While the legal obligations of drivers, health professionals and licensing authorities remain unchanged, the new edition of Assessing Fitness to Drive emphasises the important role of health professionals in advising drivers about the impact of their medical conditions/disabilities on driving in the short and long term. This acknowledges drivers’ reliance on health professional advice to inform them of driver legal reporting obligations and to support these processes. It also underpins the importance of early and repeated conversations about driving for people diagnosed with progressive conditions.

Also highlighted is the multidisciplinary management of fitness to drive and the importance of sharing of information between care providers, including specialists, general practitioners, optometrists and occupational therapists, to ensure appropriate care coordination for road safety.

Part A of the standard also includes improved guidance regarding the management of older drivers. Based around an active management approach, it describes how consideration of fitness to drive can and should be integrated into the general health and lifestyle management for older people so that the inevitable transition to non-driving can be normalised and addressed to maintain independence and community connections.

Related to the management of older drivers, but potentially an issue at any age, multiple medical conditions can prove challenging to assess and manage with respect to driving. The new edition contains updated evidence on this issue.

Disabilities are not the same as medical conditions, and the management with respect to driving requires consideration of the person’s functional capacity and the stability of the disability. New material in Part A provides specific guidance in this regard. More detailed information regarding prosthetics is also included in the Musculoskeletal chapter.

With medicinal marijuana (cannabis) now being prescribed for various conditions, consideration about safety for driving is an issue to be considered by prescribing health professionals. The new edition includes extensive information to guide decisions about driving.

The review of this cardiovascular conditions chapter was supported through consultation with the Cardiac Society of Australia and New Zealand.

Implantable cardioverter defibrillator (ICD) 

ICDs are devices that are used to detect and stop cardiac arrhythmias. The device continuously monitors the heart and delivers electric shocks when needed to restore normal heart rhythm. Criteria contained in 2016 Assessing Fitness to Drive have precluded drivers with ICDs from holding a commercial vehicle licence, in part due to the underlying condition but also due to the risk of incapacitation due to inappropriate discharge of the device. The restriction has applied to ICDs implanted for secondary or primary prevention, while allowing consideration of exceptional cases.

Recent studies considered as part of the current review suggest lower rates of shock frequency and syncope in patients where an ICD is used for primary prevention. New criteria for conditional licensing are therefore set in the 2022 edition for this group of patients with commercial licences. The criteria specify a non-driving period post implantation (6-months) and an annual review period.

Driver Licensing Authorities will support the management of this change for existing customers.

Ventricular assist devices (VADs) 

A small number of people receive therapy with these devices for heart failure. During the previous review, licensing standards were included for private drivers with left VAD. Drivers with a combined LVAD/RVAD (BiVAD) or an artificial heart, and commercial drivers requiring any type of these devices, were not fit to drive due to concerns about device failure and loss of vehicle control.

Based on new evidence, private drivers with BiVADs may now be considered for a conditional licence, subject to the same criteria as previously required for LVAD. Ventricular assist devices of any type remain unacceptable for commercial vehicle driving.

Driver Licensing Authorities will support the management of this change for existing customers.

Congenital disorders

The criteria for drivers with congenital disorders have been updated to reflect the current standards of medical care for these cardiac conditions.

The criteria for both private and commercial vehicle drivers now address considerations for surgical management, including non-driving periods for post-surgery recovery. Commercial driver criteria have been expanded to provide greater clarity of the required clinical outcomes.

The criteria for private vehicle drivers are clarified for uncomplicated congenital disorders. Those with no or limited symptoms can drive without licence restriction – this is a clarification rather than a change in criteria.

The review of the musculoskeletal chapter involved consultation with Occupational Therapy Australia and its national driving committee The review identified the need to consider the impact of chronic pain and treatments on safe diving ability. Medication effects and condition stability are now included among the factors that should be considered when recommending a conditional licence. General guidance is also provided regarding the impact of pain on concentration and attention to the driving task.

New information is also included to guide recommendations for prosthetic devices.

The review of the neurological conditions chapter involved consultation with representatives from the Australian and New Zealand Association of Neurologists, the Epilepsy Society Australia, the Movement Disorder Society of Australia and New Zealand, the Royal Australian and New Zealand College of Psychiatrists, the Cognitive Dementia and Memory Service, and Occupational Therapy Australia.

Dementia and cognitive impairment 

Reflecting the progressive nature and unpredictable trajectory of dementia, the driving standards require that a person with dementia may not hold an unconditional private or commercial licence but depending on their capacity may hold a conditional licence, subject to periodic review.

During the current review, it was identified that dementia is being diagnosed at an earlier stage using modern diagnostic techniques, and that this should be reflected in the standard. The definition of dementia relating to ineligibility for an unconditional licence has therefore been qualified to exclude pre-clinical and prodromal dementia unless there are clinically significant symptoms. Regular monitoring and consideration of fitness to drive remains a key feature of managing this progressive condition, and early conversations about managing the transition to non-driving are essential.

Seizures and epilepsy

The management of seizures and epilepsy in relation to driving is a complex matter. The introduction of a ‘default standard’ in 2012 has provided a framework to facilitate the process and has been generally well accepted. Since then, ongoing improvements have included clearer guidance and flow charts to illustrate the decision-making process. Changes resulting from the current review reflect ongoing improvement to add clarity around particular areas of management and are summarised below.

• Criteria for unreliable or doubtful clinical information

Health professionals are largely reliant on patient self-reporting to determine seizure history. To address circumstances where the clinical information is unreliable or doubtful, new criteria have been included for private and commercial drivers. This enables the examining health professional to formally assess the person as unfit to drive if there is concern about the veracity of the information provided.

• Resumption of unconditional licence after first seizure or acute symptomatic seizures 

The new edition includes criteria relating to resumption of an unconditional licence for first seizure and acute symptomatic seizures for private and commercial vehicle drivers. The criteria provide clarity of the circumstances under which the driver licensing authority may consider return to driving on an unconditional licence, which supports consistency of practice. The criteria for resuming driving on an unconditional licence for the default standard remain unchanged.

• Recommended reduction in dosage of anti-epileptic medication in a person who satisfies the standard to hold a conditional licence 

This aspect of the standard seeks to address circumstances where a reduction in anti-epileptic medication dosage is proposed for a person already on a conditional licence. Previously this applied in circumstances where the dose reduction was due to side effects. Revised criteria for both private and commercial drivers now include circumstances where the dose is being reduced following a period of temporary dosage increase, such as during pregnancy.

• Requirements for EEG 

For the relevant commercial vehicle driver standards, an EEG demonstrating no epileptiform activity is required for a conditional licence to be considered by the driver licensing authority. The EEG is required on initial granting of the conditional licence and not for the ongoing periodic review, which is now clarified in the wording of the standard.

• Description of ‘safe’ seizures 

For clarity, explanatory text has been added to describe a type of seizure that can be managed under the ‘safe’ seizure standard for private vehicle drivers.

“Isolated infrequent myoclonic jerks (without impaired awareness) may be considered safe in the context of no seizures of any other type for more than 12 months.”

• Assessment of provoking factors 

In the criteria relating to seizure in a person whose epilepsy was previously well controlled for private vehicle drivers, the new edition clarifies that sleep deprivation should not be considered a provoking factor as it cannot be reliably avoided.

• Clarifications on medication withdrawal or change

In the criteria relating to planned withdrawal of one or more antiepileptic medications in a person who satisfies the standard to hold a conditional licencefor private vehicle drivers, the new edition clarifies that the 3-month nondriving period applies if a driver is being switched from one anti-epileptic drug to another.

• Reduction of the default standard

There are numerous circumstances in which a reduction in the default standard may be applicable. Revisions to this edition now clarify that in such circumstances the longest non-driving seizure-free period should apply.

• Stroke 

The assessment requirements for private drivers post stroke have been refined to reduce unnecessary assessments and reporting.

Private drivers who are discharged from specialist care within 4 weeks of a stroke and have been assessed as fit to drive when discharged may continue to drive on their current licence and without need for reassessment, unless otherwise indicated. New text is also included to ensure a robust process in this regard:

Documentation of the assessment should be provided at discharge which includes details of the driver’s licence indicates that they have not suffered any permanent neurological deficits that will impact driving, and that they are fit to drive at the end of the non-driving period.

There are also clearer licensing criteria for situations when a person may require a conditional licence after a stroke. The criteria also indicate that periodic assessment is not required after initial medical review if the driver’s condition is stable and there are no other relevant co-morbidities that require fitness to drive monitoring.

• Subarachnoid haemorrhage 

The review identified that cases involving low-risk non-aneurysmal subarachnoid haemorrhage restricted to the cerebral convexity present a low risk to driving safety and should be excluded from the licensing criteria unless impairments are present.

• Autism spectrum disorder (ASD)

The review identified that information and guidance was required to enable assessment of persons with ASD. Specialist advice noted that the variability of ASD characteristics and the degree of severity were too diverse for a specific standard. General guidance is however provided in the text of the chapter.

The review of the psychiatric conditions chapter involved consultation with representatives from the Royal Australian and New Zealand College of Psychiatrists (RANZCP), who advised that the medical standards are generally appropriate and are working reasonably well in practice.

Stakeholder submissions in previous reviews have sought more detailed guidance on managing specific psychiatric conditions. A key finding from the MUARC report was that no single category of disorder was associated with an increased motor vehicle crash risk. Specialist advice reiterated the suitability of the current standards to manage and assess driving fitness for people with a psychiatric disorder.

Specialist advice also identified that only a driver with a significant new mental health condition should require periodic review by a psychiatrist, and that those with stable long-term conditions can be well managed by the person’s general practitioner after initial assessment by a psychiatrist. Reflecting this usual management approach, periodic reviews for commercial vehicle drivers may be performed by a person’s general practitioner under specified circumstances (in place of specialist reviews). The psychiatrist must perform the initial assessment, and all must agree to the arrangement.

To support management of high-risk individuals, specific contraindications for driving (red flags) are included in the chapter. These identify circumstances where an advisory non-driving period may be warranted until the condition has been evaluated.

• Psychogenic non-epileptic seizures (PNES) 

Medical standards have been included for seizures diagnosed as psychogenic (pseudo-seizures) as these may otherwise be managed under the default epilepsy standard. The criteria include seizure free periods and address clinical features and condition severity.

• Attention deficit hyperactivity disorder (ADHD) 

Stakeholders contributing to the review requested information and/or standards for this condition. Based on specialist opinion, additional information is included regarding assessment for ADHD but not specific licensing criteria.

The review of the substance misuse chapter involved consultation with Prof. Edward Ogden.

As for psychiatric conditions and reflecting the usual management of people with stable conditions, periodic reviews may now be performed by a person’s general practitioner under specified circumstances (in place of specialist reviews). The specialist must perform the initial assessment, and all health professionals involved in the driver’s management must agree to the arrangement.

The criteria have been modified to emphasise the conditional licensing requirements and include the use of alcohol interlocks where appropriate and where applicable in jurisdictions for private vehicle drivers. Additional changes to the text provide greater clarity regarding assessment requirements, including objective measures of abstinence.

The review of the vision and eye disorders chapter involved consultation with representatives from the Royal Australian and New Zealand College of Ophthalmologists, Optometry Australia and Orthoptics Australia. Advice on practical driver assessment was also provided by Occupational Therapy Australia and its national driving committee. There are a number of changes to this chapter:

• Visual fields

The standard for private vehicle drivers has been clarified by including the additional criterion to define when a driver no longer meets the requirements for an unconditional licence:

if there is any significant field loss (scotoma) with more than four contiguous spots within 20 degrees radius from fixation.

The text has also been revised to provide clarity around the assessment of visual fields.

• Monocular vision 

Minimum visual standards for monocular commercial vehicle drivers are now included to provide clarity. In 2012, a stricter approach to managing commercial vehicle drivers with monocular vision was introduced, requiring individual assessment. Licensing authorities and industry stakeholders reported some difficulties with the introduction of this change as it was not clear what criteria should be considered in this assessment. The text now includes a detailed checklist of factors to be considered in licensing monocular drivers (and visual field defects in general).

For commercial vehicle drivers, the review period for drivers with a conditional licence has changed from one year to two years.

• Visual acuity

The visual acuity standard remains the same, however the established therapy of orthokeratology is now included as an option for meeting the acuity requirements for a conditional licence (private and commercial). This treatment is managed similarly to corrective lenses. Guidance is provided. Individual driver licensing authorities may have requirements in terms of demonstrating appropriate use of the therapy and review periods for conditional licensing.

• Diplopia 

Specialist advice confirmed that a person is not fit to hold a commercial licence, either unconditional or conditional, if they have double vision when looking up to 20 degrees from fixation. If they have double vision when looking beyond 20 degrees of fixation they may be considered for a conditional licence. Diplopia within the central 20 degrees refers to 20 degrees from central fixation and not 20 degrees across fixation. Minor text changes have been made to clarify this point. The change of wording is for clarification and does not impact the intention of the standard.

• Telescopic lenses (bioptics)

There continues to be considerable interest in these devices. While the requirements remain unchanged, more detailed information is included to provide a rationale for the position including the supporting evidence.

There have been no changes to the medical criteria or general guidance in the blackouts chapter.

The review of the diabetes chapter involved consultation with the Australian Diabetes Society, and submissions received from a number of other stakeholders.

The focus continues to be on the main risks to safety including hypoglycaemia and end organ effects. There have been no changes to the licensing criteria, however additional guidance is provided regarding the use of glucose monitors to support awareness of hypoglycaemia. It is noted that devices with alarms should not replace an individual’s capacity to sense or experience other early warning signs of hypoglycaemia.

There remains a hearing standard for commercial vehicle drivers and there have been no changes to the licensing criteria as a result of this review.

Guidance is provided to differentiate the roles of hearing professionals (audiologists and audiometrists) in assessing hearing.

While there have been no changes to the licensing criteria for sleep disorders, more detailed guidance is provided for the clinical assessment and management with respect to driving, including identification of at-risk individuals for further evaluation. This content will assist management and support consistent application of the medical criteria.