Driver Licensing

For Physicians

Overview

A medical professional's goal is to ensure patients are healthy. Safe driving is vital to a person's health and well-being and to public safety generally. The South Dakota Department of Public Safety seeks to support the relationship between medical care providers and their patients through a process that allows a person to continue driving as long as it is safe.

In 2009, 11 people age 65 and older died in traffic crashes and 470 were injured in South Dakota(2009 South Dakota Motor Vehicle Traffic Crash Summary). Currently, more than 14 percent of the South Dakota population is age 65 or older. By 2030, the U.S. Census projects that seniors will exceed 23 percent of South Dakota's population. Health professionals can expect to be confronted by mobility problems as their patients age.

Physicians are in a unique position to assess impairments, address underlying causes of functional and cognitive decline, and provide their patients with options that may prolong safe driving. By adopting preventive practices, physicians can better identify drivers at risk for crashes, help enhance their driving safety, and ease the transition to driving retirement if and when it becomes necessary.

In South Dakota mandatory reporting is not required for those who are believed to no longer have the ability to drive safely. However, it is highly encouraged that medical professionals voluntarily submit a Medical Statement detailing any medical issues that may interfere with safe driving so the medical community and Department of Public Safety can work in partnership to keep our roadways safe.

Alternatively, a medical professional, family member, or member of law enforcement may submit a Driver Evaluation Requestto the Driver Licensing Program of the Department of Public Safety if they are concerned about a person's ability to safely operate a motor vehicle and would like to have his or her driving skills re-evaluated by an examiner.

Resources

Two excellent resources are now available to help medical professionals evaluate and provide guidance to patients:

Physicians and other medical professionals can help patients stay healthy by being aware of how medical conditions impact driving ability. Any medical condition that affects physical or mental functioning may affect driving fitness. When the physical or mental effects of the condition are progressive in nature, periodic evaluations are required. According to the NHTSA/AAMVA Driver Fitness Medical Guidelines, medical conditions that affect driving fall into three categories:
  • Conditions that create functional limitations (chronic compromise);
  • Conditions that involve a possible loss of consciousness (acute compromise); and
  • Use of substances (alcohol, drugs, and medications) judged to be incompatible with safe driving.

The guidelines note that men can expect to cease driving about 6 years before their death and for women the figure is about 11 years, which means health professionals will inevitably be faced with mobility issues as their patients age. This does not mean the health professional withdraws or suspends driving privileges; only the Department of Public Safety's Driver Licensing Program has the authority to make that decision. The health professional's role is to provide the Driver Licensing Program with the information it requires to make the appropriate decision about the individual's ability to drive safely in light of the driver's state of health.

Some conditions or their treatment may have temporary effects on driving fitness. The Physician's Guide to Assessing and Counseling Older Drivers recommends that advice given to the patient while managing the condition always include driving considerations. The physician's first priority is to ensure that an unsafe driver does not drive. According to AMA Policy E-2.24, in situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician's advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the Driver Licensing Program.

Following is a description of common medical conditions, the role these conditions play in a person's ability to drive safely, and what action should be undertaken by the physician or medical professional. The information for this section was drawn from the Driver Fitness Medical Guidelines and the Physician's Guide to Assessing and Counseling Older Drivers. Medical professionals will also find detailed information on the full range of medical issues that may affect driving and guidance on counseling drivers in these two resources.

Cardiovascular Disease

For patients with cardiac conditions, the risk of pre-syncope or syncope is a factor in medical fitness to drive. In cases of arrhythmia, the physician should identify and treat the underlying cause, if possible, and recommend temporary driving cessation until the symptoms are under control.

Impact On Driving: Any situation that results in a loss of consciousness or causes dizziness or similar problems impacts driver safety.


Physician's Role
:

  • Determine if the medical condition falls within the functional and/or cognitive impairment that triggers mandatory reporting.  For instance, patients with unstable coronary syndrome (unstable angina or myocardial infarction) should not drive if they experience this condition at rest or behind the wheel.
  • Counsel patients they can resume driving when they have been stable and asymptomatic for one to four weeks following treatment. Driving may resume one week after coronary angioplasty and four weeks after coronary artery bypass.


Dementia


Dementia is impairment in short-term and long-term memory and can involve difficulties with abstract thinking, impaired judgment, other disturbances of higher cortical function, or personality change. Dementia can interfere with a person's ability to work and an ability to maintain usual social activities or relationships with others.



Cognitive impairments in dementia can reduce driver performance and increase the risk of driver errors that can lead to a vehicle crash.  By mid-century, the number of individuals affected by dementia will triple with clear implications for driving risk.

   



Impact On Driving: A diagnosis of dementia is not, on its own, a sufficient reason to withdraw driving privileges. A significant number of drivers with dementia can drive safely in the early stages of their illness. The determining factor in withdrawing driving privileges is driving ability and the amount and type of driving exposure (risk assessment). When the individual poses a heightened risk to self or others, the result is a suspension of driving privileges. Private clinicians do not directly measure driving competence. They do, however, review information on demographics, the person's medical history, and assess the person's cognitive abilities. Physicians can refer the patient to occupational therapists and driving rehabilitation specialists for further evaluation and behind the wheel assessments. There is consensus that suspicion of dementia should trigger a functional evaluation of the driver's fitness to drive. However, the cognitive deficiencies in mild and moderate dementia vary and predicting on-road driving performance is difficult. Self-awareness, insight, and judgment are vital to safe driving but are also difficult to measure. Except in the most severe cases, the road test is an integral part of any functional evaluation.

Physician's Role:

  • Conduct or refer a patient for a functional evaluation of the person’s fitness to drive if dementia is a possible diagnosis.   NHTSA’s Driver Fitness Medical Guidelines provide these indicators that can help determine if the person needs an evaluation:
    • The person's age is 80 years or older;
    • There is a history of a recent crash or moving violation;
    • The patient uses psychoactive medications such as benzodiazepines, neuroleptics, antidepressants, or use of medications for Alzheimer's disease;
    • There is a history of falls; and
    • Scores from simple screening tools indicate the possibility of a cognitive deficit.
  • If the diagnosis involves dementia, take the following action:
    • Address the issue of driving safety with the patients and their families. When appropriate, patients should be included in decisions about current or future driving restrictions and cessation; otherwise, physicians and families must decide in the best interests of the patient whose decision-making capacity is impaired.
    • Encourage patients to develop a driving cessation plan that includes alternative transportation options and recommend the plan be coordinated with family members and caregivers. If necessary, refer the patient to the local Area Agency on Aging.
    • Perform a focused medical assessment (and serial assessments when needed) that includes information from family members or caregivers on any new impaired driving behaviors (e.g., motor vehicle crashes) and an evaluation of cognitive abilities, including memory, attention, judgment, and visuospatial abilities.
  • Be aware of the following facts:
    • Severe dementia is incompatible with safe driving and precludes the need for a functional evaluation.
    • It is impossible to predict on-road driving performance based on the results of cognitive deficit tests for individuals with mild and moderate dementia because the deficiencies are so varied.
    • Self awareness/insight and judgment fare vital to safe driving but are difficult to measure in cognitive tests, which makes the road test a necessary part of a functional evaluation.
    • Tests that predict driver performance (Trail Making A and B26) are useful in identifying individuals who may perform badly on road tests and need further evaluation but are not sufficient for licensing decisions.
    • The Mini Mental Status Exam (MMSE) or Folstein test is a screening tool useful in identifying people with a cognitive problem that requires further assessment, but cannot be used in licensing decisions.
    • A score of 24/30 or less on the MMSE equates to a 70-percent chance of failure on the road test and a score of 19/30 to a 95-percent failure rate. However, a score of 24 also equates to a 30-percent chance of success. A score of 30/30 on the MMSE also does not preclude the chance of failure on the road test.

Diabetes

In diabetes, the body does not produce enough insulin or properly use it, which results in elevated blood glucose. In the U.S. an estimated 20 million children and adults have the disease.

The disease can result in frequent urination (polyuria), extreme thirst (polydipsia), weight loss, fatigue, irritability, and blurred vision. Chronic complications include heart and blood vessel disease, stroke (large and small blood vessel), visual loss due to retinopathy and hemorrhages, foot ulcers, infections, neuropathy, joint deformities (Charcot joints), pain, and kidney disease or failure.

Diabetics may also develop nerve damage that causes pain or numbness in the hands, arms, feet, and legs with the most common a loss of sensation in the feet that makes walking difficult.

 

Impact on Driving: Accordingto NHTSA's Driver Fitness Medical Guidelines, the best available evidence on diabetes and driving indicates the average driver with diabetes has a statistically significant (19%) increase in risk for a motor vehicle collision compared to individuals without diabetes.

Diabetes impacts driver safety in several ways including the symptoms of neuropathy which can result in diminished sensation of the hands and feet that make it difficult to operate the steering wheel and pedals; long term affects on vision and cognition; and the risk factors associated with hypoglycemia caused by insulin therapy.

Indirect evidence from multiple independent studies consistently shows that moderate-to-severe hypoglycemia impairs driving ability, cognition, and psychomotor function in some individuals with type 1 diabetes. To address the issue, diabetic drivers should receive information on the increased risk and the effects of hypoglycemia.

DMVs concentrate their efforts on those drivers who suffer hypoglycemic episodes that require the assistance of a third party. Any drivers who experience such episodes should not drive until their treating clinician is certain the risk is minimized. A reasonable period for not driving is usually three months. However, it is the clinical judgment of the treating clinician that is the important factor since the individual's particular situation will be the major factor.

Physician's Role:

  • Provide information to drivers on the increased risk associated with diabetes and effects of hypoglycemia on driving. Individuals should not drive during acute hypoglycemic or hyperglycemic episodes until they have been free of an episode for at least three months. Counsel them on the importance of frequent stops and snacks, easy availability of glucose supplements, and early recognition of signs of impending hypoglycemia.
  • Be aware insulin-treated diabetes is not, in itself, a justification for disqualification from driving. However, the potential for a hypoglycemic episode is higher for the insulin-treated diabetic than for diabetics treated by oral medication. Provide education on the problems associated with driving and insulin treatments.
  • Ensure drivers with diabetes see their treating clinician at least annually; more frequently for those with control issues. Drivers should communicate any change in status, such as the initiation of insulin treatment, to DPS.
  • Before recommending the patient with diabetes continue driving, ensure the patient has a good understanding of the disease, they are free of hypoglycemic episodes requiring third-party intervention, and the person is willing to follow the suggested treatment plan. The patient should demonstrate they are able to recognize incipient hypoglycemia and can take the appropriate action when they become symptomatic.


Physical Limitations


Pain and decreases in motor strength or physical functioning associated with any physical limitation can affect driver safety. Conditions in this category include the following:

  • Arthritis
  • Amputation
  • Cerebral Vascular Accident (Stroke)
  • Multiple Sclerosis
  • Parkinson's Disease
  • Spinal Cord Injury

Arthritis causes an inflammation of the joints, which causes pain, decreased flexibility, joint instability, and possible weakness in the effected limbs or torso.

Strokes and other insults to the cerebral vascular system may cause sensory deficits (numbness or loss of sensation), motor deficits (weakness), and cognitive impairment(memory, hemispatial inattention). These symptoms, which range from mild to severe, can resolve immediately or persist for years.

Neurological disorders such as multiple sclerosis and Parkinson's Disease are progressive with symptoms and affects growing worse with time. These diseases often cause muscle weakness, tremors, fatigue, and cognitive or perceptual deficits.

Impact on Driving: Any condition that affects the upper or lower limbs, the neck, and back can impact the ability to drive. Individuals suffering from these conditions along with anyone who has lost (or lost the use) of one or more extremities should contact a driver rehabilitation specialist. These specialists can prescribe vehicle adaptive devices and/or adaptations to limb prostheses, and train the patient in their use. For any adaptive device, driving should be restricted until the driver demonstrates safe driving ability.

The use of artificial limbs on vehicle foot pedals, however, is unsafe because there is no sensory feedback (i.e., pressure and proprioception). For these drivers, specialized hand controls in place of pedals are required.

A driver rehabilitation specialist can also help a driver for immobilization of wrist, hand, or fingers, which makes it difficult to manipulate the controls and steering wheel. Adaptive devices would alleviate these control issues.

The impact on driving from a permanent loss of function depends on the extent of the loss. Minimal limitations, such as partial loss of one or several fingers or toes, may not require modification of the driver's vehicle because they have no effect on the ability to drive.

For temporary conditions where the driver has a limb in a cast or other immobilizing device, it can take time to reach a level of functioning needed for safe driving. After a 3-4 week immobilization, an ankle may take up to 9 weeks before the achieving full function. While this does not mean a resumption of driving will take that long, the driver should test the ankle or other limb before driving.

Physician's Role:

  • Refer patients who have lost or lost the use of a limb to a driver rehabilitation specialist. Without an evaluation, the driver may continue driving a vehicle without modifications creating a potentially dangerous situation.
  • Advise drivers with a temporary acute injury (fractures, dislocations)or a post-surgical situation, to refrain from driving as long as the immobilization is in place or until there is full mobility.
  • Assess the extent of the physical and psychomotor limitations and determine the need for further functional evaluation. Refer the individual to an occupational therapist or driving specialist if there are any doubts about the capacity of the driver to perform the tasks required for driving safely.

Seizures

A seizure is a sudden change in behavior that may range from loss of consciousness or body control to a mild subjective feeling, due to acute abnormal brain electrical activity. People who have had a seizure are generally at greater risk for another seizure than people who have never had a seizure. As a rule, the longer the seizure-free period, the less likely a person is to have another seizure. Epilepsy is the common medical disorder characterized by recurrent seizures.

Impact on Driving:

 

According to NHTSA, the number of fatal driver crashes related to seizures is small. Some seizure types such as simple partial seizures that do not interfere with consciousness or motor control and seizures that are unlikely to occur while driving (nocturnal seizures or those related to reversible illnesses) are unlikely to have an impact on driver safety.

The most common type of seizures relate to epilepsy. Patients with epilepsy (seizure disorders) are at increased risk for motor vehicle crashes because of the seizure, the underlying condition causing seizures, or the side effects of anti-epileptic drugs. Epilepsy patients who have ongoing seizures are legally or medically forbidden to drive.

Usually patients who are seizure-free for periods varying from three to 18 months are permitted to seek driving privileges, and many drive. How long a person has remained seizure free is helpful in predicting the risk of seizure occurrence. The annual risk of seizure recurrence is less than two percent after 8 years and less than one percent after 10 years.

Physician's Role:

  • Be aware of the following:
    • Anti-epileptic drugs (AEDs) can produce side effects in some patients that may affect driving. Clinicians should monitor drug levels regularly and counsel these patients to restrict their driving until any side effects pass.
    • Cessation of AEDs may lead to a new seizure. Counsel drivers who experience a seizure until therapeutic levels of AEDs are achieved.
    • Seizures induced by the ingestion of alcohol or drugs must be followed by a six-month period of abstinence before resuming driving.
  • Counsel patients who have experienced a unique seizure to cease driving until an investigation of the cause can occur. The person can start driving again if the neurological and cardiac investigations do not reveal a cause or if a treatable cause has been identified and the therapy is successful.
  • Schedule an annual examination for patients with epilepsy. These controls can be relaxed based on a clinical assessment.

Sleep Disorders

Drowsy driving, driving with fatigue, or sleepiness are common causes for a motor vehicle crash that involve otherwise healthy but sleep-deprived drivers. Drivers with obstructive sleep apnea (OSA), however, appear to be at particular risk. OSA involves a recurrent airway obstruction during sleep, which results in a cessation of breathing and reduced blood oxygen saturation. Treatments for OSA include continuous positive airway pressure (CPAP), surgical procedures, medications, and treatment of underlying risk factors, particularly obesity.

Some individuals with OSA may be unaware of their sleepiness and cognitive impairment, leading them to engage in risky driving behavior. OSA is relatively common and affects about two to four percent of middle-aged people. Symptoms of OSA include chronic loud snoring, witnessed apneas or breathing pauses during sleep, and daytime sleepiness. Sleep fragmentation leads to chronic sleep deprivation and excessive daytime sleepiness, a cause of cognitive dysfunction. Repeated nocturnal hypoxia also causes cognitive deficits, some of which may be irreversible.

 

 

Impact on Driving: Evidence indicates OSA increases crash risk and CPAP is the only treatment demonstrated to reduce crash risk. However, once initiated, the treatment must continue for as long as the person wishes to maintain their driver’s license. Any interruptions of CPAP, even if only for one day, can have adverse effects on driving fitness. Since CPAP takes at least two weeks to be fully effective, any interruption in treatment means at least a two-week interruption in driving. In the event of non-compliance, no matter what the reason, the patient should cease driving immediately.

Physician's Role:

  • Counsel drivers with OPA they can drive if there is no daytime drowsiness or if the apnea hypopnea index (AHI) is less than 20. Drivers with daytime sleepiness or an AHI of 20 or more may drive only if treatment is effective or as long as the patient continues therapy.
  • Counsel drivers to continue driving if the sleep disorder is effectively treated with a pharmaceutical.

Vision

Visual Acuity Visual acuity refers to the smallest size detail a person can see. The ability to read a letter chart from a certain pre-specified distance is how the condition is measured. Impairments in visual acuity can result from a number of eye and neurological conditions such as macular degeneration, cataracts, end-stage glaucoma.

Impact on Driving:Visual acuity is associated with highway sign legibility. Drivers with the impairment are more likely to make errors in identifying signs at a distance. Other aspects of the roadway environment such as lane markings may also be difficult to see.



Physician's Role:

  • Ensure all drivers are following the statutory requirements (DPS vision test of both eyes at the time of renewal - every five years).
  • Recognize any visual condition that leads to a lowering of visual acuity may render the driver unfit for driving without restrictions. The restrictions can include limiting driving to low-risk areas and conditions (e.g., familiar surroundings, non-rush hour traffic, low speed areas, daytime, and good weather conditions). In more severe cases, the patient may be required to undergo a functional evaluation.
  • Be aware of the following:
    • Changes in visual acuity following stroke or traumatic head injury can result in cognitive changes, which may require an evaluation of visual processing speed.
    • The sudden loss of one eye may require a period of adaptation to monocular vision before resuming driving.
Reporting

How to Request a Driver Evaluation
If you are concerned about a person's ability to safely operate a motor vehicle and would like to have that person's driving skills re-evaluated by a driver examiner, please complete the Driver Evaluation Request form and submit it to the Department of Public Safety Driver Licensing Program. The department may require re-evaluation only when there is reason to believe that the driver might not be qualified to hold a license. On the form it is important to note the specific observations, events and incidents that cause you to question the driver's qualifications. Please return it by mail to:

Department of Public Safety, Driver Licensing Program, 118 West Capitol Avenue, Pierre, SD 57501

When a form is received, DPS sends a letter to the individual who has 15 days to send in a medical and vision statement. If both of these are satisfactory, DPS will schedule a driving evaluation. If either of the statements is not satisfactory DPS will send a notice cancelling the individual's driving privileges.

How to Submit a Medical Statement
As a medical professional, if you believe a patient has medical issues that may prevent safe driving, please complete the Medical Statement form. Please ensure that all required sections are filled out and that the form is signed. This information helps the Department of Public Safety make decisions to ensure that all drivers licensed to operate a motor vehicle on the roadway are safe.Please return the Medical Statement by mail or fax to:

Department of Public Safety, Driver Licensing Office, 118 West Capitol Avenue, Pierre SD 57501 or fax to (605) 773-3018.



Confidentiality and HIPAA


For purposes of sharing medical information under the Health Insurance Portability and Accountability Act (HIPAA), the Department of Public Safety is considered a public health entity. The Department of Public Safety is the state agency responsible for public health matters relating to the monitoring of drivers who may be ineligible for driving privileges because of a disease or disability resulting in a cognitive or functional impairment that affects the driver's ability to safely operate a motor vehicle.

The medical information contained in the reports required by DPS is confidential and shall only be used to determine the qualification of a person to safely operate a motor vehicle, and for taking any action deemed necessary by DPS.