Psychology
2011. Vol.2, No.6, 615-623
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.26094
Driving after Brain Injury: A Clinical Model Based on a Quality
Improvement Project
Anna Lundqvist1,2, Johan Alinder2, Ingalill Modig-Arding2,
Kersti Samuelsson1,2
1Rehabilitation Medicine, Department of Clinical and Experimental Medicine, Faculty of Health Sciences,
Linköping University, Linköping, Sweden;
2Department of Clinical Rehabilitation Medicine, University Hospital, Linköping, Linköping, Sweden.
Received May 24th, 2011; revised July 13th, 2011; accepted August 25th, 2011.
The question of whether a person can resume driving after acquired cognitive dysfunction is raised in primary
care services and in hospital departments where patients suffering from brain injury are treated. These organiza-
tions rarely have a specialized program that evaluates driving fitness. This article describes a semi-structured
and individualized model that serves as clinical guidelines for determining fitness to drive. The model is based
on former research and clinical experience. It is exemplified by the procedure of forty-three individuals with
congenital or acquired cognitive dysfunction due to head trauma or disease. A multidisciplinary team including
medical, neuropsychological, occupational, and practical driving specialists optimised the clinical applicability
of a driving assessment using quantitative and qualitative methods. The team discussions, including several pro-
fessional evaluations and assessments, are considered very important for interpreting results, for understanding
whether the cognitive impairments will have consequences on driving, and whether the individual can compen-
sate for cognitive difficulties. The current way to determine a patient’s fitness to drive after cognitive dysfunc-
tion is an individually adapted combination of assessment methods that are often performed stepwise. This
well-practiced evaluation process reveals that in many cases neither off-road tests nor on-road tests alone are
sufficient to ensure sound decisions. To improve on these evaluations, this study concludes that a team-based
consensus approach consisting of specialized national teams should be established to support primary care ser-
vices in assessing fitness to drive in more complicated cases.
Keywords: Traffic Psychology, Cognitive Dysfunction, Driving Assessment, Teamwork, Clinical Model
Introduction
In 2007, Kofi Annan, former Secretary-General of the United
Nations, called the high traffic accident rate in the world “the
hidden epidemic” (Annan, 2007). Although alcohol is the pre-
dominant factor that kills people in car accidents every year
(Vägverket, 2008; National Institutes of Health Department of
health and human services USA, 2009), illness and injury that
affect the brain are also factors that cause traffic accidents
(Boake, Macleod, High, & Lehmkuhl, 1998; Pietrapiana, Tami-
etto, Torrini, Mezzanato, & Perino, 2005; Schanke, Rike, Møl-
men, & Østen, 2008). Recently, traffic accident research has
found that fatigue is a main risk factor (Anund, 2009).
A person’s fitness to drive means the driver can manage traf-
fic situations without being a traffic risk, anticipate demands in
specific traffic situations, and prepare oneself for action. Driv-
ing safely requires flexibility, fast information processing
speeds, and insight that includes strategic planning and the
ability to understand when not to drive (Brouwer & Ponds,
1994; Brouwer & Withaar,1997; Withaar, 2000). Thus a per-
son’s fitness to drive after brain injury must be evaluated with a
broad perspective that includes current and pre-morbid medical,
psychological, and cognitive functions as well as driving skill
(Brouwer & Ponds, 1994).
Medical Reg ulations for Fitness to Drive
Countries establish their own driving rules and regulations.
Most national driving license agencies recognize that many
diseases and other medical conditions may affect a person’s
ability to drive a motor vehicle safely. The laws about when a
license can be withdrawn from a driver vary between different
countries. Some countries require physicians to report to the
driving license authority if they have a patient whose driving
abilities might be compromised. Other countries require the
drivers themselves to report a medical change before they re-
sume driving (Pellerito, 2006).
In Sweden, basic requirements for a driving license after
disease or head trauma are legally formulated in the Swedish
Code of Statutes, the official publication of all Swedish laws
(Swedish National Road Administration, 1998). Persons who
want to start taking driving lessons must apply for driving per-
mit. The Swedish Code of Statutes does not formulate concrete
requirements for receiving a professional driving license.
However, persons who have a license for heavy vehicles (e.g.,
buses and lorries), often professional drivers, are obliged to
present to the driving license authorities a health declaration
from a physician. Other drivers have a license for driving a
private car. Physicians are legally obligated to report to the
licensing authority if they find a patient unfit to hold a driving
license due to medical conditions. Such reports often result in
withdrawal of the driving license. The physician has the possi-
bility to avoid this obligation on two conditions: if the patient is
seriously impaired so the question of driving will not be raised
or if the physician finds it obvious that the patient will obey a
temporary verbal driving prohibition, which should be docu-
mented in the medical casebook and followed up by the physic-
cian. The requirements for a driving license are rather easy to
interpret for conditions such as visual field deficiency and epi-

A. LUNDQVIST ET AL. 616
lepsy, but more problematic when it comes to cognitive im-
pairments due to progressive diseases such as dementia and MS
or after brain injury.
Assessment of Driving Performance
Different methods have been used to assess a person’s driv-
ing performance. Statistical relationships between neuropsy-
chological test results and on-road assessment outcomes have
been evaluated in many studies (Lundqvist, Alinder, & Rönn-
berg, 2008; Schanke & Sundet 2000; Akinwuntan, Feys, De
Weerdt, Pauwels, Baten, & Strypstein, 2002; Akinvuntan, De
Weerdt, Fey, Baten, Arno, & Kiekens, 2005; Akinwuntan, Feys,
De Weerdt, Baten, Arno, Kiekens, 2006; Coleman, 2002;
Lundqvist, Alinder, Alm, Gerdle, Le- vander, & Rönnber, 1997,
Lundqvist, Gerdle, & Rönnberg, 2000; Mazer, Korner Bitensky,
& Sofer, 1998; Nouri, Tinson, & Lincoln,1987; Nouri & Lin-
coln,1992; Devos, Akinwuntan, Nieuwboer, Truijen, Tant, &
De Weerdt, 2011), yet there is no accepted method that pro-
duces sufficient and necessary infor- mation about relevant
functions for driving performance on the individual level and
there are no cut-off limits of test results that explicitly state the
minimum test scores for driving fitness (Schanke & Sundet,
2000; Vrkljan, McGrath & Letts, 2011).
Furthermore, because self-awareness, driving experience,
and pre-morbid personality and attitudes are identified as im-
portant factors for coping with cognitive impairments, these
issues should be considered when deciding on a patient’s driv-
ing fitness (Schanke, Rike, Mølmen, & Østen, 2008; Lundqvist,
Alinder, & Rönnberg, 2008; Tate,1999). Although cognitive
test results are the base for driving assessment, qualitative ob-
servations are important for interpreting possible consequences
of the quantitative information and for forming a final decision.
There is a chance that patients at risk might not be identified
when using either off-road tests or on-road tests alone. Cons-
quently, quantitative as well as qualitative results from different
assessments should be used to determine a person’s driving
fitness after acquired brain injury.
Injury and illness affect cognitive functions in different ways.
Therefore, it is important to know which functions should es-
pecially be assessed. Some patients, mostly suffering from
frontal traumatic brain injury have a higher risk for accidents
compared to people in general (Boake, Macleod, High, &
Lehmkuhl, 1998; Schanke, Rike, Mølmen, & Østen, 2008).
They can perform well on neuropsychological tests measuring
cognitive speed, but might still have executive impairments,
impaired insight and judgement. Therefore, it is important to
scrutinize those functions. Concerning patients with right-
hemisphere injuries, e.g. after stroke, it is especially important
to assess their insight, attention, visual scanning and visuo-
spatial functions, which are most important driving on-road in a
multi-stimuli environment. Some of the geriatric patients with
mild dementia might have attention impairments, cognitive
slowness, orientation problems and difficulties understanding
instructions.
In primary care services and in many hospital departments
such as neurological, geriatric, and rehabilitation clinics, the
question of whether the patient can resume driving should be
raised more often. The physician in primary care services has
the responsibility to evaluate the patient’s medical condition,
but a single medical examination is often insufficient to judge
whether the patient is at risk from a medical point of view (Jo-
hansson, Bronge, Lundberg, Persson, Seideman, & Viitanen,
1996). Occupational therapists in primary care services can
screen for cognitive function that along with a medical exami-
nation can be sufficient in finding those individuals who have
comprehensive cognitive impairments or physical impairments
that make them unfit to drive. In more complicated cases, a
multidisciplinary approach is required; however, clinics rarely
have a specialized program to assess driving fitness (Larsson,
Lundberg, & Falkmer, 2007).
A Clinical Driving Assessment Model
There is a need for an organized, structured, and verified
procedure to assess and recommend whether a person can re-
sume driving after cognitive dysfunction. A team-based spe-
cialized driving assessment program is part of our outpatient
rehabilitation services. The multidisciplinary team consists of a
MD, a neuropsychologist, and an occupational therapist (OT),
all experienced in evaluating driving fitness. In addition, a
speech therapist is consulted if required. The team collaborates
with a driving instructor who is specialized in driving evalua-
tions for persons with medical dysfunctions. The aim of this
study is to describe a model and clinical guidelines for deter-
mining driving fitness for patients with cognitive dysfunction in
a rehabilitation setting. The guidelines are based on a clinical
assessment procedure using quantitative as well as qualitative
methods for data collection as well as for analysis. The assess-
ment process includes medical and cognitive factors and an
on-road driving assessment that all together serve as a basis for
a final decision about a person’s driving fitness made by the
driving assessment team through a team discussion.
Methods
Subjects
The team-based clinical assessment procedure was used to
evaluate 43 persons suffering from cognitive dysfunction due to
congenital or acquired brain injury, mild dementia, or cognitive
dysfunction related to other neurological disease and to heart
disease. The 43 persons were the total number of patients who
were referred to the driving assessment team in 2007 and 2008.
Out of these, five young persons were assessed to determine
their fitness for receiving driving permits (to start taking driv-
ing lessons). All of these had a congenital brain injury: one
Myelodysplastic Meningocele, three Cerebral Palsy, one Mild
Mental Retardation.
Thirty persons were evaluated for resuming driving a private
car and eight persons were evaluated for a professional driving
– seven for driving heavy vehicles and one for driving a taxi
(Figure 1). These eight had already resumed driving a private
car. Sixteen persons had a verbal driving prohibition from the
physician and nine were still allowed to drive, although their
physician had referred them to be evaluated for their driving
fitness. Seven had a withdrawn driving license. Thirty-three
were men and five were women. The group was heterogeneous
according to age, time since injury onset, and diagnosis. Me-
dian age was 63 years (SD 14.6). The individuals were assessed
about 26 months (SD 33) after illness/injury onset. The large
standard deviation was due to four persons who were referred
many years after they were injured. As seen in Table 1, the
most common diagnosis was stroke.
Procedures
The medical examination consisted of a detailed medical
history, a neurological examination, and an examination of

A. LUNDQVIST ET AL. 617
Figure 1.
Outcome for 38 people who were referred f or dr iv in g a ssessment.
Table 1.
Diagnoses for 38 people who were assessed for fitness to drive, 33 men
(87%) and 5 women (13%).
Diagnosis n %
Stroke 18 47
Traumatic brain injury 6 16
Mild Dementia 7 18
Tumour 2 5
Heart disease 2 5
Other (anoxia, other neurological disease) 3 8
Total 38 99
static and dynamic visual acuity with a moving object as the
target (Lundberg & Johansson, 2007. The neuropsychological
assessment, testing cognitive functions, consisted of tests based
on previous research (Lundqvist, Alinder, Alm, Gerdle, Le-
vander, & Rönnberg 1997, Lundqvist, Gerdle, & Rönnberg,
2000; Lundqvist, 2001). The neuropsychological assessment
used the Trail Making Test B (TMTB) and three computerized
tests from the Automated Psychological Test Battery (APT)
(Levander,1988): the Complex Reaction Time test including
reaction inhibition (requiring executive function); the K test (a
focused attention test); and the Simultaneous Capacity test (a
divided attention test). Additional neuropsychological tests
assessing visuo-constructive functions (Complex Figure Test,
Block Design), executive functions (Wisconsin card Sorting
Test), and working memory (Color Word Test) were applied
when required. To address additional cognitive functions, the
Nordic version of SDSA (NorSDSA) (Lundberg, Caneman,
Samuelsson, Halamies-Blomqvist, & Almqvist 2003) was used
for all subjects either by the neuropsychologist or by the OT.
The SDSA is an adapted version of The British Stroke Driver
Screening Assessment (SDSA) (Nouri & Lincoln,1992;
Lundberg, Lundberg, Caneman, Samuelsson, Halamies-Blom-
qvist, & Almqvist 2003). The neuropsychological assessment
also included an interview containing questions for evaluating
the patient’s self-awareness and pre-morbid and current per-
sonality.
The OT interviewed the subjects about their driving history
and conducted a cognitive screening that included testing for
visual neglect using the Behavioural Inattention Test (BIT)
(Wilson,Cockburn, & Halligan,1987), testing for attentiveness
using a simple driving simulator (SIM), and testing for reaction
speed (Lundberg &Johansson, 2007; Brouwer, Ponds, & Van
Wolffelaar,1989; Brouwer, & Waterink, 1991; Van Wolffelaar,
van Zomeren, Brouwer, & Rothengatter, 1988). In collabora-
tion with the driving instructor, the OT could also request a
standardized on-road assessment for about 60 minutes with a
variety of driving situations regarding action and environment.
All individuals drove under similar circumstances during the
on-road assessment. The driving instructor was responsible for
instructions, the driving route, and safety, while the OT made
the assessment after a discussion with the driving instructor.
The subjects drove a car with manual or automatic gearshifts
and a dual-brake system. The OT evaluated the subjects’ on-
road driving skill using a modified version of the Performance
Analysis of Driving Ability, the ‘P-Drive’ protocol (Patomella,
Caneman, Kottorp, & Tham, 2004; Patomella,Tham, & Kottorp,
2006; Patomella, Tham, Johansson, & Kottorp, 2010). The
original P-Drive on-road contains twenty-seven items, which
form a unidimensional scale. According to Patomella et al.
(2010) “it (P-Drive on-road) upholds aspects of internal scale
validity and reliability for producing a linear measure of driving
ability in people with stroke, dementia and mild cognitive im-
pairment”.
The on-road assessment is the last part of a total driving as-
sessment and the OT had access to the medical as well as to the
neuropsychological results before an on-road assessment. On-
road driving was evaluated in relation to the patient’s medical
and/or cognitive impairments to detect if impairments were
verified in the driving assessment or if the patients compen-
sated for impairments by self-awareness, driving experience,
and pre-morbid driving behaviour. Thus this on-road assess-
ment was more extensive than a traditional on-road assessment
as it was the intent to evaluate the person’s self-awareness and
driving experience as compensation strategies for an impaired
medical condition. During the interviews, all team members
focused on self-awareness and attitudes about driving from
their professional perspectives.

A. LUNDQVIST ET AL. 618
The team assessed all subjects (in part or fully) using the de-
scribed procedure (Table 2). Twenty patients completed the
entire procedure with a full assessment containing medical
examination, neuropsychological assessment, cognitive screen-
ing, and on-road assessment. Four persons required using cars
with automatic transmission; two of these required a special
lever for the turn signals and the accelerator. The remaining
used cars with manual transmission. The neuropsychological
assessment was not included for eight patients. All of them had
the diagnosis mild dementia and were already diagnosed at the
geriatric clinic.
The on-road assessment was not included for ten patients
because the team could determine their driving fitness/unfitness
without these examinations and/or because the patients’ driving
license was temporarily withdrawn. Two had diagnosis stroke
and anoxi. They had such great difficulties that they were con-
sidered not capable of driving. Seven with diagnosis stroke,
trauma, mild dementia, and cognitive dysfunction due to diabe-
tes and hearth attack had their driving license withdrawn, and
for one with diagnosis tumour, the medical assessment and the
neuropsychological test results were convincing positive for
driving.
The decision whether the patient was fit for driving was
made only after reviewing the quantitative and qualitative as-
sessments. As the Swedish Code of Statutes does not formu-
late concrete requirements for professional driving, the team
members based their decisions on higher cognitive demands
and responsibilities for professional drivers.
Ethical Considerations
The report is a clinical description to ensure the quality of
clinical assessment (Hälsooch sjukvårdslagen, 1982). There-
fore, it is not subject to evaluation by an ethics committee.
Statistical Methods
The Mann-Whitney U-test (p < 0.01) was used to compare
the outcome measure, i.e. the cognitive assessment results for
the group, which was determined by the assessment team to
resume driving, with the group, which was determined by the
assessment team not to resume driving.
Outcome
Every decision about a patient’s driving fitness was based on
a team discussion considering quantitative as well as qualitative
information. Thus, the outcome measure was the final decision
determined by the assessing team.
Driving Permit Group
Four men and one woman with congenital brain injury were
Table 2.
Type of assessment fo r 38 persons.
Type of assessment n %
Medical examination, neuropsychological assessment,
cognitive screening, and on-road assessment 20 53
Medical examination, neuropsychological assessment/
cognitive screening 10 26
Medical examination, cognitive screening, on-road
assessment 8 21
Total 38 100
assessed for a medical declaration to be attached to the applica-
tion for driving permit. All patients received a medical exami-
nation, a neuropsychological assessment, and cognitive screen-
ing. Mean age was 24.8 years (SD 5.4). All patients were
approved to start taking driving lessons.
Driving a Private Car and Professional Driving
Group
Thirty subjects were assessed for resuming driving a private
car and eight persons were assessed for driving heavy vehicles,
mostly professional driving. The outcome of the driving as-
sessment according to the assessment team decision is shown in
Figure 1. Of the 30 persons referred for private driving, 12
fulfilled the requirements, and 18 did not due to cognitive
slowness, impaired divided attention, visuo-spatial impairments,
or impaired insight. Two of these did not fulfil the basic medi-
cal demands for driving due to impaired visual acuity and/or
epilepsy. Eight had diagnosis stroke while six suffered from
mild dementia.
Four of the eight patients who were referred for driving a
heavy vehicle fulfilled the requirements. Four were recom-
mended not resuming professional driving: two due to cogni-
tive slowness and decreased attention (although they could
resume driving a private car) and two did not fulfil the basic
medical demands and thus could not continue driving in any
form.
To summarize, four persons did not fulfil basic medical de-
mands for driving and five persons had such great impairments
(e.g., visual neglect, pronounced mental slowness, and/or im-
pulsivity) that the referral physician or a local OT in primary
care services should have been able to make the decision. The
subjects who passed the assessment were heterogeneous ac-
cording to diagnoses, question of referral, and comprehension
of assessment. The findings reflect the assessments made in a
clinical setting, which must offer individually adapted assess-
ments for patients with a range of medical background condi-
tions, combined with quantitative test results as well as qualita-
tive observations.
Assessment Tools
The team made a decision for 38 persons. The decisions were
based on both quantitative and qualitative information. Neuro-
psychological assessment was made for 28 individuals. As
mentioned before, eight patients with mild dementia were not
assessed neuropsychologically. They were already diagnosed at
the geriatric clinic. All of them were determined by the assess-
ment team not to resume driving. In addition, several subjects
in the not-resuming group did not complete the neuropsy-
chological assessment either due to incapacity, tiredness, or
difficulties understanding instructions, or the team could make
a decision without the examination (Table 3).
The qualitative aspect was considered most important in all
assessments. That is, observations of the person in the assess-
ment situation and his/her comments and reactions are valuable
for understanding and interpreting the cognitive and executive
test results. During the interview, the neuropsychologist evalu-
ated the person’s self-awareness of impairment and insight.
During the on-road driving assessment, the OT evaluated the
person’s potential compensatory driving strategies. Twenty-
eight individuals went through an on-road assessment; ten did
not. Six of them were determined by the assessment team not to
resume driving.
To make an overall quantitative quality check of cognitive

A. LUNDQVIST ET AL. 619
Table 3.
Assessment test data for 38 people. Means and standard deviations for the group of people resuming versus not resuming driving according to the
assessment team decision, Mann-Whitney’s U- Test p-value 2-sided for independent samples. Statistical level p < 0.01.
Test Resuming driving M (SD) n = 16 Not resuming driving M (SD) n = 22 Mann-Whitney U- Test p-value
BIT (max 40) 38.8 (1.2) n = 12 34.6 (3.8) n = 17 p < 0.001
SIM (max 1.0) 0.88 (0.20) n = 12 0.55 (0.35) n = 21 p < 0.002
Trail Making Test B (sec) 121.3 (62.1) n=12 205 (83.9) n = 13 p < 0.002
Block Design (max 68) 34.4 (10.1) n = 12 27.2 (11.1) n = 12 n.s.
Complex Figure Test (max 36) 34.5 (2.8) n = 12 30.9 (7.9) n = 12 n.s.
Wisconsin Card Sorting Test (max 6) 3.7 (1.68) n = 12 2.3 (1.22) n = 9 n.s.
Color Word Test (sec) 134.3 (36.9) n = 11 190.2 (72.5) n = 11 p < 0.05
APT k-test (T-value) 50.0 (5.7) n = 12 39.1 (10.0) n = 11 p < 0.001
APT Reaction Time (T-value) 41.3 (12.3) n = 12 25.2 (14.1) n = 12 p < 0.01
APT Simultaneous Capacity (T-value)48.3 (10.6) n = 12 37.9 (8.3) n = 9 p < 0.05
NorSDSA total 1.73 (1.20) n = 12 −0.63 (2.0) n = 20 p < 0.001
assessment tools, we made a group statistical analysis compare-
ing the “resuming driving group” with the “not resuming driv-
ing group” for all the 38 referred persons. The final decisions
related to these tests are shown in Table 3. The two groups
significantly differed with respect to the cognitive screening
(SIM), the computerized focused attention test (APT k-test),
TMTB, and the NorSDSA. On tests demanding attention and
cognitive speed, the resuming driving subjects performed sig-
nificantly better than the subjects who did not resume driving.
Although several of the tests could separate the majority of
cases between “resume driving” and “not resume driving” ac-
cording to the assessment team decision, there was no single
test that provided enough information alone to make a final
decision. We propose a stepwise evaluation process where the
final decision is based on a synthesis of the investigations and
consensus from an experienced driving assessment team (Fig-
ure 2; Hopewell, 2002).
Discussion
It takes time and it is a great challenge to develop a solid
clinical procedure for driving assessment after injury or disease,
but this work is crucial. The responsibility to determine a per-
son’s fitness to drive after different medical conditions or inju-
ries affecting the brain is a difficult and complex issue, espe-
cially in cases of lack of insight and judgment. In many coun-
tries fitness to drive is a medico-legal issue that is deferred to
physicians, but in some countries determining one’s fitness to
drive is left to the drivers themselves. Many physicians con-
sider having insufficient competence and lack of tools to make
such a judgment (Hakamies-Blomqvist , Henriksson, Falkmer,
Lundberg, & Braekhus, 2002). Accordingly, it is important to
have methods that can support a medical perspective where the
issue is a matter of risk assessment. There is most likely a need
for specialized assessment teams to support primary health care
services to make more comprehensive assessments. A with-
drawal of a driving license will lead to heavy consequences,
especially for persons who rely on driving in their work. Such
decisions should be based on proven procedures.
Clinical guidelines based on research and many years of
clinical experience must be considered as “good enough” in this
description. Our clinical experience (more than ten years) can
serve as a basis to describe a clinical model for a final decision
about a person’s fitness to drive. We hope that our structured
clinical procedure can be of use in other medical services deal-
ing with individuals with cognitive dysfunction due to trauma
or disease.
Driving Permit
All persons who were assessed for driving permit (n = 5)
were evaluated with respect to medical requirements. They all
had some cognitive impairment, but the examination could not
tell whether the persons would be able to compensate for their
impairment in a driving situation. Therefore, it was recom-
mended that they take driving lessons before being evaluated. A
follow-up by the team, however, showed that two did not man-
age the driving lessons and one person never started the driving
lessons. These findings agree with an unpublished follow-up
study that addressed the outcome of driving permission among
young people with ADHD or Asperger disease. More than 10%
of the subjects never started their driving education, and more
than half of the subjects never received their driving license
(Johansson, 2009). One explanation of this might be that once
they secured their permission, they were confirmed as compe-
tent as anybody else, which was enough for them. Another
explanation was that the subject was not motivated to drive, but
other people in their lives were pushing them to apply for a
driving license. Consequently, it is important to inquire about
the applicant’s motivation and purpose for having a driving
license especially considering the time and expense required for
such testing.
Driving a Private Car and Professional Driving
Sixteen of the subjects had a verbal driving prohibition from
the physician at the time when they were referred for assess-
ment. Obviously, physicians use their possibility to give a
temporary verbal driving prohibition. However, we have found
that patients often interpret a veral prohibition as a temporary b

A. LUNDQVIST ET AL. 620
Figure 2.
A multidisciplinary and multi stage decision model for a s sessing driving performance (modified after Ho pewell, 2002).
condition (three to six months). Therefore, the physician has to
explain explicitly the conditions of the prohibition and offer an
appointment to the patient for a follow-up. At the follow-up, the
physician reassess whether the patient can drive. One advantage
of a verbal prohibition is that the person is allowed to do an
on-road assessment. Seven persons had a withdrawn driving
license; in some cases, this was due to poor medical conditions
in the early rehabilitation phase. Once a driving license is with-
drawn, it is not possible to conduct an on-road assessment,
which could be a valuable complement in the total assessment
in many cases.
Remarkably, nine patients were driving while they were
waiting for the assessment. Seven of them did not fulfil cogni-
tive and/or medical requirements for holding a driving license.
Consequently, it is strongly recommended that the doctors give
a verbal prohibition when referring a patient for this kind of
assessment.
Four persons were referred despite the fact that they did not
fulfil basic medical demands prescribed in the Swedish Code of
Statutes (Swedish National Road Administration, 1998). It is
strongly recommended that patients fulfil these demands before
they are referred to a specialized assessment team. In addition,
five persons had such great impairments that an OT in primary
care services should have been able to make a basic screening
of cognitive functions, which could reduce the need for referral.
A doctor might refer a patient to avoid a negative influence on
the doctor-patient relationship or to consult with other profess-
sionals about the patient’s impairments and how they relate to
driving fitness. When a doctor needs support, there should be a
possibility to refer the patient for comprehensive assessment by
another doctor or preferably by a team with special competence.
The team then becomes the responsible entity for making re-
commendations and the final decision regarding the patient’s
driving fitness.
There were two persons who were referred because they
needed to drive heavy vehicles. After their assessment, it was
decided that they were unable to operate even a private car.
This is an important ethical complication. Therefore, a person
who is referred for assessment of driving fitness must be accu-
rately informed about the legal aspects and possible cones-
quences of this investigation before accepting the procedure.
Assessments
Cognitive functions are assessed using cognitive screening

A. LUNDQVIST ET AL. 621
and neuropsychological tests, which we know from earlier
studies, are relevant for driving assessments (Lundqvist, 2001).
Statistical relationships between neuropsychological test results
and on-road assessment outcomes have been found in several
studies, e.g. in a recent review and meta-analysis by Devos,
Akinwuntan, Nieuwboer, Truijen, Tant, & De Weerdt, 2011),
which also support our former results that TMTB is a signifi-
cant test to use. Still we believe that using cut-off scores are
just a part of the total driving assessment. Although the clinical
screening battery NorSDSA has shown to have varying sensi-
tivity and specificity (Lincoln, & Fanthome, 994; Selander,
Johansson, Lundberg, & Falkmer 2010), it can complement
other tests and as such serve as a screening tool. We found,
however, that the instructions were often difficult to understand
for the elderly, leading to false negative results.
Eight patients were not assessed neuropsychologically. They
had such significant impairments that a cognitive screening was
sufficient for making the decision. They went through a medi-
cal examination and an on-road assessment.
During the interviews, different team members focused on
different qualitative characteristics. Insight and self-awareness
are most significant predictors for driving (Lundqvist & Alin-
der, 2007; Schanke & Sundet 2000; Patomella, Kottorp, &
Tham, 2008). Pre-morbid factors, such as driving style, should
be systematically evaluated during the interview, since traffic
accidents are generally concentrated on a few drivers (Martin,
& Estevez, 2005). Therefore, sensation seeking, risk proneness
behaviour, and impulsivity should be investigated when evalu-
ating a patient’s fitness to drive (Schanke, Rike, Mølmen, &
Østen, 2008; Tate, 1999).
The on-road assessment evaluates whether the medical
and/or cognitive problems have consequences for driving.
Therefore, the observations during driving are interpreted in
relation to the patient’s current impairments and/or pre-morbid
factors. The on-road driving assessment also gives information
about the patient’s capacity to compensate for impairments in a
real driving situation by being sufficiently aware of their im-
pairments and safely adjusting their driving (Lundqvist &
Alinder, 2007). One woman suffering from a left hemisphere
injury had episodic memory impairments and cognitive infor-
mation processing slowness. She had significant driving ex-
perience and was well aware of her impairments and adjusted
her driving to her current capacity. The team discussion is of
utmost importance for understanding whether the impairments
will have consequences on driving and whether the individual
can compensate for the difficulties in the activity. If patients are
unaware of their impairments, they might continue their pre-
morbid driving style, a situation that could mean their reaction
times are too slow for their post-morbid conditions. Some pa-
tients might be aware of their impairments, but still be at risk
due to cognitive slowness or motor impairments. All these cir-
cumstances are important to discuss in the team.
Subjects with aphasia are difficult to assess off-road due to
their difficulties understanding instructions, a limitation that
might significantly influence the test results. Therefore, it is
even more important to make an on-road assessment for as-
sessing whether he/she fulfils demands for attention, reaction
speed, planning, and understanding and obeying traffic signs. A
speech therapist is sometimes needed in the assessment to give
the patient optimal conditions for a fair judgment.
An on-road assessment is often seen as the “golden standard”
and the best way to evaluate driving performance (Schanke &
Sundet 2000; Hasselkorn, Mueller, & Rivara, 1998; Katz,
Golden, Butter, Tepper, Rothke, Holmes, & Sahgal, 1990;
Galski, Bruno, & Ehle, 1992; Sivak, Hill, Henson, Butler, Sil-
ber, & Olson, 1984). Although the on-road assessment is done
on a single occasion, it is an important part of the total assess-
ment. It might be the most reasonable way to assess a patient in
a way that is as similar to his/her ordinary driving capacity as
possible. However, the driving must continue for at least 45
minutes or more to show potential difficulties.
Issues for Developing the Model
The purpose of this report is to describe a well-practiced
model that stresses the use of quantitative and qualitative as-
sessments that lead to a team consensus for a decision as solid
as possible for each individual. One limitation is that we have
not used protocols for the interviews. There are several tools to
assess self-awareness (Anderson & Tranel,1989; Kottorp, 2006;
Sherer, Bergloff, Boake, High, & Levin,1998) and self-reported
on-road behaviour (Reason, Manstead, Stradling & Baxter,
1990), although with varying quality (Vrkljan, McGrath &
Letts, 2011), that can be used in the future. In addition, another
goal is to structure the interview for driving history and to de-
velop protocols for pre-morbid factors. We also illustrate the
constraints of clinical settings such as persons with a withdrawn
driving license, persons who should not have been referred, and
persons who lost their driving license after the assessment. Due
to limited resources, we were unable able to assess persons
suffering from Parkinson’s disease or multiple sclerosis al-
though there is a great need for driving assessments in these
groups. Similarly, it is important to develop strategies and
methods for basic training and compensation so as many
brain-injured people as possible can resume driving (Leon-
Carrion, Dominguez-Morales, Barroso, & Martin, 2005; Klon-
off, 2010).
Conclusions
Driving performance is a multifactorial activity that depends
on cognitive, executive, and affective factors as well as driving
experience and pre-morbid factors. The current report clearly
shows that some patients would not have been sufficiently as-
sessed if off-road tests or on-road assessments alone had been
used. Clearly, off-road tests or on-road tests alone are insuffi-
cient for ensuring sound decisions. The assessment of a pa-
tient’s fitness to drive is an individually adapted combination of
assessments that can be efficient when applied in a stepwise
manner. A multidisciplinary team including medical, neuro-
psychological, occupational, and practical driving experts opti-
mises the assessment quantitatively as well as qualitatively in a
team-based consensus approach. Therefore, specialized national
teams should be established to support primary care services in
assessing driving fitness in more complicated cases.
Declaration of Interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the paper.
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