Abstract
Over 40% of people with dementia drive, with a two to five times greater accident risk than controls. This has fueled public concerns about the risk of traffic accidents by drivers with dementia (DWD). We compared driving regulations on seniors and DWD between ten European and Asia-Pacific countries to identify key implications for national strategies. Moderate to severe dementia was a reason for driver’s license revocation in all countries. However, regulations on mild dementia varied considerably, with most basing their decisions on severity, rather than simply the presence of dementia. Most used validated assessments, but responsibility for triggering the administrative process fell on drivers in some countries and on physicians in others. Administrations should consider the following when developing driving policies: 1) ideal regulations on DWD should ensure that restrictions are implemented only when needed; 2) fitness to drive should be assessed using validated instruments; 3) the use of processes that automatically initiate driving competency examinations following a diagnosis of dementia should be explored; and 4) restrictions should be delicately tailored to a range of driving competence levels, and assistive incentives compensating for lost driving privileges should be provided.
INTRODUCTION
The number of older adults and people with dementia (PWD) is projected to rise rapidly worldwide during the next few decades [1]. This increase has fueled public concerns as drivers with dementia are more prone to traffic collisions and may need to stop driving at some point [2, 3]. Reports say that 22–46% of people with mild to moderate dementia still drive, and that these individuals have a two to five times greater risk of being involved in a traffic accident [4, 5].
This may be especially troublesome for middle- and low-income countries. Reports of dementia prevalence show steeper inclines in such countries, which may be associated with low awareness and poor health care [1]. This rise in prevalence, coupled with comparatively poor traffic infrastructure, could result in a significant social problem if not dealt with beforehand.
From a public health perspective, it is challenging to identify older drivers (OD) who may be unfit to drive at an early stage without unnecessarily restricting others. Although there is considerable consensus that drivers with dementia (DWD) may be more prone to driving accidents and may eventually need to stop driving at some point, when that should be and how that should be determined has been subject to much debate [6, 7]. A number of developed countries have initiated legislative regulations on driving of OD and DWD, with each reflecting national or sometimes regional characteristics [8–10]. Comparing the similarities and differences in the frameworks of driving regulations between countries will lend perspective to other countries considering similar regulations.
In this study, we compared the regulations on driving licenses (DL) of OD and DWD between ten developed countries (the US, Canada, Australia, the UK, Germany, France, Italy, Japan, China, and South Korea) to find key implications in developing or optimizing national strategies for regulating DL of OD and DWD. These strategies may be especially important for developing countries that have not enacted such policies yet.
MATERIALS AND METHODS
Between October 2014 and April 2015, a survey on national DL regulations for OD and DWD of the seven countries that participated in the G7 Dementia Summit (US, Canada, UK, Germany, France, Italy, and Japan) and three additional Asia-Pacific countries (Australia, China, and South Korea) where dementia has become a national health priority was conducted. Based on legislations and official documents published by the respective authorities or departments, we investigated and compared the framework of the regulations on DL of OD and DWD focusing on the following four topics: legal basis for regulating DL, DL renewal processes, assessments and reporting of driving competency, and restrictions of driving privileges. We have provided details of the surveyed documents or websites as Supplementary Material.
RESULTS
Legal basis for regulating DL of OD and DWD
All countries had articles regulating DL of OD or DWD that defined licensing requirements and procedures in the acts on transport listed in Table 1. Japan further regulates DL of DWD through the Long-Term Care Insurance Act in addition to the Road Traffic Law. In three countries (US, Canada, and Australia), regional differences existed in the legislations for regulating DL of OD and DWD between states, provinces, or territories within each country.
With the exception of China, no countries restricted driving based solely on age. Instead, driving was restricted based on medical conditions that may impair fitness to drive. All countries except Italy defined dementia or cognitive impairment as a medical condition with which one is unfit to drive. Italy broadly defined “diseases of the nervous system” as one of the conditions for which a certificate of fitness to drive could not be issued.
Processes of DL renewal for OD and DWD
Renewal procedure
Although the renewal procedures of DL for OD varied across the countries and territories, they generally included any of these three methods regardless of age: in-person visit, online submission, or mail submission. In Italy, Japan, and China, in-person visits were the only option for renewing DL for both general drivers and OD. In the US, Canada, and Korea, only in-person visits were allowed for OD. In the UK and Australia, all three methods were available for OD in all but a few territories, and only in-person visits were allowed for DWD. In France, DL renewal was a simple administrative procedure, and Germany did not have a renewal process.
Renewal cycle
In most countries, the DL renewal cycle was shortened after a certain age, usually starting from 65 to 70 years of age, as summarized in Table 2. Shortened cycles ranged from 1 to 6 years, and were generally much shorter than that of the general population (4–10 years). China, unlike other countries, prohibited driving after 70 years of age, and the eligible age for DL application depended on the type of vehicle. For example, the range was 18 to 70 years of age for a small car, and 18 to 60 years for a low-speed truck or three-wheeled motorcycle. On the contrary, the renewal cycle in France was 15 years for drivers of all ages, and in Germany, DL were valid for life as long as the driver was medically fit to drive.
Other requirements
In Japan, OD aged 70 years or older were required to complete the Traffic Safety Education program and obtain a certificate when renewing their license. Similarly, additional education was required for OD in renewing DL in some provinces of Canada, such as Ontario.
In Japan, OD aged over 75 years were further required to display the Kōreisha mark on both the front and rear of the car, which is a statutory sign used to indicate, “Aged Person at the Wheel.”
Assessments and reporting of driving competency of OD and DWD
Additional assessments for OD and DWD
Eight countries, with the exception of France and Germany, required OD to undergo additional assessments such as function tests (vision, sensory, hearing, etc.), medical evaluations, and/or road tests that were not usually required of the general population. DWD received further additional assessments, such as a written knowledge test, cognitive assessments, and/or neuropsychological tests in all countries except Korea and China (Table 2). In Korea, additional testing for DWD, which consisted of a general physical and functional examination, was required only if the driver was hospitalized for over 6 months. In France and Germany, no additional assessments were required for OD but a written knowledge test; cognitive assessments and/or neuropsychological tests were required of DWD, and France further required DWD to undergo an additional medical examination by an accredited physician. These physicians received special training regarding evaluation of driving competence, and a list of such accredited physicians was available to the public. If a DWD failed to submit a required medical examination result, he/she was subject to imprisonment or monetary fines for a false declaration. In Germany, DWD had to get an additional medical consultation or a Medical Psychological Assessment of a Driver’s Aptitude (MPA) from a physician only when requested by legal authorities.
The US, UK, Canada, Australia, Germany, and Italy had national medical guidelines in assessing a patient’s fitness to drive, which included standards on medical assessments, medical conditions that may impair driving, and requirements for assessments in cooperation between respective authorities and medical/health professional groups. In the US, the American Medical Association (AMA) and the National Highway Traffic Safety Administration (NHTSA), by clinical consensus, have recommended a number of office-based cognitive tests including the Trail Making Test, Part B (TMT-B), and the Clock Drawing Test (CDT). Studies have examined various combinations of these measures, with varying results. A recent study applied the Assessment of Driving-Related Skills (ADReS) battery, which includes the TMT-B and the CDT along with visual acuity tests and range of motion examinations, to older adults with and without cognitive impairment and concluded that its utility as an office-based screening tool was limited [11]. Investigations of other measures have also showed limited utility [12]. On the other hand, a test battery that included the Snellgrove Maze Task, the Eight-Item Informant Interview to Differentiate Aging and Dementia, and the CDT showed good accuracy in predicting on-road driving test failures in older adults with dementia [13]. In Canada, based on the CMA Driver’s Guide and the Canadian Council of Motor Transport Administrators (CCMTA) Medical Standards for Drivers, driving competency is assessed using the Mini-Mental State Examination (MMSE), CDT, Montreal Cognitive Assessment (MoCA), and TMT-B. We are unaware of any studies examining the battery as a whole, but there have been several reports concerning the individual components, with some evidence supporting the utility of the MoCA [14] and TMT-B [15]. Reports concerning the MMSE [14, 16] and CDT [13, 18] have been controversial.
Duty of reporting DWD to relevant authorities
The reporting of any medical condition that may impair driving ability was mandatory in all countries except Germany. Moreover, while this was part of the renewal process in all other nations, France required reports regardless of the renewal process.
The responsibility of reporting lay with the drivers themselves in most states of the US, UK, Australia, Italy, France, Japan, China, and Korea, and was done by submitting an application form that included a self-declaration or self-checklist on medical conditions to the relevant authorities. In the UK, drivers needed to submit a self-declaration of medical fitness to the Driver and Vehicle Licensing Agency (DVLA) after age 70, and drivers with mild dementia had to renew their DL annually. DWD who did not report their diagnosis to the DVLA could be fined up to £1,000. In Italy, France, and Japan, DWD or drivers suspected of having dementia needed to obtain a medical certificate or designated official document from physicians showing that they were fit to drive regarding the diagnosis of dementia and its severity. In Italy, this certificate was the legal responsibility of the certifying physician, and ensured that only certified drivers could renew their DL. In France, reporting of a driver’s medical condition by general practitioners was considered a breach of patient-doctor confidentiality and unlawful in any case. Japan was unique in having an additional automated system that automatically shared medical information with the relevant authorities if a driver was diagnosed with dementia. Two legislations formed the basis of this system: the Road Traffic Law and the Long-Term Care Insurance Act. In Korea, if a DWD received hospitalization for more than six months, provincial public health service centers reported the diagnosis to the National Police Agency. The UK and some Australian territories recommended physicians to advise DWD to stop driving immediately. Physicians were allowed to report such medical conditions to relevant authorities on behalf of the patient, but only if the physician first advised the DWD to stop driving immediately, and the individual was unable to follow or did not comply with the physician’s recommendations. Such cases were legally exempt from breaching doctor-patient confidentiality.
In California, Oregon, and Pennsylvania in the US, and in Canada, the responsibility for reporting driving fitness lied with physicians and/or other health professionals. In Canada, physicians could report an individual without obtaining consent, and could be held legally responsible if a person at risk of unsafe driving due to a medical condition was involved in a motor vehicle crash.
Restrictions of driving privileges of OD and DWD
Criteria for restricting driving privileges
As most countries consider dementia a medical condition that is incompatible with driving and required mandatory reporting, DWD usually needed to stop driving when recommended by a doctor. In most countries, apart from Japan and China, revocation of DL was based not solely on the presence of dementia but on its severity. Consequently, in the US, Canada, Australia, UK, Germany, and France, if cognitive impairment or dementia that could impair cognitive functions necessary for driving were identified, authorities could request further assessments including neuropsychological tests and the results could be used to determine license revocation. The relevant administrations of the US, Canada, Australia, UK, Italy, France, and Korea had medical committees composed of health care professionals that advised on the evaluation of and standards for driving fitness from a medical standpoint.
Levels of restriction on driving privileges
In Japan, DL of DWD were revoked or suspended regardless of severity as the information concerning the driver’s diagnosis was automatically forwarded to the prefectural police. In China, DL of DWD were revoked, regardless of severity, at the annual assessment for its renewal. However, in other countries, since revocation was decided based on the severity of dementia, moderate to severe dementia was a more general reason for DL revocation.
In the US, UK, Canada, and Australia, DWD could renew their DL as long as they fulfilled standards on periodical reassessments. These assessments were required of drivers with mild dementia and were usually repeated annually. In the UK, the renewal cycle could be stretched to a maximum of three years with yearly reviews under a conditional license. The US, Canada, and Australia occasionally issued conditional DL to drivers with mild dementia. In the US, if a driver with mild dementia passed a driving test, he or she could maintain his or her DL with some restrictions, such as no nighttime driving, no freeway driving, or restriction of driving area (within a certain radius). In Korea, if a DWD passed the aptitude test, there were no restrictions on their driving privileges nor specific guidelines for driving. The only restriction was suspension of the DL for up to a year during referral to a divisional evaluation committee of the Korea Road Traffic Authority.
Some countries, such as the US, UK, Australia, and France, had an appeal process after revocation for DWDs who did not agree with the decision. In France, the administrative validity of medical opinions was limited to within two years. In Germany, automatic resumption of driving after a pre-specified suspension period was allowed for cases with dementia.
Other disadvantages
If drivers who should not drive because of dementia were caught driving, their insurance coverage could be limited or invalidated in the UK, Canada, Germany, France, and Italy.
DISCUSSION
DL renewal procedures were stiffer for DWD and OD compared to the general population in all 10 countries. However, as shown in Table 2, there were considerable differences among details, especially in regulations concerning drivers with mild dementia. Although the presence of dementia was sufficient for DL revocation in China and Japan, decisions were based on severity in the other eight countries.
Driving by seniors or persons with dementia whose fitness to drive is impaired can be a danger to others as well as themselves, and thus their driving should be regulated in some way. However, in most developed countries, driving is also a routine skill of most adults, a symbol of independence in old age, and a necessity in rural areas. Thus, restricting or prohibiting it is a complicated matter, and the diverse range of regulations we found in just ten countries reflects this.
Ideally, driving privileges should be provided to anyone who meets preset standards, and the privileges should be restricted or revoked once an individual is unable to meet such standards regardless of age or presence of dementia. Therefore, we believe the following are the most fundamental questions to policymakers in developing regulations for DWD: 1) When should their driving be restricted? 2) How should their fitness to drive be evaluated? 3) How should the regulation process proceed? 4) How should their driving privileges be restricted?
When should their driving be restricted?
Restrictions based solely on age, as those in China, pose grave risks of unnecessary discrimination as “per-driver crash involvement rates” of OD are no higher than their younger peers [19]. Policies based only on the presence of dementia, as those in China and Japan, may also be too simplistic. Previous guidelines from the American Academy of Neurology (AAN) [20] recommended that all people with mild dementia should give up driving. However, these guidelines have been changed following study results showing that as many as 76% drivers with mild dementia can safely drive [6, 21–23]. On the other hand, most agree that individuals with moderate to severe dementia are unfit to drive [20], and empirical evidence shows that the driving performance of drivers with mild dementia may also decline rapidly to the point where they are unfit to drive [11]. Thus, the optimal time to limit driving may be when drivers are within the stage of mild dementia, and frequent assessments during this stage may be the optimal way to distinguish between competent and incompetent drivers.
How should their fitness to drive be evaluated?
Seven countries (the US, Canada, Australia, UK, Italy, Germany, and France) determined fitness to drive of DWD based on cognitive assessments and we consider this a sound policy. A number of countries have further provided assessment guidelines at the national level. However, there was no consensus on a standard assessment procedure, and recommended tests did not have sufficient sensitivity and/or specificity to accurately predict the risk of driving as a single determinant. The previous AAN guidelines [20] recommended that individuals with Clinical Dementia Rating scale (CDR) global scores of 1 or higher should refrain from driving, but this may be too simplistic for real-life situations. Therefore, at the current time, recommended neuropsychological tests should trigger further in-depth testing of practical driving ability, such as simulation tests or an on-road driving test, rather than be considered as an independent indicator for restricting driving privileges. As assessments of driving competence in DWD are mainly based on clinical evaluation and neuropsychological tests, perhaps psychiatrists and neurologists are best qualified to make expert recommendations concerning driving competence. Moreover, the addition of certification programs to these two branches of medicine may further optimize these recommendations. Final decisions should be made by legal authorities based on these expert recommendations.
How should the regulation process proceed?
Scrutiny of driving competence was initiated differently, sometimes by physicians, sometimes by the driver, and sometimes based on automated procedures, such as the process in Japan. Initiation by physicians may be considered to be more objective, but carries the risk of damaging doctor-patient rapport and restricting the right of self-determination. However, report by drivers may be more self-deterministic, but be frequently missed or delayed as DWD may not be fully aware of their competence or may not want to report their condition. Perhaps these conflicting issues can be handled through automatic initiation of scrutinizing driving competence; a diagnosis of dementia in medical records is automatically shared with licensing authorities, and then this shared information triggers detailed assessments of driving competence but without necessarily restricting driving. This would further make room for individual considerations, as a diagnosis would not automatically lead to restriction of driving privileges. In such cases, standardized diagnostic guidelines would need to be provided to minimize the risk of a diagnostic error. Furthermore, in cases with mild dementia, administrative actions would need to be limited to shortening renewal cycles rather than enacting limits on driving.
How should their driving privileges be restricted?
Restrictions imposed on DWD involved revocation of DL in most countries. But we need to impose multi-level administrative measures on DWD tailored to their gradually deteriorating driving competence. For example, a conditional DL that allows driving limited to daytime only or within a certain boundary may be issued in the US. We also need to provide DWD with assistive incentives for their infringed driving privileges. In Japan, public transportation vouchers are provided to DWD who have lost their DL. These assistive incentives may also induce voluntary return of DL by DWD, which will reduce the social costs of regulating DL of DWD.
Regulatory issues for DWD are emerging in countries confronting rapidly aging populations. Accordingly, these countries may urgently need to construct safe driving policies for DWD through reasonable social and medical consensus. Ideal polices on DWD should ensure that restrictions are implemented only when needed, fitness to drive is decided based on validated assessments, administrative processes of scrutinizing DL are automatically initiated when a driver is diagnosed with dementia, restrictions on driving privilege are delicately tailored to a range of levels of driving competence, and assistive incentives for compensating loss of DL are provided.
Footnotes
ACKNOWLEDGMENTS
This research was supported by a grant from the National Institute of Dementia of Korea (Grant Number: NIDR-1501-0011) and a grant from the Korean Health Technology R&D Project, Ministry for Health, Welfare, and Family Affairs, Republic of Korea [grant number HI09C1379(A092077)].
