SINGAPORE MEDICAL ASSOCIATION

SECOND EDITION, 2011

MEDICAL GUIDELINES ON
FITNESS TO DRIVE
2
CONTENTS
■ Foreword ..... ....... ....... ....... ....... ....... ..... .. ..... .. ..... .. ..... .. ..... .. ..... ....... ....... .. 4

■ Preface .................................................................................................... 5

■ Medical Examination Requirements for Drivers ............................... 7

■ Simple Screening Instruments for Clinic Settings ............................ 11

■ Medical Guidelines by Conditions

• Cardiovascular Diseases .............................................................. 15

• Musculoskeletal System ............................................................... 25

• Neurological Disorders .................................................................. 29

• Vision ............................................................................................... 34

• Respiratory Diseases .................................................................... 36

• Diabetes Mellitus and other Endocrine Diseases ..................... 38

• Hearing ............................................................................................ 40

• Cognitive Disorders (Progressive) ...................... ............. ........... 40

• Psychiatric Diseases ..................................................................... 42

• Medication ....................................................................................... 43

• Appendix 1 ...................................................................................... 47

• Acknowledgement ......................................................................... 51

• Committee Members ..................................................................... 52

3
 FOREWORD

It has been ten years since the last guideline on fitness to drive was published,
and it is timely that the guidelines have been updated.

This is because of the rapid changes in our society, including the ageing of
the population and the onset of an increase in the burden of chronic diseases.
This is juxtaposed against the rapid advances in the medical fields and the
new developments in the thinking and approach towards diseases.

The new guideline is crafted by an expert committee consisting of doctors

from multiple disciplines and representatives from relevant organisations
such as the Traffic Police and the Land Transport Authority. They have spent
most of the year updating the document and deliberating on some of the
more controversial points over numerous meetings. We must acknowledge
the vast amount of work spent by the committee and the specialised domain
knowledge brought to the table by all parties.

Certification of fitness to drive has legal and statutory ramifications for our
society. There are areas of difficulty when it comes to balancing the interests of
society against the fiduciary relationship that exists between doctors and their
patients. This is viewed with the perspective that driving is a privilege granted
to the individual by society at large. Other areas of difficulty include assessing
functional ability of the patient to drive and therefore there has been emergence
of the Driving Assessment and Rehabilitation Programme (DARP) that seeks
to provide objective evidence of a patient's ability to drive.

As always, this is a guideline and serves to help the doctor to decide on areas
of difficulty that he may have in certification. We hope that the individual doctors
will find this a useful tool in clinical practice, and that society will benefit from
the judicious use of this guideline.

DR CHONG YEH WOEI

President, 52 nd Council
Singapore Medical Association

4
 MEDICAL GUIDELINES ON FITNESS TO DRIVE
PREFACE

The first edition of the guidelines was published in 1997. Many developments
have taken place in the past few years and the Workgroup on Revision of SMA
Medical Guidelines on Fitness to Drive was formed to update the Guidelines.
Some of the revisions are due to changes in the law, while others take into
account developments or advancements in treatment. For instance, epilepsy
can now be controlled.

Traffic accidents are a common problem in many countries. They often result in
injury or unnecessary loss of life to persons, in addition to damage to property.

There are many causes of traffic accidents. Studies have shown that the
human factor is more important than vehicle and road factors in contributing
to road traffic accidents. Medical unfitness of drivers contributes towards
the human factor. There are a few firm statistics regarding the contribution
of disease state or conditions to the causation of accidents. The available
evidence suggests that medical conditions of drivers, except for the effects of
alcohol, are not a major factor. However, medical conditions can significantly
impair the ability to drive.

Efforts in road safety and accident prevention have led to improved design
and structure of vehicles and roads, as well as requirements for fitness
examinations for certain categories of drivers.

Driving a vehicle may pose a potential threat to the driver as well as to road users.

In the interest of promoting greater road safety and prevention of accidents, it

was felt timely that a committee be set up to review existing fitness requirements
for drivers, and to draw up guidelines for doctors on the certification of fitness to
drive. This committee, under the umbrella of the Singapore Medical Association,
comprised a number of doctors from various disciplines, and also included
representatives from the Traffic Police and Land Transport Authority.

These guidelines were drawn up with reference to similar guidelines from the
UK, Australia, New Zealand and the USA. The draft guidelines were finalised
after being sent to various specialist medical societies for comments and
suggestions. It is recognised that there is little scientific evidence available
that can be used to assess the degree of impairment of driving that results
from any specific medical disability. The standards are mainly empirical in
nature but represent collective medical opinion.

5
As with guidelines in other countries, higher standards of fitness are
recommended for vocational drivers - those who drive professionally. This
is because they drive for longer hours and under more difficult conditions
than drivers of private vehicles. In the case of taxi and bus drivers, they are
also responsible for the safety of their passengers besides that of other road
users. For drivers of heavy goods vehicles, the risk of death or serious injury
to other road users in collision with their vehicles is also very high because
of their mass and longer braking distance required.

These guidelines are meant to assist doctors in certifying persons fit to drive.
They are not comprehensive as it is difficult to provide for every medical
condition. As guidelines, they also allow some flexibility to doctors. However,
in case of uncertainty, referral to a relevant specialist may be necessary. The
guidelines also help doctors to advise their patients who have certain medical
conditions on the advisability of driving and the precautions to observe. Doctors
do not have a statutory obligation to notify the traffic authorities, but they may do
so if they feel that a patient, who continues to drive despite their advice, may be
a danger on the road. The Singapore Medical Council has stated that in such
situations, medical confidentiality may be breached in the public's interest.

The Committee thanks the various organisations and persons who have
provided valuable advice and assistance, and invites comments and suggestions
for improvement which will be considered in any revision of these guidelines.

Committee on Medical Guidelines on Fitness to Drive

Singapore Medical Association

Note:
In these guidelines, Group 1 includes holders of Class 1, 2 and
3 driving licences. Group 2 includes holders of Class 4 and 5
driving licences and vocational licences (including drivers of
taxis and buses). The medical standard for Group 2 drivers is
more stringent than that for Group 1 drivers. For example, the
visual standard for Group 1 is at least 6/12 in one eye and 6/36
in the other eye, while the visual standard for Group 2 is at least
6/12 in both eyes.

6
 MEDICAL EXAMINATION REQUIREMENTS FOR DRIVERS

INTRODUCTION

The Traffic Police Department is the licensing authority for all classes of driving
licenses. The Vehicle & Transit Licensing Group of the Land Transport Authority
(LTA) issues additional vocational licences to drivers of public service vehicles
(PSV) such as taxis and buses. For example, a person who wants to drive a
taxi must possess a valid Class 3 driving licence issued by the Traffic Police
Department before he can apply for and be issued with a taxi driver's vocational
licence by LTA.

In the interest of road safety, the licensing authorities have to ensure that the person
who is granted a licence to drive a particular class of vehicle is physically and
mentally fit to drive the vehicle. The medical fitness to drive is generally certified by
a registered general practitioner or a specialist doctor if required.

At present, the medical fitness requirement for driving licenses is normally imposed
when a person reaches a certain age (65 years and above), except for vocational
licence applicants or holders where medical examination is compulsory at the point
of application. For renewal of vocational licences, vocational license holders are
required to pass a medical examination every 2 years between the ages of 50
years and 64 years, and once every year from age 65 years onwards.

However, for both driving and vocational licence holders, the Road Traffic Act
(RTA) also empowers the authorities to require the licensee at any time to undergo
a medical examination and submit medical evidence of his continuing fitness to
hold a licence. This is especially so when the authorities receive information of a
licensee not being fit to drive. An examining doctor may inform the Traffic Police
Department or LTA of the medical condition of his patient who, in his opinion,
is not fit to drive. The source of such information forwarded will be kept strictly
confidential. Write to either:

Deputy Head, Testing and Licensing Branch

Traffic Police Department
10 Ubi Avenue 3
Singapore 408865
Fax:65471955

Vocational License Services

Bus & Vocational Licensing Division
Land Transport Authority
10 Sin Ming Drive
Singapore 575701
Fax: 6553 5329

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TRAFFIC POLICE DEPARTMENT

Current Medical Requirements for Drivers below 65 years old

At the point of application for a Class 1 to 3 driving licence, the applicant

will have to undergo an eyesight test at the respective testing centre. He
will also have to declare that he is not suffering from any disability that is
likely to cause the driving of a motor vehicle to be a source of danger to
the public. No formal medical examination is imposed.

Current Medical Requirements for Aged Drivers (65 years and

above)

Rule 4A of the Road Traffic (Motor Vehicles, Driving Licences) Rules

require drivers of age 65 and above (and every 3 years thereafter) to be
certified physically and mentally fit to drive by a registered medical
practitioner of his own choice before a licence can be granted or renewed.

Therefore, irrespective of the class of vehicle that he is driving/riding, an

applicant is only subjected to a compulsory full medical examination when
he reaches the age of 65 years.

Notwithstanding, if it appears to Traffic Police (by means of self-report or

information submitted by member of public) that there is reason to believe
that a driver is suffering from a disease or physical disability that is likely
to cause him to be a source of danger to the public when he is driving,
Traffic Police will subject the driver to a medical examination. Unless he
passes the medical examination, his licence will be revoked. [Section 37
of RTA]

For the holder of a class 4, 4A or 5 driving licence, upon attaining the age
of 65 years, he must be certified by a registered medical practitioner to
pass a Proficiency Driving Test before a licence is granted or renewed.
This is required annually thereafter until the driver reaches 70 years of
age.

From 1 January 2016, the upper age limit has been extended until heavy
vehicle drivers turn 75 years old. With the revision, heavy vehicle drivers,
aged between 70 to 74 years old, can retain their licences if they pass an
annual enhanced medical examination and proficiency driving test.

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 SUMMARY

Class of
Driving Age of Requirement
Licence Driver
(at point of
application or
renewal)
All Classes (at below 65 Eyesight test and
point of years declaration of fitness at
application only) driving centres. No formal
medical examination
required.
Class 2, 2A, 2B, 65 years and To be certified physically
3 & 3A above and mentally fit by a medical
practitioner. Medical
Examination required once
every 3 years (i.e. 65, 68,
71, etc.)
Class 4, 4A & 5 65 to 69 To be certified physically
years and mentally fit by a
registered medical
practitioner. If fit, the driver
is required to pass a
Proficiency Driving Test.
Annual medical examination
required.
Class 4, 4A & 5 70 to 74 To be certified physically
years and mentally fit by a
registered medical
practitioner. If fit, the driver
is required to pass an
enhanced Proficiency
Driving Test. Annual
enhanced medical
examination required.

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LAND TRANSPORT AUTHORITY

At the point of application for a vocational licence to drive public service vehicles,
the applicant is required to undergo the prescribed medical examination and chest
X-ray by a registered medical practitioner. When the licence holder reaches 50
years of age, he will again be subjected to the prescribed medical examination
at regular intervals.

SUMMARY

Age of Driver Requirement for Vocational Licences

At point of application Prescribed medical examination and chest X-ray.

50 years to 64 years Prescribed medical examination every 2 years.

65 years to statutory Prescribed medical examination every year.

upper age limit

For Taxi Driver's Assessment on Fitness to Drive.

Vocational License
Holders at 70 years

TRAFFIC POLICE DEPARTMENT VEHICLE & TRANSIT SINGAPORE

POLICE FORCE LICENSING DIVISION
LAND TRANSPORT AUTHORITY

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 SIMPLE SCREENING INSTRUMENTS FOR CLINIC SETTINGS

The following is a simple assessment battery to assess driver competency and

red flags to look out for.

The three key factors for safe driving are:

• Vision
• Cognition and perception
• Sensory and motor function

Impairments in these functions may increase a person's risk for motor accidents.
Doctors are able to screen for these factors in their clinics without performing an
actual driving assessment using the proposed test battery presented below.

1. TAKING OF DRIVING HISTORY

Ask the patient for his years of driving experience, accidents and near-misses.
If the patient is currently not driving, the doctor should ask how long since he
stopped driving and the reasons for it.

2. ASSESSMENT OF VISION

Visual acuity (both distant and near) and peripheral vision are important in safe
driving. Visual acuity enables a person to take necessary actions for oncoming
traffic and hazards, as well as seeing controls inside the vehicle and street signs/
directories. Peripheral vision allows one to have a multi-dimensional view of the
road and the vehicle to facilitate safe lane changes and the awareness of other
vehicles/pedestrians during driving and parking. Doctors are able to assess these
aspects of vision using:

• General questions about the patient's eye health e.g. any blurred vision,
do they wear prescriptive eyewear, and are they on any follow-up for visual
conditions like cataracts
• General observations of the eye for cataracts or any other oculomotor
impairment
• Snellen's Chart for Visual Acuity
• Confrontation Test for Peripheral Vision

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3. ASSESSMENT OF COGNITION AND PERCEPTION

Driving is a complex activity, which requires higher-order cognitive abilities. These

include:

• Short and long-term memory

• Visual perception, visual processing and visuospatial skills
• Selective and divided attention
• Executive reasoning skills

Driving (especially in complex situations) requires one to process increasing

amounts of cognitive and perceptual information, which require rapid decision-
making and actions/responses. Any issues in this category may lead to increased
risks of road traffic accidents.

Registered medical practitioners can include these short screening tools in their
clinic assessments:

• Clock Drawing Test (Freund Clock Scoring for Driving Competency)

to assess visual perception
• Locally validated Abbreviated Mental Test (AMT) or Mini Mental State
Examination (MMSE) or Chinese Mini Mental State Examination to
assess cognition

These tools are located in Appendix 1 on page 47.

You may be interested to know that occupational therapy driving assessment

and rehabilitation programmes use the AMT and MMSE to screen for cognitive
impairment. In addition, the Colour Trails Test is used to assess driver competency
in the areas of attention. The test does not require the patient to be English-literate
and thus is suitable for the local context. Research on the Colour Trails Test (Part
B) indicates a correlation between low performance on the test to poor driving
performance in on-road assessments. The Motor Free Visual Perception Test
(MVPT), Visual Closure sub-test has also been shown to be most predictive of "at-
fault crash involvement" by drivers and is used during our driving assessments.

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4. ASSESSMENT OF SENSORY AND MOTOR FUNCTIONS

Driving is a physical activity that requires neuro-musculoskeletal abilities, such as:

• Range of motion of extremities, trunk and neck

• Muscle strength
• Coordination in hands and legs and eye-hand-foot coordination

Patients who suffer from neuro-musculoskeletal problems may also experience

pain along with other limitations, which may directly affect their driving abilities.

Range of Motion

It is suggested that range of motion of the following joint movements are tested
in the doctor's clinic:

• Neck rotation
• Trunk rotation
• Shoulder adduction, abduction and flexion
• Elbow and wrist flexion-extension
• Clenching fists
• Hip abduction, adduction, flexion and extension
• Knee extension and flexion
• Ankle dorsi-flexion and plantar flexion

Manual Test of Strength

It is suggested that the patient's motor strength be tested for the following
movements bilaterally:

• Shoulder adduction, abduction and flexion

• Elbow and wrist flexion and extension
• Handgrip strength
• Hip abduction, adduction, flexion and extension
• Knee extension and flexion
• Ankle dorsi-flexion and plantar flexion

It is also suggested that doctors note tremors (resting and intentional) or motor
planning difficulties during the screening procedure.

In addition to the assessments detailed above, sensation, proprioception,

kinesthesia, balance, mobility and transfers are also assessed. Reaction time will
be tested using a brake and reaction timer when necessary.

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5. RED FLAGS

The following are "red flags" that examining doctors should look out for when
assessing fitness to drive:

• Frequently experienced general symptoms like fatigue or weakness

• Diseases affecting vision (for example, cataracts, diabetic retinopathy,
macular degeneration, glaucoma, retinitis pigmentosa, visual field, reduced
visual acuity)
• ENT-related symptoms like headaches, head trauma, visual changes, vertigo
• Respiratory symptoms like shortness of breath
• Cardiac symptoms like chest pain, dyspnoea on exertion, palpitations,
sudden loss of consciousness
• Musculoskeletal changes like muscle weakness and pain, joint weakness
and pain, decreased range of motion
• Neurologic symptoms like loss of consciousness, feelings of faintness, seizures,
weakness/ paralysis, poor coordination, tremors, loss of sensation, numbness
and tingling
• Psychiatric symptoms like depression, anxiety, memory loss, confusion,
psychosis, mania
• Medications that can cause drowsiness or impair judgment

References:

1) American Medical Association (2003). Physicians' Guide to Assessing

and Counselling Older Drivers.
(http:llwww.ama-assn.org/ama/pub/category/10791.html)

2) Unsworth, C. A., Lovell, R. K., Terrington, N. S., & Thomas, S. A. (2005).

Review of tests contributing to the occupational therapy off-road driver
assessment. Australian Occupational Therapy Journal, 52(1), 57-74.

14
 CARDIOVASCULAR DISEASES

Sudden cardiac death while driving is uncommon. Statistics on non-fatal

cardiovascular events among drivers are not available but such events probably
do contribute to road traffic accidents.

Sudden cardiac deaths are unpredictable. About 50% of cases do not have a
history of heart disease. Medical examination of drivers will not totally eliminate
this problem but identification of the "high risk group" is important. These "high risk"
drivers include those liable to develop myocardial infarction, aortic aneurysmal
rupture or dissection, impairment of consciousness due to malignant cardiac
arrhythmia or heart block.

Vocational drivers who are eventually certified unfit to drive are usually assessed
by a cardiologist after a series of investigations which may include ECG, stress
test, echocardiography, Holter monitoring, electrophysiological studies, coronary
angiography or cardiac catheterisation.

The guidelines for Group 1 (Class 1, 2 and 3 licences) and for Group 2 (Class 4,
5 and vocational licences) are summarised in a tabulated form on the following
page. Guidelines for Group 2 licences are more stringent.

15
CARDIOVASCULAR GROUP1 GROUP2
DISORDERS (CLASS 1, 2 & 3 LICENCES) (CLASS 4, 5 &
VOCATIONAL LICENCES)

Angina Not fit until angina is Not fit until symptom-free

satisfactorily controlled. and the person is able
to complete the exercise
stress test to the required
standard*. Annual review
required. *(See Exercise
Stress Testing.)

Myocardial Not fit for at least one Not fit for at least 2 months.
Infarction month after episode. May return to driving only
if symptom-free and there
Coronary Artery are no other disqualifying
Bypass Graft conditions and patient is
able to complete exercise
Any Episodes of stress test to required
Unstable Angina standard*. Annual review
required. *(See Exercise
Stress Testing.)

Coronary At least 1 week off driving. Stop driving for at least

Angioplasty Resume driving if recovery 2 weeks. Resume only if
satisfactory. symptom-free and able to
complete exercise stress
test to required standard.
Those with coronary stents
should be observed for at
least 2 months and pass
an exercise stress test to
required standard*. Annual
review required. *(See
Exercise Stress Testing.)

Hypertension Driving may continue Temporarily unfit if casual

while blood pressure is systolic BP is 200 or more
being controlled unless and diastolic BP is 110 or
medication causes side more. Resume driving when
effects that will affect BP is stable and controlled
driving. and there are no side
effects to affect driving.

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CARDIOVASCULAR GROUP1 GROUP2
DISORDERS (CLASS 1, 2 & 3 LICENCES) (CLASS 4, 5 &
VOCATIONAL LICENCES)

Cardiac Arrhythmia Driving must cease if Recommend unfit if in the

Significant arrhythmia is liable to cause past 2 years arrhythmia
arrhythmias include: loss of consciousness. had caused impairment of
(a) Paroxysmal consciousness. If the
supraventricular Resume driving only after arrhythmia does not cause
tachycardia satisfactory control of such symptoms and there
including atrial symptoms. is no documented
flutter, atrial structural cardiac
fibrillation abnormality and applicant
(b) Paroxysmal can pass exercise stress
ventricular test to required standard*,
tachycardia applicant can be issued
(c) Heart block AV a licence. *(See Exercise
block -3°, Mobitz Stress Testing.)
Type 2 block
(d) Symptomatic sick
sinus syndrome

ECG Abnormality

Old infarcts Fit unless other disqualifying Must pass exercise stress
condition is present. test to required standard*.
*(See Exercise Stress
Testing.)

Left ventricular Fit unless other disqualifying Fit unless other disqualifying
hypertrophy condition is present. condition is present.

Left bundle branch Fit unless other disqualifying Fit unless other disqualifying
block condition present. condition is present.

Right bundle branch Fit unless other disqualifying May be ignored unless
block - partial or condition is present. associated with presence
complete of disqualifying condition.

Resting ST-T Fit unless other disqualifying Must be assessed for

abnormality condition is present. cause. Fitness depends on
absence of disqualifying
condition.

Pre-excitation Fit unless other disqualifying May be ignored unless

condition is present. associated with presence
of disqualifying condition.
(See Cardiac Arrhythmia.)

17
 CARDIOVASCULAR GROUP1 GROUP2
DISORDERS (CLASS 1, 2 & 3 (CLASS 4, 5 &
LICENCES) VOCATIONAL LICENCES)

Congenital Driving may continue if Fit if mild lesions not

Heart Disease no other disqualifying causing symptoms
condition. and there is no other
disqualifying condition.
Symptomatic congenital
heart disease should be
assessed for need for
surgery.

Complex disorders to be
considered individually for
fitness to drive.

Aortic Aneurysm Driving may continue Unfit. May resume driving

after satisfactory control after satisfactory repair and
of blood pressure. no evidence of myocardial
ischaemia is present.

Dissection of Aorta Unfit. Resume driving Unfit. May resume driving

after satisfactory after satisfactory recovery
recovery from successful from successful surgical
surgical repair. repair.

Cardiomyopathy May drive if no other Unfit except for mild cases

(dilated, hypertrophic disqualifying condition. of cardiomyopathy.
or restrictive)

Heart or Heart Lung May drive if no other Unfit.

Transplant disqualifying condition.

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 CARDIOVASCULAR GROUP1 GROUP2
DISORDERS (CLASS 1, 2 & 3 (CLASS 4, 5 &
LICENCES) VOCATIONAL LICENCES)

Peripheral Vascular May continue driving. Fit unless associated with

Disease symptomatic coronary artery
or cerebrovascular disease.

Pacemaker Insertion Resume driving if Recommend permanently

asymptomatic and no unfit. Exception - may be
disqualifying condition considered fit if simple AV
present. Patient should block and not pacemaker
be under regular review. dependent.

Simple Syncopal Attack Fit. Fit.

Postural Hypotension Fit. Fit.

Malignant Vasovagal Assess individually. Unfit.

Syndrome

Exercise Stress Not required. Applicant must safely

Testing complete at least 9
minutes of standard
Bruce treadmill protocol
or achieve at least 85% of
maximal predicted heart
rate if he can only manage
less than 9 minutes of
exercise. Applicant must
not develop angina or
ischaemic ECG response
(while off cardioactive
drugs for 24 hours).

19
CARDIOVASCULAR GUIDELINES FOR GROUP 2 LICENCES

1. ISCHAEMIC {CORONARY) HEART DISEASE

1.1 Angina

Persons with angina are not fit to drive.

They can resume driving only when they are free of angina and are
able to complete the exercise stress test to the required standard*.
*(See Exercise Stress Testing.)

1.2 lschaemic ECG Changes

Persons with abnormalities on the ECG such as Q waves or ST-T

changes should be investigated for cause and assessed for the risk
of myocardial infarction. They must pass an exercise stress test to the
required standard*. *(See Exercise Stress Testing.)

1.3 Myocardial Infarction, Coronary Bypass, Unstable Angina

Drivers must stop driving for 2 months. They can return to driving only
if symptom-free and are able to complete the exercise stress test to the
required standard*. *(See Exercise Stress Testing.)

1.4 Coronary Angioplasty

After a successful angioplasty, persons should stop driving for at least

2 weeks. They may resume driving only if symptom-free and are able
to complete the exercise stress test to the required standard*. Those
with coronary stents inserted should be observed for at least 2 months
before they can resume driving. They should be symptom-free and are
able to complete the exercise stress test to the required standard*. *(See
Exercise Stress Testing.)

Annual reviews are recommended for 1.1 to 1.4.

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2. HYPERTENSION

2.1 Persons with severe hypertension of 200/110 mm Hg and above should

stop driving until hypertension is controlled without any side-effects that
can affect driving.

2.2 Newly diagnosed hypertensives should be observed for 2 weeks while on

medication. Those who have side effects such as postural hypotension,
giddiness or drowsiness should be observed for a longer period.

3. HEART FAILURE

Persons with New York Heart Association Functional Class 3 and 4

heart failures should be certified permanently unfit in view of high annual
mortality rate. (For those with mild heart failure and are certified fit to drive,
annual reviews are essential.) Fitness for Class 1 and 2 heart failures is
subject to annual review. (See table below.)

New York Heart Association Functional Classification

Class I Patients with cardiac disease, but without resulting in limitation

of physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, dyspnoea or anginal pain.

Class II Patients with cardiac disease resulting in slight limitation of

physical activity. They are comfortable at rest. Ordinary activity
causes fatigue, palpitation, dyspnoea or anginal pain.

Class Ill Patients with marked limitation of physical activity. They are
comfortable at rest. Less than ordinary activity causes fatigue,
palpitation, dyspnoea or anginal pain.

Class IV Patients with cardiac disease resulting in inability to carry on any

physical activity without discomfort. Symptoms of heart failure
or anginal syndrome may be present even at rest. If any physical
activity is undertaken, discomfort is increased.

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4. VALVULAR HEART DISEASE

4.1 Asymptomatic persons with no ECG and chest X-ray abnormalities are
fit to drive.

4.2 Persons with mitral valve prolapse are fit to drive unless it is associated
with severe mitral regurgitation or significant cardiac arrhythmia. (See
Cardiac Arrhythmia.)

4.3 Persons with symptomatic valvular heart disease or have had heart
valve replacement with or without anticoagulant treatment are unfit if in
the past 5 years there is a history of:

• Cerebral ischaemia
• Embolism
• Significant arrhythmia (see Cardiac Arrhythmia)
• Heart failure
Otherwise, they can be certified fit subject to annual review.

5. CARDIAC ARRHYTHMIA

Persons with significant cardiac arrhythmia are unfit to drive. Significant

cardiac arrhythmias include the following:
• Paroxysmal ventricular tachycardia
• Untreated complete heart block or Mobitz Type 2 AV block
• Symptomatic sick sinus syndrome unless treated with pacemaker

Persons with paroxysmal supraventricular tachycardia (SVT), atrial flutter

or atrial fibrillation are allowed to drive if the arrhythmia is satisfactorily
controlled with ablation or drugs and there is no recurrence for at least 3
months.

6. ECG ABNORMALITY

6.1 Pathological Q Waves in 2 Leads or More

Such persons must pass an exercise stress test to the required standard*.
*(See Exercise Stress Testing.)

22
6.2 Left Ventricular Hypertrophy

Such persons should be assessed for aetiology. Fitness depends on

absence of disqualifying condition.

6.3 Left Bundle Branch Block

Investigations are required to determine the aetiology. Fitness to drive

depends on the absence of disqualifying condition.

6.4 Right Bundle Branch Block - Partial or Complete

Fitness depends on absence of disqualifying condition.

6.5 Resting ST-T Abnormality

Fitness depends on absence of disqualifying condition.

6.6 Pre-excitation

Wolff-Parkinson-White Syndrome is a disqualification if associated

with severe tachyarrhythmia not controlled by definitive therapy.

7. CONGENITAL HEART DISEASE

7.1 Persons with asymptomatic atrial or ventricular septal defects, pulmonary

stenosis or other congenital heart disease could be allowed to drive.

7.2 Persons with symptomatic congenital heart disease should be assessed

for need for surgical correction. Each case of congenital heart disease
has to be assessed individually for fitness to drive.

8. DISEASES OF AORTA

8.1 Aortic Aneurysm

Presence of an aortic aneurysm of diameter greater than 5cm is a

disqualification until after satisfactory repair.

23
8.2 Dissection of Aorta

Unfit to drive until satisfactory recovery from successful surgical repair.

9. CARDIOMYOPATHY - DILATED, HYPERTROPHIC OR RESTRICTIVE

Persons with cardiomyopathies should be certified unfit except for mild cases.

10. PERIPHERAL VASCULAR DISEASE

Fitness depends on absence of associated ischaemic heart disease

or cerebrovascular disease.

11. CARDIOMEGALY ON CHEST X-RAY

Drivers with cardiomegaly should be investigated for aetiology. Fitness

to drive depends on absence of disqualifying condition.

12. MALIGNANT VASOVAGAL SYNCOPE

Unfit to drive.

13. EXERCISE STRESS TESTING

Vocational and heavy goods vehicle drivers with suspected angina,

history of ischaemic heart disease, angioplasty, coronary artery bypass
or abnormal resting electrocardiogram suggestive of myocardial
ischaemia should undergo an exercise stress test.

Applicant must safely complete at least 9 minutes of standard Bruce

treadmill protocol or achieve at least 85% of maximal predicted heart
rate if less than 9 minutes of exercise is completed. Applicant must not
develop angina or ischaemic ECG response (while off cardioactive
drugs for 24 hours).

24
 MUSCULOSKELETALSYSTEM
GENERAL CONSIDERATIONS

For safe driving, a person must be able to control the vehicle, including in an
emergency. In general, he must also be able to carry out visual checks by looking
over his shoulder. Higher standards of fitness are required for driving large and
heavy vehicles like lorries and buses, and vehicles ferrying members of the public
like taxis and ambulances (i.e. Group 2).

The guidelines are summarised in a tabulated form below.

MUSCULOSKELETAL GROUP1 GROUP2

DISORDERS (CLASS 1, 2 & 3 (CLASS 4, 5 &
LICENCES) VOCATIONAL LICENCES)

Upper Limb Persons with amputation Persons must have full

Disorders of either hand or forearm painless movement of
below the elbow are fit if: both arms and hands.
• An adequate prosthesis
is fitted; and Persons with an
• The vehicle is equipped immobilised left hand
with automatic should not drive a manual
transmission; and transmission.
• They are able to drive
the vehicle safely (as After removal of the cast
demonstrated in a or splint, a minimum of 2
driving test). weeks is needed to allow
adequate return of upper
Persons with amputation limb function.
of the fingers are fit if:
• The vehicle is equipped All amputees should
with automatic obtain a doctor's
transmission; and clearance before driving.
• They are able to drive
the vehicle safely. To undergo DARP.

Persons with polyarthritis

of the upper limbs are fit if:
• The condition is mild;
and
• They are able to drive
the vehicle safely.

25
MUSCULOSKELETAL GROUP1 GROUP2
DISORDERS (CLASS 1, 2 & 3 (CLASS 4, 5 &
LICENCES) VOCATIONAL LICENCES)

Persons with weakness of

the upper limbs are fit if:
• The vehicle is
equipped with
automatic transmission;
• They have adequate
power and grasp to turn
the power steering and
manipulate the gears;
and
• They must have
adequate sensation.

Persons with a plaster

cast or splint should not
drive until the casUsplint is
removed.

Lower Limb Applicants with a below- Persons with an

Disorders knee amputation of one immobilised left leg
leg* are fit if: should not drive a manual
• An adequate prosthesis transmission.
is fitted; and
• The vehicle is equipped After removal of the cast
with automatic or splint, a minimum of 2
transmission; and weeks is needed to allow
• They are able to drive adequate return of lower
the vehicle safely limb function.
(as demonstrated in a
driving test). Persons with total joint
*(If the right leg is replacement on the right
amputated, the accelerator side need a minimum of
pedal will have to be 4 weeks before resuming
modified for use by the left driving (automatic
foot.) transmission).

26
MUSCULOSKELETAL GROUP1 GROUP2
DISORDERS {CLASS 1, 2 & 3 {CLASS 4, 5&
LICENCES) VOCATIONAL LICENCES)

Applicants with amputation All amputees should

of toes are fit if: obtain a doctor's
• They have adequate clearance before driving.
control of the foot pedals.

Applicants with arthritis of

the lower limbs are fit if:
• The condition is mild; and
• They are able to have
adequate reach and
power.

Applicants with weakness

of the lower limbs are fit if:
• The vehicle is equipped
with automatic
transmission;
• They have adequate
power in the lower
limbs to manipulate the
foot pedals; and
• They must have
adequate sensation.

Drivers with plaster casts

and splints should not
drive until the casVsplint is
removed.

27
MUSCULOSKELETAL GROUP1 GROUP2
DISORDERS (CLASS 1, 2 & 3 (CLASS 4, 5 &
LICENCES) VOCATIONAL LICENCES)

Spinal Disabilities Persons wearing a neck Persons with neck brace

brace or cast should not or cast should not drive
drive until satisfactory until satisfactory recovery
recovery and the and the brace/cast
brace/cast becomes becomes unnecessary.
unnecessary.
Persons with chronic low
Persons with marked backache and prolapsed
deformity of the spine or lumbar disc should not
painful restriction of drive.
movement should not
drive. Persons with spinal
injuries should obtain a
Persons with symptomatic doctor's clearance before
prolapsed lumbar disc driving.
should not drive. Persons
with chronic lower
backache can continue to
drive provided:
• They are able to drive
the vehicle safely; and
• The vehicle is
equipped with
automatic transmission
and power-assisted
brakes.

28
 NEUROLOGICAL DISORDERS

Under the current Road Traffic Act, persons suffering from epilepsy are not
allowed to drive. Such persons must declare their condition when applying for
a driving licence. Should they develop epilepsy after they have obtained their
licence, it is their duty to inform the authorities.

At present there is no statutory requirement for doctors to notify the Traffic Police
or Land Transport Authority should they come to know that their patients with
epilepsy continue to drive. Hospital-based doctors are usually the first to come in
contact with such patients. The Singapore Medical Council has stated that there is
no breach of medical confidentiality if doctors notify the authorities of the patient's
unfitness to drive if their driving will post a definite danger to the public.

The Committee has studied the literature on driving and epilepsy, in particular,
the guidelines issued by the Driving and Vehicle Licensing Agency of the United
Kingdom, and the Joint International Bureau of Epilepsy and International League
Against Epilepsy (IBE/ILAE).

The epilepsy guidelines recommended below cannot be implemented until

the Road Traffic Act has been amended and the prohibition on persons with
epilepsy has been relaxed to conform to the current opinion of epilepsy experts.
The Committee also recommends that persons with a history of epilepsy should
be certified fit to drive only by a neurologist.

NEUROLOGICAL GROUP1 GROUP2

DISORDERS (CLASS 1, 2 & 3 (CLASS 4, 5 &
LICENCES) VOCATIONAL LICENCES)

Seizures and Provoked single seizure Provoked single seizure

Epilepsy
Persons with a history When a single seizure, or
of a single seizure or a single seizure episode
seizure episode but have in which there are 2 or
remained seizure-free for more seizures during a
at least 1 year while off 24-hour period, occurs for
anti-epileptic drugs are the first time, it is essential
allowed to drive provided to establish the cause.
there is no evidence of When a clearly identifiable
cerebral abnormality and and reversible cause can
EEG is normal. be found, such persons
can resume driving only
after a seizure-free period
of at least 1 year, and the
EEG is normal.

29
NEUROLOGICAL GROUP1 GROUP2
DISORDERS (CLASS 1, 2 & 3 (CLASS 4, 5 &
LICENCES) VOCATIONAL LICENCES)

Uni;irovoked seizure(s) Uni;irovoked single seizure

& ei;iilei;isy (i.e. recurrent
Persons with a history of uni;irovoked seizures)
unprovoked seizure(s)
may be allowed to drive if: Persons with unprovoked
• The person has been single seizure of whatever
seizure-free for 3 years type with no identifiable
and off all anti-epileptic or reversible cause will be
drugs for at least 1 year; treated as having epilepsy.
• There is no structural Driving is banned until the
brain lesion; and person is seizure-free for
• There is no epileptiform a period of at least 10
abnormality on the EEG. years. Driving may
resume if the patient is
Sleei;i seizures off all anti-epileptic drugs
and when the following
Persons who only have conditions are met:
seizures while asleep or • There is no structural
immediately on awakening brain lesion;
are allowed to drive • There is no epileptiform
provided this pattern has abnormality on the
been consistent for at EEG; and
least 2 years. • Neurological
examination is normal.

History of febrile seizure

& benign focal ei;iilei;isy of
childhood

Persons with such history

are allowed to drive.

Sleei;i seizures

Persons who only have

seizures while asleep or
immediately on awakening
are regarded as having
recurrent seizures and
the recommendation for
recurrent unprovoked
seizures will apply.

30
Cerebra-vascular Stroke Stroke
Diseases
Patients without any residual Able to return to driving
disability may resume if all following conditions
driving after 1 month. are met:
• >1 year post-stroke
Patients with disabilities • Stroke is not due to
such as residual weakness, high-risk underlying
significant visual field defects, condition which is left
perceptual or mental untreated (e.g. high
impairment, in coordination, grade carotid stenosis,
etc, severe enough to untreated aneurysm)
interfere with control of the • Fully recovered
vehicle should not drive. • Passed DARP*
• Compliant with treatment
Patients with mild residual • Final clearance given
disabilities that may not by a neurologist
interfere with control of
the vehicle may undergo Transient lschaemic
DARP* >1 month after Attack {TIA)
stroke. They may be Able to return to driving
allowed to drive if they if all following conditions
pass DARP*, after final are met:
review by a neurologist.
• >6 months post-TIA
(for single TIA) or
Transient lschaemic >1 year post-TIA
Attack {TIA) (multiple TIAs or
brainstem TIA)
Single TIA: Allowed to
return to driving once free
• TIA is not due to high-
risk underlying
ofTIA for 1 month. condition which is left
untreated (e.g. high
Multiple TIA: Allowed to grade carotid stenosis)
return to driving once free
of TIA for 6 months.
• Compliant with treatment
• Final clearance given
by a neurologist
SAH / AVM / AneuQ£sms /
SDH/EDH SAH / AVM / Aneu0£sms /
SDH/EDH
Patients can only be
allowed to drive if they Patients can only be
have no residual deficits allowed to drive if they
and certified fit by a have no residual deficits
neurosurgeon on a case- and certified fit by a
neurosurgeon on a case-
by-case basis. by-case basis.

31
Traumatic Brain Minor or Mild TBI (admission
Injuries (TBI) GCS 13-15 with brief loss of
consciousness)

Able to return to driving

only after 1 month,
provided fully recovered
without residual cognitive,
physical or behavioural
deficits or seizures. If
incomplete recovery,
to have review by a
neurosurgeon first.

Moderate to Severe TBI

(admission GCS 3-12)

Able to return to driving

only after review by a
physician or neurosurgeon.
Referral to DARP* may
be considered if a patient
has made full recovery
with no residual physical,
cognitive or behavioural
deficits, dizziness or visual
impairment or presence
of cognitively impairing
medications.

Histoey of Alcohol Abuse or

Scar Epilepsy

Driving is not allowed.

NOTE: If in doubt, refer to

specialist or DARP*.

32
Chronic In this category of disorders are Parkinson's disease, muscular
Neurological dystrophy, myasthenia gravis, motor-neurone disease, organic
Disorders brain syndrome, multiple sclerosis, spinal cord disease, post-
Affecting poliomyelitis, etc. There is a wide range offunctional impairment
Coordination & and disabilities. Each case has to be assessed on its own and
Muscle Control a driving test may be necessary for applicants.

In general, if the applicant has weakness, lack of coordination,

involuntary movements or visual impairment of sufficient
degree to interfere with safe driving, then he should be
assessed unfit to drive.

Vertigo & In this group are Meniere's disease, labyrinthine disorders,

Sudden Attack brainstem disorders, etc.
of Disabling
Giddiness Stop driving upon diagnosis Stop driving until symptom-
until symptom-free for 3 free for 1 year.
months.

Unexplained Loss In this group are cases of loss of consciousness where no

of Consciousness cause can be found. Excluded are situational fainting, simple
vasovagal syncope, cough and micturition syncope and
malignant vasovagal syncope.

Stop driving until 1 year of Stop driving until 1 year of

freedom from attack. freedom from attack.

*DARP, or the Driving Assessment and Rehabilitation Programme, aims to

enable clients with medical conditions to learn or return to driving. For more
information, contact the Occupational Therapy Department in Tan Tock Seng
Hospital at telephone 6357 8338 or visit http://www.ttsh.com.sg

33
 VISION

Good vision is essential for the proper operation of a motor vehicle. Any marked
loss of visual acuity or narrowing of the horizontal visual fields will diminish a
person's ability to drive safely.

Visual acuity should be tested with a Snellen's Chart at 6 metres and in good
illumination. Spectacles and contact lenses are allowed. (If spectacles and/or
contact lenses are needed to improve visual acuity, this should be stated on the
licence. E.g. requires prescriptive lens for driving.) If corrective surgery has been
done, license needs to be updated.

GROUP 1 LICENCE

Class 1 to 3 driving licence holders (except taxis) should have visual acuity of at
least 6/12 in one eye. If the worse eye has a visual acuity of less than 6/36, or if the
person has monocular vision, his horizontal field of vision should be tested.

GROUP 2 LICENCE

Drivers of taxis, buses and vehicles like lorries and trucks should have visual
acuity of at least 6/12 in each eye.

HORIZONTAL FIELD OF VISION

It is unnecessary to test for this except in the case of a person who is "one-eyed",
i.e. with visual acuity less than 6/36 in the worse eye. Such persons must have
a horizontal field of at least 120°. They should only drive private vehicles. For
Group 2 licence, binocular vision is required.

The horizontal field is tested with both eyes open. If spectacles are needed, they
should be worn for the test. The test has to be measured with an instrument,
e.g. perimeter or synoptophore, and should preferably be performed by an
ophthalmologist.

34
COLOUR VISION

For all classes of driving, the driver should be able to identify red, green and
amber lights.

This can be tested by showing the person the standard red, green and amber
colours exhibited one at a time and in a random manner. (See colour chart on
page 2.)

VISUAL FIELD DEFECTS

Persons with significant visual field defects like homonymous hemianopia or

quadrantinopia are unfit to drive.

DIPLOPIA

Paralysis of the extraocular muscles giving rise to double vision would render
the person unfit to drive. But strabismus is not a bar to driving unless it is
accompanied by double vision.

NIGHT VISION

Night vision defect may cause difficulty with driving at night. But this condition
usually occurs only in mild degrees. Marked defect in night vision occurs in
disease like retinitis pigmentosa and advanced chorioretinitis and these
conditions should be regarded as a bar to driving.

EYE CONDITIONS WHICH REQUIRE ASSESSMENTS AT REGULAR

INTERVALS:

(a) High myopia (above 10.00 dioptres)

(b) Macular degeneration
(c) Cataract
(d) Glaucoma
(e) Diabetic retinopathy

Drivers with such eye diseases should be referred to an ophthalmologist for

treatment and follow-up.

35
 RESPIRATORY DISEASES

There are very few respiratory disorders which will preclude a person from driving
permanently. Temporary cessation of driving may be necessary for persons
with infectious pulmonary tuberculosis and are driving air-conditioned vehicles
ferrying passengers.

Persons in chronic respiratory failure or those with a tendency to develop syncope

or clouding of consciousness should not drive.

GROUP 1 LICENCE

See guidelines on items 3 to 6 for Group 2 licence.

GROUP 2 LICENCE

1. PULMONARY TUBERCULOSIS

Applicants whose chest X-ray shows abnormality suggestive of pulmonary

tuberculosis should be investigated for activity.

1.1 Inactive Pulmonary Tuberculosis

The chest X-ray may show scarring, calcification or granuloma. Those with
a past history of treated pulmonary tuberculosis and have old chest X-rays
for comparison may be passed fit if chest X-ray shows no significant change.

1.2 Active Pulmonary Tuberculosis

Persons with chest lesions suggestive of active pulmonary tuberculosis

require investigation and treatment. Those who are smear-positive or
symptomatic should stop driving as they may infect their passengers
especially in air-conditioned taxis, buses and coaches. The majority will
be rendered non-infectious after 2 to 3 weeks of adequate doses of
anti-tuberculous drugs unless they harbour multi-resistant organisms.

Medical certification for fitness to drive a taxi, bus or coach should be

delayed until the person is rendered non-infectious and is not functionally
impaired either because of advanced disease or complications in treatment.

After tuberculosis treatment has commenced, it is considered safe to

return to work after 3 weeks of treatment.

36
2. PULMONARY BULLAE

Large bulla besides causing functional respiratory impairment may cause

spontaneous pneumothorax. Such persons should be referred to a
respiratory physician for assessment and treatment after which they may
be assessed fit to drive.

3. SEVERE ASTHMA AND SEVERE CHRONIC OBSTRUCTIVE

AIRWAY DISEASE

It is recommended that drivers who are in chronic respiratory distress or

have frequent attacks of asthma should not drive. Those who have a
history of syncope during an attack are permanently unfit to drive.

4. SLEEP APNOEA SYNDROME

Drivers who suffer from excessive wake-time sleepiness should stop

driving and be referred to a physician trained in treating sleep-related
breathing disorders for treatment. Review for fitness can be undertaken
after the condition is adequately controlled.

5. COUGH SYNCOPE

Cough syncope usually follows a paroxysm of explosive and vigorous

coughing often associated with chronic lung disease or bronchitis.
Syncope is often brief. Such persons should not drive until attacks have
been successfully controlled.

6. CARCINOMA OF LUNG WITH GRAIN METASTASIS

Unfit in view of the possibility of fits. Reassess if treatment is successful

and brain scan shows no evidence of intracranial tumour after one year.
Annual reviews are advised.

37
 DIABETES MELLITUS & OTHER ENDOCRINE DISEASES

From the viewpoint of driving safely, problems due to diabetes may be classified
into two groups:

(a) Those acute metabolic disturbances that relate directly to control of blood
sugar. They may occur early in the course of the disease, particularly
during initiation of treatment. Hypoglycaemia is the most important as it
may rapidly impair the ability of an otherwise fully competent driver. It is a
risk associated with treating diabetic patients with oral anti-diabetic
agents (particularly insulin secretagogues) or insulin. The doctor should
discuss the prevention and recognition of hypoglycaemia with such patients.
The doctor should also discuss the appropriate responses to episodes,
which should include cessation of driving, self-treatment, seeking medical
help and ensuring that the hypoglycaemia is resolved before driving is
resumed. Discussion points should also include:

• The interaction between food, medication and activity;

• Having rapidly absorbable carbohydrate foods in the vehicle;
• Self monitoring of blood glucose where appropriate;
• Not skipping meals when there is an intention to drive;
• Ensuring that food is eaten after injections (prandial insulins) and/or
medication before driving.

(b) Those which result from later complications of diabetes, e.g. cataract or
retinopathy causing visual impairment, or neuropathy impairing the ability
to operate foot pedals. Assessment of the fitness of diabetics with late
complications should be based on the system affected.

38
GROUP 1 LICENCE

An insulin-controlled diabetic who is stabilised on treatment may drive a private

vehicle. Those who are unstable in their treatment (for whatever reason) may be
unfit.

GROUP 2 LICENCE

Drivers with diabetes should inform the doctor. A diabetic driver should ensure
that he is treated, and his condition should be stable before applying or renewing
the vocational license.

Doctors providing management should proactively manage the risks of these

drivers to help them achieve driving safety. Those who are suffering from serious
effects of hypoglycaemia, or are unstable in their treatment (for whatever reason)
are unfit.

OTHER ENDOCRINE DISEASES

Marked hyper or hypothyroidism may affect driving either as a direct consequence

of the disease or as a result of the complications. Drivers with the disease should
be satisfactorily treated before being allowed to drive.

39
 HEARING

GROUP 1 LICENCE

Drivers should be able to hear the sound of car horns in general. An aided
threshold of at least 50dB averaged over 250 and 500Hz, is acceptable.

GROUP 2 LICENCE

Bus and taxi drivers must be able to hear a passenger who wishes to speak to
them without having to take their eyes off the road by turning their heads. Heavy
goods vehicle drivers should be able to hear above the noise of the engine.
They should be able to respond to warnings when reversing their vehicles. A
driver carrying dangerous goods should be able to communicate, by telephone if
necessary, regarding handling of spillages or other emergencies.

For practical purposes, the ability to hear ordinary conversational speech at

about 1.5 metres would be acceptable. Hearing aids are allowed. Where an
applicant fails this simple screening test, the person may need assessment with
an audiometric examination. An aided threshold of at least 50dB averaged over
250 and 500Hz, is acceptable.

COGNITIVE DISORDERS (PROGRESSIVE)

DEMENTIA

Dementia results in a progressive decline in cognitive function that may affect

the ability of an afflicted person to drive safely. On the other hand, persons
with dementia may still be competent to drive in the earlier stages of disease.
Furthermore, driving is an important expression of independence, freedom and
mobility for older people. Driving licences should not be revoked therefore by
arbitrary decisions based solely on a driver's cognitive ability. A recent longitudinal
study reported that persons with mild Alzheimer's Disease (AD) remained safe
drivers for an average of 11 months, while those with very mild AD remained safe
drivers for an average of 1.7 years. 1 The issue of driving in dementia requires
therefore the balancing of individual freedom on one side versus public safety
on the other.

40
The judgement with respect to the ability to drive safely of a person with dementia
should only be made after a systematic and comprehensive assessment,
including practical testing. (See section on Simple Screening Instruments for
Clinic Settings for the Abbreviated Mental Test and Clock Drawing Task.) In
general, persons whom the physician is unsure if the diagnosis of cognitive
impairment might affect driving safety should be referred for further clinical and
driving assessment.

GROUP 1 LICENCE

Persons with moderate to advanced dementia should not be allowed to drive 1 •

Persons with mild dementia should be referred for a formal driving assessment.

(a) If deemed safe, they should be allowed to drive 1 ; in some instances,

restrictions such as driving only when accompanied, driving only during
daytime hours and not driving on expressways, may be recommended.

(b) They should be reassessed at least every 6 to 12 months depending on

the recommendations of the driving assessment. Families and caregivers
need to observe for any warning signs that may indicate unsafe driving.
Whenever there is a change in status noted, consideration should be
given for earlier formal driving assessment or in certain cases, cessation
of driving.

GROUP 2 LICENCE

Persons with dementia who exhibit behavioural disturbances that may pose a
danger to driving (such as aggression, inadequate impulse control, psychosis,
e.g. hallucinations, fluctuating consciousness) should be considered unsafe
for driving 2 • These persons should not drive vocationally or operate any heavy
goods vehicles.

References:

1. Ott BR, Heindel WC, Papandonatos GD, Festa EK, Davis JO, Daiei/a LA,
Morris JC. A longitudinal study of drivers with Alzheimer disease Neurology
2008; 70:1171-8.

2. Herrmann N, Rapoport MJ, Sambrook R, Hebert R, McCracken P, Robillard A,

for the Canadian Outcomes Study in Dementia (COSIO) Investigators.
Predictors of driving cessation in mild-to-moderate dementia. CMAJ 2006;
175(6):591-5.

41
 PSYCHIATRIC DISEASES

Psychiatric illness per se does not disqualify a person from driving. Persons with
psychiatric illness are fit to drive if all the following conditions are met:

• The psychiatric condition is stable, i.e. not in the acute phase.

• Functional cognitive impairment is assessed as minimal.
• The patient is compliant with treatment.
• The maintenance dose of medication does not cause noticeable sedation.
• The patient has insight to self-limit at times of a relapse and knows to
seek treatment promptly.
• The family is supportive of the patient driving.
• The patient does not have chronic behaviours which are incompatible
with safe driving, e.g. violence, aggression, suicidality.

Acute episodes of mental illness which may render a person temporarily unfit to
drive are as follows:

PSYCHOSIS

An acute episode of psychosis poses a substantial risk.

The most common cause of acute psychosis is schizophrenia. In this case, the
risks are greater if disordered thinking is related to motoring techniques or to
fellow motorists' "interference", or if patients are suicidal or suffer from delusions
of persecution.

In acute mania, elation, irritability, distractibility, grandiosity, indiscretion, poor

judgement and flight of ideas all pose hazards.

DEPRESSION

Severely depressed patients who are suicidal or have severe psychomotor

retardation or agitation or impaired concentration pose a risk.

42
ANXIETY DISORDERS

Severe, acute anxiety (including panic attacks) may interfere with concentration
or cause "freezing". Symptoms of doubt and indecision (also seen in severe
obsessive compulsive disorder) may also involve risk. Driver competency may
be adversely affected when in a state of stress or anxiety in excess of individual
norms.

SUBSTANCE ABUSE

Misuse of illicit drugs and alcohol is incompatible with safe driving.

ALCOHOL DEPENDENCY

Drinking and driving is one of the most serious of road safety problems, and
therefore, the doctor has the responsibility to identify those patients with an
alcohol problem who drive, and advise them on their medical fitness to drive.

MEDICATION

Patients who are currently taking medications known to have side effects that
can impair their reaction time and/or the ability to drive should be advised not to
drive until their individual response is known or the side effects no longer
result in impairment.

In addition, psychoactive prescription medications can potentiate the cognitive

impairment caused by alcohol (e.g. alcohol combined with antihistamines or
benzodiazepines). Combinations of psychoactive medications can give rise
to additive effects on cognitive impairment and thus reaction time. Patients
experiencing a withdrawal reaction from psychoactive or psychotropic
medications may be temporarily impaired in their driving ability and should be
advised to refrain from driving until the acute symptoms have abated.

43
General guidances on the use of psychoactive medications are as follows:
(Adapted from The ICADTS Working Group on Prescribing and Dispensing
Guidelines for Medicinal Drugs affecting Driving Performance 2001)

i. The use of some psychoactive drugs has been associated with an

increased risk of causing an injurious accident. Patients should receive
this information and receive the maximum benefit of this knowledge.
ii. Consider an alternative in the light of experimental research showing
large differences between the effects on driving performance of various
drugs within the same therapeutic class, e.g. antihistamines - older
(sedating) versus newer (non-sedating) generation.
iii. Start with the lowest doses. Whenever possible, avoid multiple dosing
throughout the day.
iv. Do not reflexively "double the dose" if patients fail to respond to
psychoactive medication.
v. Avoid prescribing different psychoactive medications in combination.
vi. Do not rely solely upon the manufacturers' advice for counselling patients
about the effects of the drug upon driving.
vii. Advise patients concerning the ways they can minimise the risk of
causing a traffic accident if it is impossible to avoid prescribing an
obviously impairing drug or one with unknown impairing potential. Involve
patient in a risk-benefit discussion before prescribing medications.
viii. Monitor the patient's driving experience with the drug.
ix. Patients should be warned of the additive effects of psychoactive
medications, especially when multiple psychoactive medications are
used, with that of alcohol on cognition.

The common classes of medication known to have such effects include, but are
not limited to, those in the list below.

1. Sedatives and hypnotics

These drugs impair psychomotor function and mental acuity, motor skills
and retards responses or reaction time. In particular, sedatives and
hypnotics, including benzodiazepines, are more likely to cause cognitive
impairment in individuals more than 65 years of age than in younger
individuals. Patients who are more heavily sedated for therapeutic
reasons should not drive. Concomitant use of alcohol with sedatives or
hypnotics further raises the risk of impairment.

2. Antidepressants and antipsychotics

Careful observation is advised during the initial phase of dose adjustment.
Patients should not drive if they experience drowsiness or sedation,
impairment in mental acuity or cognition, and/or orthostatic hypotension.

44
3. Antihistamines and anticholinergics
Drowsiness and dizziness are frequently encountered side effects of the
older-generation antihistamines. The newer "non-sedating" antihistamines
are considered safer but may still have a sedative effect on some patients.
Only Fexofenadine has been shown to have an absence of psychomotor
or cognitive function comparable to placebo. A close second alternative is
Loratadine.

Anticholinergics may cause sedation and delirium, especially in older

individuals. Patients who develop such side effects should not drive.

Patients using any of these medications for the first time must be warned
not to drive until it is determined whether they are prone to these side effects.

4. Anticonvulsants
Careful observation is advised during the initial phase of dose adjustment.
Anticonvulsant drugs can cause sedation, psychomotor retardation,
cognitive impairment and orthostatic hypotension in some patients. In
addition, patients should be advised of the risk of seizure activity and the
associated driving restrictions.

5. Antihypertensives
Antihypertensives can cause sedation, fatigue and orthostatic hypotension
particularly during the start of treatment. Patients using these drugs for
the first time must be cautioned regarding driving until treatment is
stabilised. Chronic use of anti hypertensives should not be a concern.

6. Antiarrhythmics
Class IA antiarrhythmics and Digoxin can cause sedation and drowsiness.
Caution is advised if newly-started or dosage has been recently increased.
In addition, patients who experience frequent syncope due to arrhythmias
should be thoroughly assessed for suitability of pacemaker implantation
by a cardiologist.

7. Opioids and Opiates

Euphoria, depression or inability to concentrate may follow with the use
of opioids or opiates, including codeine which is one of the constituents
commonly found in pain medication and cough syrups. Patients should
be warned about the potential sedation.

45
8. Oral antihyperglycemic agents and Insulins
Patients taking oral antihyperglycaemic agents and/or using any type of
insulins should be advised on the risks of potential hypoglycaemic events
and how to recognise and react should a hypoglycaemic event occur.
Frequent self-testing or monitoring may be warranted to ensure that
drivers who spend a long time on the road (e.g. taxi drivers) are not
experiencing hypoglycaemic unawareness especially in long-standing
diabetes. Patients who have this condition are unable to recognise signs
and symptoms of hypoglycaemia or these signs are absent or minimal.
Prolonged hypoglycaemia without treatment or intervention, especially
if severe, can result in serious sequelae, including loss of consciousness
and grand mal seizures.

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 APPENDIX 1

1. CLOCK DRAWING TEST

The Clock Drawing Test (CDT) assesses a patient's long-term and short-term
memory, visual perception, visual-spatial skills, selective attention, and executive
skills. Preliminary research indicates an association between specific scoring
elements of the clock drawing test and poor driving performance.

Administration

Give the patient a pencil and a blank sheet of paper.

Say this to the patient:

"I would like you to draw a clock on this sheet of paper. Please draw the face of
the clock, put in all the numbers, and set the time to ten minutes after eleven."

This is not a timed test, but the patient should be given a reasonable amount
of time to complete the drawing. The examiner scores the test by examining
the drawing for each of eight specific elements of the Freund Clock Scoring for
Driving Competency as follows:

PLEASE TICK "YES" OR "NO" TO THE FOLLOWING: YES NO

1) All 12 hours are placed in correct numeric order,

starting with 12 at the top.

2) Only the numbers 1-12 are included (no duplicates,

omissions, or foreign marks).

3) The numbers are drawn inside the clock circle.

4) The numbers are spaced equally or nearly equally

from each other.

5) The numbers are spaced equally or nearly equally

from the edge of the circle.

6) One clock hand correctly points to two o'clock.

7) The other hand correctly points to eleven o'clock.

8) There are only two clock hands.

47
Any incorrect element in the Freund Clock Scoring signals a need for intervention.
Clock drawing tests have been found to correlate significantly with traditional
cognitive measures, and to discriminate healthy older patients from ones with
dementia. The Freund Clock Scoring is based on eight "principal components"
that were derived by analysing the clock drawings of 88 drivers aged 65 and
older against their performance on a driving simulator. Errors on these principal
components were found to correlate significantly with specific hazardous driving
errors, signaling the need for formal driving evaluation.

If the patient's performance signals the need for interventions, it is suggested

that the physician can perform more detailed cognitive testing as needed, and
also to identify the cause of the cognitive decline.

It has been reported that the sensitivity and specificity of CDT is significantly
affected by low education. Many normal older persons find such a task to be
unfamiliar and culturally alien, thereby affecting the ability of the test to reflect
their true cognitive status. The use of CDT as a useful screening test may be
limited to older patients with higher literacy rates.

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2. ABBREVIATED MENTAL TEST (AMT)

The Abbreviated Mental Test (AMT) is a 10-item cognitive screening instrument

designed to identify cognitive impairment. In a validation study in 1991, a cut-off
score of 7 and below was found to optimally identify cognitive impairment. This
instrument has been validated locally with adjusted cut-offs established for age
and education (Sahadevan, Lim, Tan & Chan, 2000).

Administration

Record the patient's education level: _ _ years

Say this to the patient:

"Please remember the following phrase "37 Bukit Timah Road". I will be asking
you to repeat the phrase to me later."

Score
1) What is the present year? (western calendar e.g. 20__ )

2) What time is it now? (within 1 hour)

3) What is your age? (for Chinese, +1 year is acceptable)

4) What is your date of birth? (western year +/- month and day)

5) Where are we now?

6) What is your home address? (block, house, street)

7) Who is Singapore's present Prime Minister?

8) Show picture of nurse or doctor and ask "What is his/her job?"

9) Count backwards from 20 to 1.

10) Please recall the memory phrase.

Total

Scoring:

Dementia may be suspected if:

• Education 0-6 years and AMT score is 0-6
• Education more than 6 years and AMT score 0-8

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3. MODIFIED CHINESE MINI MENTAL STATUS EXAMINATION (MMSE)

The Mini Mental State Examination (MMSE) was originally designed to provide a
brief, standardised assessment of mental status that would serve to differentiate
between organic and functional disorders in psychiatric patients. Over the years, it
has become a widely used instrument to detect and track progression of cognitive
impairment associated with Alzheimer's Disease and other neurodegenerative
disorders. Although the Chinese MMSE is more cumbersome and requires more
time to complete, it is believed to be more useful than the AMT when testing
patients with more than 12 years of education or greater levels of literacy.

Maximum
Score Score
1a) What day of the week is it? 1
1b) What is the date today? 1
1c) What is the current month? 1
1d) What is the current year? 1
2) Where are we now? 1
3) What floor are we on? 1
4) In which estate are we? 1
5) In which country are we? 1
6) Repeat the following words: "lemon, key, balloon". 3
7) Subtract $7 from $100 and make 5 subtractions. 5
8) Can you recall the 3 words? 3
9) What is this? (Show a pencil.) 1
10) What is this? (Show a watch.) 1
11) Repeat the following:
English: "No ifs, ands or buts"
Chinese: "Forty-four stone lions" 1
12) Follow a 3-stage command: "Take this piece of
paper, fold it in half and put it on the floor." 3
13) Read and carry out the instruction written on this
piece of paper: "Raise your hands." 1
14) Copy this drawing (Overlapping Hexagons) on a
piece of paper. 1

Total 28

Modified Chinese MMSE: Optimal cut-off values adjusted for age and education

Years of Education 60 - 74 years old > or = 75 years old

0 - 6 years 20 I 21 18 / 19
>or= 6 years 23 / 24 22 I 23

50
 ACKNOWLEDGEMENT

The SMA Committee on Medical Guidelines on Fitness to Drive acknowledges

with grateful thanks the helpful advice and assistance of:

Dr Tan Hwee Huan, Department of Endocrinology, Khoo Teck Puat Hospital

Department of Epidemiology and Public Health, National University Hospital

Department of Geriatric Medicine, Tan Tock Seng Hospital

Department of Occupational Therapy, Tan Tock Seng Hospital

Department of Otolaryngology, Singapore General Hospital

Driving Assessment and Rehabilitation Programme

Institute of Mental Health

Land Transport Authority, Singapore

National Neuroscience Institute

Pharmaceutical Society of Singapore

Singapore Association of Occupational Therapists

Singapore Cardiac Society

Singapore National Eye Centre

Singapore Orthopaedic Association

Singapore Society of Otorhinolaryngology

Singapore Thoracic Society

Traffic Police Department

51
 COMMITTEE ON
MEDICAL GUIDELINES ON FITNESS TO DRIVE

Chairman

Dr Chong Yeh Woei

Vice-Chairman

Dr Tammy Chan

Members

Dr Lee Yik Voon

Dr Chan Kay Fei
Ms Florence Cheong
A/Prof Chin Jing Jih
Dr Chin Swee Aun
Dr Chong Mei Sian
Dr Karen Chua
Dr Andrew Dutton
Ms Irene Goh
Dr Heeyoune Jung
Dr Gwee Kok Peng
Ms Anna Koh
A/Prof Lee See Muah
ASP James Ng
Dr Richard Ng
Dr Francis Ngui
ASP Seow Ming Hsien
A/Prof Sum Chee Fang
Dr Nigel Tan
Ms Doreen Yeo

Ex-Officio

Dr Wong Chiang Yin (until April 2009)

Dr Abdul Razakjr Omar (until April 2011)
Dr Wong Tien Hua

Administrative Secretaries

Ms Krysania Tan (until August 2010)

Ms Adeline Chua (until May 2008)
Ms Gracia Ong (from June 2008)
Mr Lee Sze Yong (from October 2008)

52
BIBLIOGRAPHY

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J.F. Taylor (editor).
The Medical Commission on Accident Prevention, UK, 1995.

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Land Transport Division, New Zealand, 1990.

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F.C. Edwards, R. I. Mccallum and P. J. Taylor, 1988.

4. Fitness Standards for Ambulance Drivers.

St John Ambulance, UK, 1993.

5. Guidelines on Fitness to Drive.

Family Health Service, Ministry of Health, Singapore, 1993.

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Australian Medical Association (Queensland Branch), 1979.

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Federal Register (USA) revised 1983.

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G. Lau.
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Dr Alfred J. Kerwin
Canadian Medical Association Journal, 1984, 131 :312-314.

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Greg E. Larsen et. al. JAMA 1994, 271:1335-1339.

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Commission Drivers' Licensing. September 1992.

12. Health Assessment for Work -A Guide.

Australian College of Occupational Medicine.

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Postgraduate Medicine Journal, 1992, 68:624-628.

53