An International Approach to Enhancing a National Guideline on Driving and Dementia

  • Mark J. Rapoport
  • Justin N. Chee
  • David B. Carr
  • Frank Molnar
  • Gary Naglie
  • Jamie Dow
  • Richard Marottoli
  • Sara Mitchell
  • Mark Tant
  • Nathan Herrmann
  • Krista L. Lanctôt
  • John-Paul Taylor
  • Paul C. Donaghy
  • Sherrilene Classen
  • Desmond O’Neill
Geriatric Disorders (W McDonald, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Geriatric Disorders


Purpose of Review

The purpose of this study was to update a national guideline on assessing drivers with dementia, addressing limitations of previous versions which included a lack of developmental rigor and stakeholder involvement.


An international multidisciplinary team reviewed 104 different recommendations from 12 previous guidelines on assessing drivers with dementia in light of a recent review of the literature. Revised guideline recommendations were drafted by consensus. A preliminary draft was sent to specialist physician and occupational therapy groups for feedback, using an a priori definition of 90% agreement as consensus.

Recent Findings

The research team drafted 23 guideline recommendations, and responses were received from 145 stakeholders. No recommendation was endorsed by less than 80% of respondents, and 14 (61%) of the recommendations were endorsed by more than 90%.The recommendations are presented in the manuscript.


The revised guideline incorporates the perspectives of consensus of an expert group as well as front-line clinicians who regularly assess drivers with dementia. The majority of the recommendations were based on evidence at the level of expert opinion, revealing gaps in the evidence and future directions for research.


Dementia Driving Clinical practice guidelines Knowledge translation 



The authors acknowledge the encouragement and support of Yoassry Elzohairy, Paul Boase, Kirsty Olsen, and Regina McFadden in earlier stages of this work.

The editors would like to thank Dr. William McDonald and Dr. Alice Pomidor for reviewing this manuscript.


This knowledge synthesis was funded by the Canadian Institutes of Health Research (CIHR) (KRS Grant #339665). The funders played no role in the study methodology, interpretation of results, preparation of the report, or the process of disseminating this work. They accept no responsibility for the contents.

Compliance with Ethical Standards

Conflict of Interest

Several of the authors have publications on the topic that were included as part of the review. To mitigate the associated risk, the authors were not involved in the screening or data extraction of their own publications (MJR, DBC, SC, NH, JD, JC, SM, JPT). Several co-authors disclosed research grants/funding for their work (MJR, DBC, SC, NH, JD, JC, KL, SM, FM). Potential COIs were declared by MJR (Canadian Academy of Geriatric Psychiatry (CAGP) board president; consultancy at the Canadian Medical Association(CMA)), DBC (board membership for Memory Care Home Solutions, Dementia Organization, and the Advocacy Committee for the Alzheimer’s Association; consultancies at ADEPT, MEDSCAPE, Traffic Injury Research Foundation, and AAA Foundation for Traffic Safety; legal cases on medical conditions and driving), SC (honoraria from National Institutes of Health (NIH) and Canadian Association of Occupational Therapy (CAOT)), NH (research support from Lundbeck and Roche; consultancies at AbbVie, Astellas, and Merck; honouraria from Pfizer, Lundbeck, and Novartis), JC (board membership for BrainLink; consultancies at the Royal College of Physicians of Ireland, and National Transportation Commission), SM (consultancies at the CMA, the Ministry of Transportation of Ontario (MTO), and from physicians; expert testimony on TBI; honouraria for peer-reviewed speaking activities), FM (consultancy at the CMA).

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    • Rapoport MJ, Weegar K, Kadulina Y, Bedard M, Carr D, Charlton JL, et al. An international study of the quality of national-level guidelines on driving with medical illness. QJM. 2015;108(11):859–69. This is a study of the quality of guidelines on driving with medical illness, highlighting gaps in rigour and stakeholder involvement. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Salmi LR, Leproust S, Helmer C, Lagarde E. Assessing fitness to drive in the elderly and those with medical conditions: guidelines should specify methods and evidence. Inj Prev. 2014;20(3):210–2. [Editorial Research Support, Non-U.S. Gov't]CrossRefPubMedGoogle Scholar
  3. 3.
    Canadian Medical A. CMA Driver’s Guide: determining medical fitness to operate motor vehicles. Ottawa: Canadian Medical Association; 2012.Google Scholar
  4. 4.
    Iverson DJ, Gronseth GS, Reger MA, Classen S, Dubinsky RM, Rizzo M. Practice parameter update: evaluation and management of driving risk in dementia: report of the quality standards Subcommittee of the American Academy of Neurology. Neurology. 2010;74(16):1316–24. Scholar
  5. 5.
    Association AP. Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C.: American Psychiatric Association; 2013. Scholar
  6. 6.
    Duchek JM, Carr DB, Hunt L, Roe CM, Xiong C, Shah K, et al. Longitudinal driving performance in early-stage dementia of the Alzheimer type. J Am Geriatr Soc. 2003;51(10):1342–7. Scholar
  7. 7.
    Roh JH, Lee JH. Recent updates on subcortical ischemic vascular dementia. J Stroke. 2014;16(1):18–26. [Review]CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    • Yamin S, Stinchcombe A, Gagnon S. Driving competence in mild dementia with Lewy bodies: in search of cognitive predictors using driving simulation. Int J Alzheimers Dis. 2015;2015:806024. This is a useful paper about driving with Lewy body dementita, a rarely researched topic. PubMedPubMedCentralGoogle Scholar
  9. 9.
    • Emre M, Ford PJ, Bilgic B, Uc EY. Cognitive impairment and dementia in Parkinson’s disease: practical issues and management. Mov Disord. 2014;29(5):663–72. This is a useful paper about driving with Parkinson’s disease, a rarely researched topic. CrossRefPubMedGoogle Scholar
  10. 10.
    • Turk K, Dugan E. Research brief: a literature review of frontotemporal dementia and driving. Am J Alzheimers Dis Other Demen. 2014;29(5):404–8. This is a useful paper about driving with frontotemporal dementia, a rarely researched topic. CrossRefPubMedGoogle Scholar
  11. 11.
    Wong IY, Smith SS, Sullivan KA. The relationship between cognitive ability, insight and self-regulatory behaviors: findings from the older driver population. Accid Anal Prev. 2012;49:316–21. [Research Support, Non-U.S. Gov't]CrossRefPubMedGoogle Scholar
  12. 12.
    Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol. 2015;14(8):823–32. [Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov’t Review]CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    •• Chee JN, Rapoport MJ, Molnar F, Herrmann N, O’Neill D, Marottoli R, et al. Update on the Risk of motor vehicle collision or driving impairment with dementia: a collaborative international systematic review and meta-analysis. Am J Geriatr Psychiatry. 2017;25(12):1376–1390. This is a recent updated knowledge synthesis on the topic of dementia and motor vehicle collisions that informs the current work. Google Scholar
  14. 14.
    Ott BR, Festa EK, Amick MM, Grace J, Davis JD, Heindel WC. Computerized maze navigation and on-road performance by drivers with dementia. J Geriatr Psychiatry Neurol. 2008;21(1):18–25. [Research Support, N.I.H., Extramural]CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Davis JD, Papandonatos GD, Miller LA, Hewitt SD, Festa EK, Heindel WC, et al. Road test and naturalistic driving performance in healthy and cognitively impaired older adults: does environment matter? J Am Geriatr Soc. 2012;60(11):2056–62. [Research Support, N.I.H., Extramural]PubMedPubMedCentralGoogle Scholar
  16. 16.
    Organization WH. World report on road traffic injury prevention. World Health Organization. 2004.Google Scholar
  17. 17.
    Jang RW, Man-Son-Hing M, Molnar FJ, Hogan DB, Marshall SC, Auger J, et al. Family physicians’ attitudes and practices regarding assessments of medical fitness to drive in older persons. J Gen Intern Med. 2007;22(4):531–43. Scholar
  18. 18.
    Marottoli RA, de Leon CFM, Glass TA, Williams CS, Cooney LM Jr, Berkman LF. Consequences of driving cessation: decreased out-of-home activity levels. J Gerontol B Psychol Sci Soc Sci. 2000;55(6):S334–40. [Research Support, U.S. Gov't, P.H.S.]CrossRefPubMedGoogle Scholar
  19. 19.
    Marottoli RA, Mendes de Leon CF, Glass TA, Williams CS, Cooney LM Jr, Berkman LF, et al. Driving cessation and increased depressive symptoms: prospective evidence from the New Haven EPESE. Established populations for epidemiologic studies of the elderly. J Am Geriatr Soc. 1997;45(2):202–6. [Research Support, Non-U.S. Gov’t Research Support, U.S. Gov’t, Non-P.H.S. Research Support, U.S. Gov’t, P.H.S.]CrossRefPubMedGoogle Scholar
  20. 20.
    Pimlott NJ, Siegel K, Persaud M, Slaughter S, Cohen C, Hollingworth G, et al. Management of dementia by family physicians in academic settings. Can Fam Physician. 2006;52(9):1108–9.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Rapoport MJ, Herrmann N, Molnar FJ, Man-Son-Hing M, Marshall SC, Shulman K, et al. Sharing the responsibility for assessing the risk of the driver with dementia. CMAJ. 2007;177(6):599–601. Scholar
  22. 22.
    Redelmeier DA, Vinkatesh V, Stanbrook MB. Mandatory eporting by physicians of patients potentially unfit to drive. Open Med. 2008;2(1):e8–e17.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Redelmeier DA, Yarnell CJ, Thiruchelvam D, Tibshirani RJ. Physicians’ warnings for unfit drivers and the risk of trauma from road crashes. N Engl J Med. 2012;367(13):1228–36. [Research Support, Non-U.S. Gov’t]CrossRefPubMedGoogle Scholar
  24. 24.
    Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458–65. [Research Support, Non-U.S. Gov’t Review]CrossRefPubMedGoogle Scholar
  25. 25.
    •• Schünemann HJ, Wiercioch W, Etxeandia I, Falavigna M, Santesso N, Mustafa M, et al. Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise. CMAJ. 2014;186(3):e123–e42. This is a description of the framework used for creating useful clinical practice guidelines. CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Collaboration TA. The ADAPTE process: Resource toolkit for guideline adaptation. Version 2.0 2009.Google Scholar
  27. 27.
    Network GI. History of the ADAPTE Collaboration: Available from:
  28. 28.
    Physician’s Guide to Assessing and Counseling Older Drivers. 2nd ed. In: Carr DB, Schwartzberg JG, Manning L, Sempek J, editors. Washington, DC: National Highway Traffic Safety Association/American Medical Association; 2010.Google Scholar
  29. 29.
    AUSTROADS. Assessing fitness to drive for commercial and private vehicle drivers: medical standards for licensing and clinical management guidelines. Sydney: AUSTROADS/National Transport Commission of Australia; 2013.Google Scholar
  30. 30.
    Authority RS. Sla ́ inte agus Tioma ́ int: medical fitness to drive guidelines (group 1 drivers). Dublin: Royal College of Physicians of Ireland/Road Safety Authority; 2013.Google Scholar
  31. 31.
    Canadian Council of Motor Transport A. Determining driver fitness in Canada: CCMTA Medical Standards for Drivers. Ottawa: Canadian Council of Motor Transport Administrators; 2013.Google Scholar
  32. 32.
    Driver, Vehicle Licensing A. For medical practitioners: At a glance guide to the current medical standards of fitness to drive. Swansea: Drivers Medical Group, Driver and Vehicle Licensing Agency; 2013.Google Scholar
  33. 33.
    Moorhouse P, Hamilton L. Not if, but when: a communication-based intervention for driving cessation. J Gerontol Geriatol Res. 2015;4(215):2.Google Scholar
  34. 34.
    National Highway Traffic Safety. A driver fitness medical guidelines. Washington, DC: National Highway Traffic Safety Association/American Association of Motor Vehicle Administrators; 2009.Google Scholar
  35. 35.
    Network CD. Regional geriatric program of eastern Ontario. The driving and dementia toolkit. Ottawa: Regional Geriatric Program of Eastern Ontario; 2009.Google Scholar
  36. 36.
    New Zealand Transport A. Medical aspects of fitness to drive: A guide for medical practitioners. Wellington: New Zealand Transport Agency; 2009.Google Scholar
  37. 37.
    Singapore Medical A. Medical guidelines on fitness to drive. Singapore: Singapore Medical Association; 2011.Google Scholar
  38. 38.
    Group NZG. Handbook for the preparation of explicit evidence-based clinical practice guidelines: Available from:
  39. 39.
    Association CM. Canadian clinical practice guidelines summit: toward a National Strategy. Proceedings. Gatineau: Canadian Medical Association; 2011.Google Scholar
  40. 40.
    Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ. 1998;317(7162):858–61. Scholar
  41. 41.
    Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458–65. Scholar
  42. 42.
    Cluzeau F, Wedzicha JA, Kelson M, Corn J, Kunz R, Walsh J, et al. Stakeholder involvement: how to do it right: article 9 in integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Proc Am Thorac Soc. 2012;9(5):269–73. Scholar
  43. 43.
    Eccles MP, Grimshaw JM, Shekelle P, Schunemann HJ, Woolf S. Developing clinical practice guidelines: target audiences, identifying topics for guidelines, guideline group composition and functioning and conflicts of interest. Implement Sci. 2012;7(1):60. Scholar
  44. 44.
    Lomas J. Making clinical policy explicit. Legislative policy making and lessons for developing practice guidelines. Int J Technol Assess Health Care. 1993;9(1):11–25. Scholar
  45. 45.
    Unsworth C, Baker A, So M, Harries P, O’Neill D. A systematic review of evidence for fitness-to-drive among people with the mental health conditions of schizophrenia, stress/anxiety disorder, depression, personality disorder and obsessive compulsive disorder. BMC Psychiatry. 2017;17(1):318.Google Scholar
  46. 46.
    Hawley CA, Galbraith ND, de Souza VA. Medical education on fitness to drive: a survey of all UK medical schools. Postgrad Med J. 2008;84(998):635–8. [Multicenter Study Research Support, Non-U.S. Gov’t]CrossRefPubMedGoogle Scholar
  47. 47.
    Marshall S, Demmings EM, Woolnough A, Salim D, Man-Son-Hing M. Determining fitness to drive in older persons: a survey of medical and surgical specialists. Can Geriatr J. 2012;15(4):101–19. Scholar
  48. 48.
    Services DoHAH. Research Using Linked Data to Understand Motor Vehicle Injury Among Older Adults; 2016: Available from:
  49. 49.
    Green KA, McGwin G Jr, Owsley C. Associations between visual, hearing, and dual sensory impairments and history of motor vehicle collision involvement of older drivers. J Am Geriatr Soc. 2013;61(2):252–7. [Comparative Study Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov’t]CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Berndt AH, May E, Darzins P. On-road driving assessment and route design for drivers with dementia. Br J Occup Ther. 2015;78(2):121–30. Scholar
  51. 51.
    Vaughan L, Hogan PE, Rapp SR, Dugan E, Marottoli RA, Snively BM, et al. Driving with mild cognitive impairment or dementia: cognitive test performance and proxy report of daily life function in older women. J Am Geriatr Soc. 2015;63(9):1774–82. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Mark J. Rapoport
    • 1
    • 2
  • Justin N. Chee
    • 1
    • 2
  • David B. Carr
    • 3
  • Frank Molnar
    • 4
    • 5
  • Gary Naglie
    • 2
    • 6
  • Jamie Dow
    • 7
  • Richard Marottoli
    • 8
  • Sara Mitchell
    • 1
    • 2
  • Mark Tant
    • 9
  • Nathan Herrmann
    • 1
    • 2
  • Krista L. Lanctôt
    • 1
    • 2
  • John-Paul Taylor
    • 10
  • Paul C. Donaghy
    • 10
  • Sherrilene Classen
    • 11
  • Desmond O’Neill
    • 12
  1. 1.Sunnybrook Health Sciences CentreTorontoCanada
  2. 2.University of TorontoTorontoCanada
  3. 3.Washington University St. LouisSt. LouisUSA
  4. 4.The Ottawa Hospital Research InstituteOttawaCanada
  5. 5.The Bruyere Research InstituteOttawaCanada
  6. 6.Baycrest Health SciencesTorontoCanada
  7. 7.Société de l’assurance automobile du QuébecQuébec CityCanada
  8. 8.Yale UniversityNew HavenUSA
  9. 9.Belgian Road Safety InstituteBrusselsBelgium
  10. 10.Newcastle UniversityNewcastle upon TyneUK
  11. 11.University of FloridaGainesvilleUSA
  12. 12.Royal College of Physicians of IrelandDublinIreland

Personalised recommendations