old family conflicts may get played out in the safety evaluation
process (Kapust & Weintraub, 1992). The social worker tries to understand the different family perspectives and works to minimize conflicts
that can be disruptive. The potential consequences of driving cessation
are thoughtfully probed with the participant and family members who join
this meeting. Each participant is required to sign a consent form before
participation in the program. This allows for communication with the
physicians and potential reporting to the Department of Motor Vehicles,
if deemed necessary.
Neuropsychological input is often needed in the DriveWise assessment
because many individuals are referred with cognitive and perceptual
problems. Following the meeting with the social worker the participant
meets with a neuropsychologist who administers a brief screening battery
to obtain information regarding the individual’s functional skills as well
as their diagnosis. Identification of the correct diagnosis is particularly
important in light of medical guidelines from the American Academy of
Neurology (Dubinsky et al., 2000) indicating that patients with mild
dementia should undergo repeat evaluations every 6 months. Neuropsychological findings may guide the treatment recommendations developed
by the DriveWise team.
The next step in the DriveWise assessment includes evaluation by an
occupational therapist (OT), in the office and on the road. The OT
reviews each person’s medical history to identify conditions and medications that might affect driving performance. The goal of the assessment is
to maximize each person’s potential for safe driving. The in-clinic OT
evaluation assesses the participant’s physical, cognitive, and perceptual
abilities. Physical tests focus on range of motion, strength (manual muscle
testing), sensation, and coordination. Brake reaction time is assessed. Perceptual abilities include measurements of visual acuity, visual fields, and
depth perception. The participant’s cognitive skills are evaluated with
mental status screening tests and tests of visual attention.
Once the office testing is completed the participant proceeds to the
road test. Actual driving performance is evaluated by the OT and a certified driver rehabilitation specialist who is a consultant to the DriveWise
team. The road test is conducted in a specially equipped car with a brake
pedal on the passenger side. The OT and the driver rehabilitation specialist rate the driver on overall safety. The DriveWise road test is a modified
version of the Washington University Road Test (Hunt et al., 1997)
adapted for use on comparable Boston, Massachusetts, streets. This test
O’Connor, Kapust, and Hollis 357
provides information regarding driving speed, lane maintenance, distance
from other cars, turns, response to changes in the environment, observation of traffic signals, and parking. The OT, sitting in the backseat during
the assessment, observes qualitative aspects of the driver’s behavior in
terms of vigilance, confidence, distractibility, and impulse control.
Following the road test, there is a team meeting to make a determination regarding the participant’s driving fitness. Evaluation findings from
each team member are carefully considered in this decision. Final recommendations fall into three categories: pass, remediation/retesting, and
driving cessation. A letter that reviews critical aspects of the participant’s driving performance is prepared. The letter is not mailed to the
participant but is held for review during the final social work meeting.
Copies of the letter are mailed to referring physicians after the patient
receives the findings.
Approximately 1 to 2 weeks after the road test, the social worker meets
with the participant and family to provide feedback to discuss DriveWise
recommendations. Social work counseling is geared toward helping the
individual understand the reasons for the recommendations, especially
when driving cessation is advised. When a participant passes the evaluation the social worker may focus on tips for safe driving as well as recommendations for maintaining vehicle safety and driver fitness. When the
participant has a progressive medical condition, the need for periodic
retesting is discussed as per the guidelines of the American Academy of
Neurology (Dubinksy et al., 2000). When remediation is advised, the participant is referred to an external agency that will provide a driver
refresher course to address specific problems (i.e., lane changing) identified during the road test. The remediation participant must return for
retesting to assess whether the intervention has made him or her a safe
driver. Some participants decline the option for remediation; in these
cases, they agree to stop driving. A third group of participants are found
unsafe to drive. The clinical skills of the social worker are tested in this
scenario. Delivering bad news is challenging, and it is especially difficult
to deliver bad news to an individual experiencing other losses associated
with aging or illness. In our clinical experience, most individuals with
support from family members agree to stop driving. However, there are
times when the social worker needs to report DriveWise findings to the
DMV. A report to the DMV is initiated only when the team concludes
that the participant poses a public safety threat. The DriveWise participant and family members understand this arrangement as outlined in the
consent form.
358 GERONTOLOGY & GERIATRICS EDUCATION
PRELIMINARY RESULTS
To date, 380 individuals, age 19 through 95 years, have been assessed
through DriveWise. Twenty participants were older than age 90 years. Of
the 380 people who underwent road tests, 43% were deemed safe to drive.
In contrast, 40% of participants demonstrated errors during the road test
that resulted in a recommendation for driving cessation. In this situation,
alternative transportation resources were identified, and the social worker
assisted the individual and his or her family with this important and difficult life change transition. Seventeen percent of DriveWise participants
demonstrated marginal driving skills. These drivers made errors during
the road test, but the errors were not egregious; and the team believed that
remediation of specific vulnerabilities would result in safe driving. A second road test was scheduled following remediation.
There has been considerable variability in terms of the medical conditions prompting referral to DriveWise. The largest group of participants
(N = 135) was referred due to a diagnosis of dementia. In the dementia
cohort 24% passed the evaluation (n = 32) whereas 63% (n = 85) were
evaluated as unsafe to drive. Of note, severity of dementia influenced outcome in that only participants with mild dementia were able to pass the
road test. Like other driving assessment programs, DriveWise clinicians
found that performance on tests of visual analytic abilities and mental
flexibility was predictive of road test performance whereas memory problems per se were not invariably associated with unsafe driving (Deveney,
Najmi, Kapust, Hollis, & O’Connor, 2006; Elkin-Frankston, Lebowitz,
Kapust, Hollis, & O’Connor, 2007). The error pattern of dementia participants who failed the road test was examined in relation to problems with
attention, lane maintenance, speed of driving, efficient braking, and turning maneuvers. The highest number of errors in dementia participants
who failed the road test had to do with inattention and problems with lane
maintenance.
A subgroup (13%) of dementia participants performed marginally well
during the road test and were sent for remediation. Of the dementia drivers who were sent for remediation 53% passed the road test following
remediation whereas 27% either quit driving on their own or they failed
the road test after remediation. Two remediation drivers were lost to follow-up. Because dementia is a progressive condition, follow-up testing
has been advocated as a way of monitoring driving safety. Those participants with dementia who passed the DriveWise road test were referred for
a reevaluation 6 months later.
O’Connor, Kapust, and Hollis 359
Other DriveWise participants have been referred with a diagnosis of
Parkinson’s disease (PD), a progressive neurological disorder that affects
cognitive and motor abilities. Some individuals with PD experience marked
fluctuations in their level of alertness, attention, and motor functions over
the course of the day and in response to medication schedules. The variability in functional status presents a challenge for the clinician attempting to
assess driving safety in the PD group. So far, driving studies of drivers with
PD have not fully explored the impact of fluctuations on driving performance. Altogether, 24 patients with PD were referred to DriveWise. Of this
group, 42% passed and 58% failed the driving evaluation.
Some DriveWise participants have been referred in the context of static
neurological disorders such as traumatic brain injuries (n = 30) or strokes
(n = 60). These conditions may result in motor, sensory, and cognitive
deficits that affect driving but are not likely to increase over time. Of the
30 participants with brain injuries approximately 60% passed the road
test, 20% failed the road test, and 20% were sent for remediation.
Approximately 45% of the participants who suffered strokes passed the
DriveWise evaluation, while 25% failed the road test, the remaining 30%
were sent for remediation. Of the stroke and brain-injured drivers referred
for remediation, 40% passed the road test following remediation while
60% were lost to follow-up. So far, 18 DriveWise participants were
referred solely on basis of old age (range 83–93). Of this group, nine participants passed the road test while five failed. Six were sent for remediation. One half of those referred to remediation later passed the road test.
DriveWise clinicians have examined whether laboratory based tests provide useful information about driving competence. A preliminary study
revealed that neurocognitive testing alone did not predict road test performance (Kapust & Weintraub, 1992). Later studies demonstrated that tasks
of visual analytic skills and mental flexibility correlate with road test performance. One commonly used instrument, the Trail Making Test (TMT;
Reitan, 1958), has been shown to be sensitive to skills considered critical
for driving safety. This test requires the examinee to connect an array of letters and numbers in an alternating fashion. The task is dependent on visual
scanning, processing speed, and mental flexibility, aspects of cognition and
perception associated with performance on road tests and driving simulators in elders with and without dementia (Brown & Ott, 2004; Grace et al.,
2005; Hunt et al., 1997). In fact, the American Medical Association (AMA)
has recommended the use of the TMT as a screening tool to identify the
at risk driver (Wang et al., 2003). Data from DriveWise evaluations have
indicated that TMT is useful for the identification of the impaired driver
360 GERONTOLOGY & GERIATRICS EDUCATION
(Deveney et al., 2006). Other data focused on a less culturally biased
version of the TMT, the Colored Trails Test, as a predictor of road test success (Elkin-Frankston et al., 2007). Cognitive and perceptual tasks may be
useful screening instruments; however, in the opinion of these authors,
there is no substitute for the road test in terms of driving assessment.
DISCUSSION
DriveWise clinicians have relied on functionally oriented assessments
using actual driving behaviors as a reference point for decisions about driving. The program is comprehensive, but the clinicians are aware of inherent
limitations in the assessments. For instance, they know that the road test is
merely a snapshot of driving behaviors, and that performance during this
test may not accurately reflect driving outside the test situation. This is particularly true for individuals who experience fluctuations in attention and
reaction time over the course of the day. In addition, the DriveWise assessment may not be sensitive to changes in personality or judgment that may
give rise to aggressive driving or road rage. Finally, the role of remediation
as an adjunct to driving assessments has not been fully explored. Our preliminary findings suggest that remediation is quite beneficial for some
participants; however, so far the characteristics of those who will profit
from this type of intervention have not been fully elucidated.
Over the past 12 years DriveWise clinicians have refined the assessment program to reflect the best practices in the field. The team’s primary
goals are to support the dignity and independence of each participant
while ensuring safety. The DriveWise program is based on the idea that
decisions about driving competence should be made on the basis of evidence-based assessments and that supportive interventions are needed
when any individual’s driving privileges are called into question.
Implications for Gerontology and Geriatrics Education
Physicians who specialize in geriatric care must consider driving safety as
a central issue in their clinical work. Given the present population trends,
driving fitness merits close scrutiny. Many physicians are reluctant to initiate
discussions about driving with elderly drivers because they anticipate a negative emotional reaction, and they worry that this may disrupt the doctor/
patient relationship. Others do not initiate these discussions with their
patients because they do not believe that they have adequate knowledge
O’Connor, Kapust, and Hollis 361
about the patient’s functional driving skills to address this issue in a thoughtful manner. Physicians who work with the elderly should become educated
about methods to assess the older driver as well as state reporting laws.
Clinicians in the DriveWise program have been asked to participate in
public policy forums to advise our DMV about new policies for relicensing of older drivers. There are opportunities for those in the field to influence many arenas of public health and public safety as these matters
pertain to driving. Opportunities range from working on ways to make
highway design safer for the older driver to looking at successful remediation interventions. The following recommendations are geared toward
health care professionals in clinical practice with older drivers:
1. Initiate discussions about driving with every patient older than age
70 years.
2. Document discussion of driving safety in the medical record.
3. Refer the patient for a road test in a hospital-based OT program or
through the DMV when the patient or family member raises concerns
about driving safety.
4. Use counseling interventions when driving cessation is recommended.
5. Integrate the following questions in a driving history:
• Have you had any recent accidents or near misses?
• Are you confident of your driving skills?
• Are you nervous when driving?
• Are you taking medications that could affect your level of alertness?
• Have family members or friends expressed concern about your
driving?
• Have you gotten lost on familiar routes?
• Does your car have new scrapes or dents?
Gerontology and geriatric educators are encouraged to include some or
all of the above recommendations in the curriculum development for the
training of health care professionals who are in contact with older adults.
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