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Medical aspects of fitness to drive – A guide for health practitioners

This guide is to assist health practitioners in assessing the fitness to drive of any individual. It also sets out the responsibilities and obligations of health practitioners.

2. Neurological and related conditions

This section covers:

Summary table

The table below summarises the information outlined in this section. It does not describe any tests that may be necessary before some individuals can return to driving. Practitioners should ensure that they are familiar with the guidance outlined in the entire section rather than relying solely on the table.

The recommended minimum stand-down periods from driving and guidelines only apply where an individual's medical condition has been adequately treated and stability has been achieved so that road safety is unlikely to be compromised.

Medical conditionClass 1 or class 6 licence and/or a D, F, R, T or W endorsement (see appendix 3)Class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement
Severe disabling giddiness, vertigo, or Meniére’s disease Should not drive until sufficiently treated. Same as private classes.
Blackout or fainting of known cause Should not drive until cause of the blackout has been identified and treated appropriately to reduce the risk of future blackouts. Any medical condition(s) identified should be treated having regard to the relevant sections of these guidelines. Same as private classes.
Blackout or fainting of unknown cause Same as tonic clonic epilepsy. Same as tonic clonic epilepsy.
Epilepsy - tonic clonic Should not drive for 12 months. This may be reduced to a minimum of six months by The Agency subject to a supporting neurologist report (see section 2.4.1). Individuals who have more than one seizure-related crash should be seizure free for five years, with or without medication, before being considered fit to resume driving. Should not drive. However, the Agency may consider granting a licence to individuals who have been seizure free for five years and are not on any medication to control seizures.
Minor epilepsy and aura Same as tonic clonic epilepsy. Same as tonic clonic epilepsy.
Solitary seizure, (where epilepsy has not been established) Same as tonic clonic epilepsy. Same as tonic clonic epilepsy.
Sleep epilepsy Considered the same as other forms of epilepsy except if, over a minimum period of three years, an individual with sleep epilepsy has seizures only during sleep, they may be able to drive. Should not drive. The Agency may allow a licence to be granted in some circumstances (see section 2.4.4).
Cerebrovascular accident Should not drive until clinical recovery is complete with no significant residual disability likely to compromise safety. This should not be less than one month. Should not drive. Under some circumstances, the Agency may consider requests to resume driving from current licence holders (see section 2.6).
Myoclonus Individuals with features suggestive of epilepsy, or myoclonus jerks that can affect their ability to drive safely, should not drive. Same as private classes.
Transient ischaemic attacks (TIA) Should not drive for at least one month for a single TIA. Individuals with multiple TIAs may return to driving after three months provided the condition has been adequately investigated and treated. Should not drive for at least six months for a single TIA. Individuals who have multiple TIAs should not drive. However, the Agency may consider granting a licence where sound reasons to do so exist.
Neuromuscular disorders (including Parkinsonism, multiple sclerosis and motor neurone disease) Driving should cease where there is doubt of an individual's ability to control a vehicle in an emergency or other situation in which rapid responses may be needed. Should not drive. The Agency may consider granting a licence where sound reasons to do so exist, eg there is very minor muscular weakness and no other significant impairment.
Dementia and other cognitive impairments Should not drive where cognitive impairments may affect an individual's ability to drive safely. Should not drive.
Non-cerebral tumours Individuals who have pituitary tumours that are removed through a craniotomy should not drive for a minimum period of six months. For other situations, driving can resume once there is a satisfactory recovery and there is no impairment that may affect an individual's ability to drive safely. Individuals who have pituitary tumours that are removed through a craniotomy should not drive for a minimum period of 12 months. For other situations, driving can resume once there is a satisfactory recovery and there is no impairment that may affect an individual's ability to drive safely.
Cerebral tumours Should not drive for a minimum period of 12 months following successful surgery or other forms of treatment. Should not drive.
Structural intracranial lesions, including cerebral abscess, arteriovenous malformations and intracranial aneurysms Should not drive until a specialist assessment permits a return to driving. Individuals who have a craniotomy should not drive for at least six months. Should not drive until a specialist assessment permits a return to driving.
Minor head injuries Should not drive for at least three hours. In cases where loss of consciousness occurs, driving should not resume for 24 hours. Same as private classes.
Serious head injuries and structural intracranial lesions Should not drive for a minimum of six months. The return to driving will depend on the type of serious head injury and the potential to affect ability to drive safely. Should not drive for at least 12 months depending on the type of serious head injury and the potential to affect the ability to drive. A neurologist assessment will be necessary before driving can resume.

Introduction

Neurological conditions or suspected neurological conditions are a major cause of medical-related crashes in New Zealand. From police crash reports, between 2003 and 2007, 533 crashes involved a driver who either had an epileptic seizure (116 crashes) or blacked out (417 crashes). Another 10 crashes were suspected of being caused by a driver who had or was suspected of having a neurological condition. These figures do not estimate the likely numbers of drivers with neurological conditions such as dementia, as these are often reported as an age-related factor. There are likely to be drivers who had a neurological condition that the Police were not aware of.

Driving a motor vehicle requires the ability to perform precise, complex actions in response to an environment that is continually changing. Any disease process or substance (such as a medicine or recreational drug) that affects perception, judgement, alertness and responsiveness or the ability to carry out the necessary actions required to control a vehicle will impair an individual's fitness to drive.

Individuals with progressive conditions are likely to pose a greater risk unless the condition is closely monitored in relation to the ability to drive a vehicle safely. Static conditions and those that are reversible generally pose less of a problem, and mobility may often be an important consideration for such individuals. The issue in these cases is simply one of an individual's ability to drive safely. In these circumstances, the testing officer may well be a better arbiter of fitness to drive.

2.1 Severe disabling giddiness, vertigo or Meniére’s disease

Meniére’s disease, labyrinthine disorders and brain stem conditions may induce significant distracting giddiness. Where the attacks of giddiness are sufficiently disabling that they may impair an individual's ability to drive safely, the individual should be advised not to drive until their condition has been sufficiently treated.

Vertigo occurs for many reasons, most of which are due to inner ear disturbances. The most common form of paroxysmal relatively disabling vertigo is benign paroxysmal positional vertigo, which can occur in relation to head movement. Some individuals may feel sufficiently disabled by their vertigo that they should not drive, while others who have attacks are able to pull over to the side of the road.

There is no general prohibition on driving with vertigo except where the attacks of vertigo are sudden, or unpredictable, and are sufficiently disabling that they may impair an individual's ability to drive safely, eg where an individual is unable to concentrate on driving because of disabling giddiness.

General advice to medical practitioners

Where an individual is subject to attacks of disabling giddiness, medical practitioners should discuss with their patients the potential seriousness of their attacks on their driving. For example, individuals who suffer attacks where there are some warning signs should be advised to pull over to the side of the road if this is safe to do so, rather than try to continue driving during the attack.

Medical standards for all licence classes and/or endorsement types

Where the attacks of giddiness or vertigo are sufficiently disabling that they may impair an individual's ability to drive safely, the individual should be advised not to drive until it has been sufficiently treated.

2.2 Blackouts of unknown cause (excluding individuals with epilepsy)

This section deals with blackouts where the cause is unknown or cannot be established sufficiently to determine the risk of future events. It does not include individuals with epilepsy who have a blackout.

Between 2003 and 2007, 417 medical-related crashes were caused by a driver having a blackout. This is more than three times the number of crashes where an epileptic seizure was the cause of a crash. Because of the significant road safety risk, individuals who suffer a blackout of unknown cause are treated the same as an individual who has epilepsy.

We recognise that sometimes there are blackouts that cannot be explained. However, unless there is evidence that the risk of future blackouts is low (eg from a suitable observation period or through specialist investigation), the individual should be treated as if they have tonic clonic epilepsy.

The Agency may consider cases where a medical practitioner does not believe the requirements for tonic clonic epilepsy are appropriate for an individual who has a blackout of unknown cause. A request should be made to the Chief Medical Adviser and accompanied by a supporting report from an appropriate specialist.

Medical standards for all licence classes and/or endorsement types

The above conditions should be treated in the same way as tonic clonic epilepsy as far as fitness for driving is concerned, unless a cause can be established.

2.3 Blackouts of known cause (excluding individuals with epilepsy)

Episodes of transient loss of consciousness may occur in conditions other than epilepsy, eg arrhythmias, reduced cardiac output, carotid sinus syncope and certain peripheral nervous system disorders. Blackouts arising from cerebral ischaemia (transient ischaemia attacks

TIAs) or from irregularities of cardiac rhythm are treated separately under the appropriate headings. Guidance in relation to individuals who experience syncope is outlined in section 3Cardiovascular conditions(external link).

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

Individuals with sudden, unpredictable or unheralded attacks of loss of consciousness should not drive. The principal guidance is that driving should cease until:

  • the cause of the blackout has been determined, and
  • the cause has been successfully treated to minimise the potential for future blackouts, and
  • any guidance in this booklet relating to the condition that caused the blackout has been considered.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Normally, these licence classes and licence endorsements are not granted to applicants or licence holders with conditions that cause blackouts unless the cause has been identified and treated to minimise the risk of future blackouts.

When driving may resume or may occur

The Agency may consider allowing an individual who already holds such licence classes/endorsements to resume driving after six months provided that:

  • the cause of the blackout has been determined, and
  • the cause has been successfully treated to minimise the potential for future blackouts, and
  • any guidance in this booklet relating to the condition that caused the blackout has been considered, and
  • a full neurological investigation has been undertaken.

Any requests should be made to the Chief Medical Adviser and accompanied by a supporting report from an appropriate specialist.

2.4 Epilepsy

2.4.1 Tonic clonic epilepsy

Having an epileptic seizure while driving can place the driver and other road users at risk. In view of the risks to road safety, medical practitioners should notify the Agency of any individual who continues to drive while still having seizures (see section 1.4(external link)). Epilepsy does not, of itself, preclude holding a licence to drive a private motor vehicle nor does a period of uncontrolled epilepsy automatically mean a permanent ban from driving. The diagnosis of epilepsy in commercial drivers will generally result in them being considered permanently unfit to drive.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

Driving should cease if:

  • an individual is having seizures or has had a seizure in the last 12 months (although there may be exceptions to this requirement, which are discussed below)
  • an individual who requires medication to prevent seizures does not comply with medical advice about taking their medication, or undertakes activities, such as drinking in excess, that can increase the risks of having a seizure or seizures.

When driving may resume or may occur

A period of 12 months free from seizures is normally required before an individual is allowed to drive again or is allowed to obtain a driver licence. The Agency may reduce this period to six months if:

  • a favourable specialist report indicates that the likelihood of further seizures is minimal
  • there are favourable modifiers, such as seizures having occurred during medically directed medication changes, seizures secondary to acute metabolic or toxic states not likely to recur, seizures associated with reversible acute illness.

The existence of unfavourable modifiers will, in most cases, preclude any shortening of the required 12-month seizure-free period. Unfavourable modifiers include:

  • non-compliance with medication or appointments and/or evidence of lack of credibility
  • alcohol and/or drug abuse within the previous 12 months
  • previous poor driving records and/or seizure-related crashes in the past five years
  • the presence of a structural brain lesion or non-correctable brain or metabolic condition.

A request to be allowed to resume driving less than 12 months after the last seizure should be made to the Chief Medical Adviser and should be accompanied by a supporting report from a neurologist.

Individuals who have more than one seizure-related crash should be considered using the guidance for the commercial classes and endorsements for tonic clonic epilepsy, except that they can take medication to control seizures during the five-year period they are seizure free.

During any period of withdrawal of treatment, for whatever reason, there should be a minimum period of six months without seizures before resuming driving.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Generally, any individuals with these licence classes or endorsements suffering from epilepsy are normally considered permanently unfit to hold a commercial licence and should not drive under these licence classes or endorsement types.

When driving may resume or may occur

The Agency may consider granting a licence for these classes or endorsements where:

  • an individual has been seizure free for five years without taking any anti-seizure medication
  • a neurologist's opinion supports the application.

A request should be made to the Chief Medical Adviser and accompanied by a supporting report from a neurologist.

2.4.2 A solitary seizure (where epilepsy has not been established)

There is evidence that individuals who have a single seizure and who have not had a diagnosis of epilepsy established have a high risk of having further seizures in the future. Therefore, the treatment of a solitary seizure where the cause of the seizure is unknown is the same as for tonic clonic epilepsy.

There may be exceptional circumstances where an individual has a single seizure associated with a clearly identified and non-recurring provoking cause, eg where medication given for another condition has provoked a seizure and the medication is discontinued. In such cases, a request should be made to the Chief Medical Adviser, accompanied by a supporting report from a neurologist and information on the provoking cause of the seizure.

Seizures after a head injury are discussed under section 2.10.3(external link).

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

Same requirements as for tonic clonic epilepsy. See section 2.4.1(external link).

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

Same requirements as for tonic clonic epilepsy. See section 2.4.1(external link).

2.4.3 Minor epilepsy and aura

The term epilepsy includes minor seizures such as absence attacks, myoclonic seizures (see section 2.5(external link) and simple and complex partial seizures. In general, these forms of epilepsy are just as liable to be disabling and lead to potentially dangerous situations as tonic clonic epilepsy. A further complication in such conditions is that individuals suffering absence attacks (blank spells) may be unaware that such attacks are occurring, which may make any history from an individual unreliable.

Ask individuals who deny the recurrence of attacks whether there have been any symptoms suggestive of minor epilepsy, such as the occurrence of an aura. We also advise you obtain confirmation from a family member. An aura, even if not accompanied by loss or impairment of consciousness, should be considered to be a partial epileptic attack and their occurrence should be considered to constitute uncontrolled epilepsy.

Medical standards for all licence classes and/or endorsement types

The above conditions should be treated in the same way as tonic clonic epilepsy as far as fitness for driving is concerned.

2.4.4 Sleep epilepsy

Seizures occurring during sleep should be considered in the same manner as tonic clonic epilepsy in terms of fitness to drive, except where an individual has an established pattern of seizures occurring only during sleep, or upon waking, and who is completely free from seizures when awake.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

An individual with sleep epilepsy who has seizures while awake (seizures upon waking not included) should be treated the same as for tonic clonic epilepsy.

When driving may resume or may occur

An individual may resume driving if they do not have seizures when awake for 12 months and have an established pattern of seizures of at least 3 years that occur only during sleep or upon waking.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Any individuals with these licence classes or endorsements suffering from sleep epilepsy are normally considered permanently unfit to hold a commercial licence.

When driving may resume or may occur

The Agency may consider granting a licence for these classes or endorsements where:

  • an individual has only had seizures during sleep or upon waking for five years and no other seizures have occurred, and
  • a neurologist's opinion supports the application.

A request should be made to the Chief Medical Adviser, accompanied by a supporting report from a neurologist.

2.5 Myoclonus

Myoclonus associated with degenerative brain disease, post-anoxic or metabolic encephalopathies, sleep myoclonus and spinal myoclonus are not regarded as epilepsy, and therefore are not treated the same way.

Medical standards for all licence classes and/or endorsement types

When driving should cease

Individuals with myoclonus that has features suggestive of epilepsy, or where the myoclonus jerk(s) may impair driving, should be treated the same way as for tonic clonic epilepsy.

When driving may resume or may occur

Individuals with myoclonus may be allowed to drive provided that no other features are suggestive of epilepsy, and the jerky movements are not likely to make driving unsafe. Some individuals may require an occupational therapist's driving assessment.

2.6 Cerebrovascular disease

This group of conditions includes strokes arising from occlusive vascular disease (cerebral thrombosis), spontaneous intracerebral haemorrhage and transient ischaemic attacks. People who have suffered strokes are at increased risk of a second attack that may render them unconscious or incapable of handling a motor vehicle. The residual effects of stroke in terms of hemiplegia or other neurological sequelae such as perceptual and visual problems, as well as effects on cognition, are often sufficient to render an individual unfit to drive. Transient ischaemic attacks may also render an individual unconscious or unable to control a vehicle.

2.6.1 Cerebrovascular accident (CVA)

Where there is doubt about fitness to drive in terms of residual disability in any area, a driving assessment by an occupational therapist trained to provide off-road and/or on-road assessments should be undertaken.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

An individual should not drive until clinical recovery is complete, with no significant residual disability likely to compromise safety. However, this period should not be less than one month from the event.

Individuals with the presence of homonymous hemianopia are generally considered permanently unfit to drive. The presence of other disorders such as ataxia, vertigo and diplopia will also generally make individuals permanently unfit to drive unless there is a full level of functional recovery.

The presence of epilepsy-associated significant cardiovascular disorders and recurrent transient ischaemic attacks following a stroke will generally result in individuals being considered unfit to drive.

When driving may resume or may occur

Driving may resume when there has been satisfactory clinical recovery, providing that there is no residual limb disability that cannot be accommodated by appropriate vehicle modifications, and there is no evidence of cerebral damage resulting in cognitive defects, reduced reaction times, perceptual difficulties and visual problems such as homonymous field defects and/or hemispatial neglect.

Individuals are generally considered unfit to drive where there is the presence of epilepsy, associated significant cardiovascular disorders and recurrent transient ischaemic attacks following a stroke. In exceptional circumstances, the Agency may consider granting a licence after 12 months if a supporting specialist physician or neurologist's report is provided with the application. If licences are granted, the Agency may impose licence conditions for regular medical assessment of fitness to drive.

We strongly advise that, wherever there is doubt about fitness to drive in terms of cognitive or physical defects, an occupational therapist with training in driving assessment should make a full assessment. In many cases, it may be possible to allow a return to driving after suitable vehicle modifications have been made.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Licences are generally not granted to applicants with a history of cerebrovascular accident. Individuals who have suffered from a cerebrovascular event are generally considered permanently unfit to drive unless sound reasons exist for a less stringent approach. The presence of secondary epilepsy will generally result in individuals being considered permanently unfit to drive.

When driving may resume or may occur

Under some circumstances, a licence may be granted with conditions to existing holders of these classes and/or endorsement types. If there has been a full and complete recovery with no suggestion of recurrence over a period of three years, the possibility of a return to driving may be considered by the Agency (via the Chief Medical Adviser). A supporting specialist physician or neurologist's report will be required.

2.6.2 Transient ischaemic attacks (TIAs)

Transient ischaemic attacks are relatively common in older people. Their onset may induce unconsciousness, confusion, sudden vertigo and interference with limb function, which will cause difficulty in controlling a vehicle and make driving unsafe. Always consider the possibility of such attacks being due to cardiac dysrhythmias.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

Individuals should be warned not to drive for a period of at least one month following a single attack. Individuals with recurrent or frequent attacks should not drive until the condition has been satisfactorily controlled, with no further recurrence for at least three months.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Driving should cease for at least six months following a single attack, subject to the cause being identified and satisfactorily treated and a specialist medical assessment being carried out.

Individuals should not drive if they have multiple transient ischaemic attacks that impair consciousness or awareness, cause vertigo or cause visual disturbances. Licences will generally not be issued to applicants with a history of transient ischaemic attacks.

When driving may resume or may occur

The Agency may consider applications from individuals who have had multiple transient ischaemic attacks 12 months after the last attack if an appropriate specialist report supports such an application. If a licence is granted, conditions may be imposed that require the individual to be subject to regular medical assessment.

2.6.3 Amaurosis fugax

The conditions applying to transient ischaemic attacks will apply to this condition. It may, however, be possible to consider licence applications following a single episode, providing that no cardiac, vascular or haematological disease has been demonstrated.

2.7 Progressive neurological disorders (including Parkinsonism, multiple sclerosis and motor neurone disease)

All forms of severe neuromuscular disease will affect an individual's ability to control a motor vehicle safely as a result of weakness, stiffness, slowed responses and incoordination. In addition, multiple sclerosis may also cause visual problems, vertigo and sensory loss that will further complicate the picture. Medical practitioners should check for limb strength, accuracy of rapid foot movements and joint proprioception.

Medical practitioners should also be alert to cognitive impairments that may coexist with conditions such as Parkinson's disease.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

Driving should cease in all cases in which there is any doubt about an individual's ability to control a vehicle in an emergency or other situation in which rapid responses may be needed. If an individual has difficulty walking, they may also be unfit to drive.

When driving may resume or may occur

In the early stages of these conditions, it will often be possible to drive effectively, but there will inevitably come a time when driving is no longer safe. The medical practitioner will often have to make a difficult decision in these circumstances, perhaps aided by a relevant specialist. Assessments from occupational therapists with training in driver assessment, as well as practical driving tests, will often be required before making a final decision on fitness to drive.

An additional problem is that, in conditions such as multiple sclerosis, there is a variable and intermittent progression with periods of significant remission. It may be necessary to limit individuals from driving at certain periods and allow them to drive only during periods of remission.

Licence conditions may include regular reassessments, such as an annual medical report.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Individuals with these conditions should not drive.

Where driving may resume or may occur

Individuals with very minor muscular weakness may drive if they have a full assessment, including off-road and on-road assessments of driving skills, that shows that they can drive safely. Regular reassessments may be required as a condition of holding a licence.

A further exception may be made in cases of drug-induced Parkinsonism, provided that an individual is likely to make a full recovery on cessation of treatment and provided that the reason for the therapy is not a cause of exclusion in its own right.

2.8 Dementia and other cognitive impairments

A wide range of organic brain disorders result in varying degrees of dementia, demonstrated in memory loss, impaired cognition, disturbances of mood and behaviour and periods of confusion. The most common forms in the general population are likely to be those associated with increasing age, such as the results of multiple brain infarcts and Alzheimer's disease. These conditions may occur, however, in relatively young people. Cognitive impairment associated with alcohol abuse or chronic solvent exposure (whether from abuse or from occupational exposures) is not uncommon. Various other forms of dementia or cognitive impairment may also exist.

It is difficult to assess such cases as there is no single marker that will act as a determinant of fitness to drive a motor vehicle and it may often be very difficult to determine fitness to drive in the early stages of such conditions in which there is little more than mild memory impairment. Appendix 5(external link) contains a quick test using road signs that may highlight if an individual has problems in this area. In all these conditions, dangerous errors of judgement are possible. A full assessment of driving skills with an occupational therapist trained in driving assessment will often be a valuable way of determining whether an individual may continue to drive a motor vehicle. The family medical practitioner will have an important part to play in coordinating the assessment process.

Cognitive problems frequently represent a difficult situation for the medical practitioner, especially in regard to patient compliance. The issue of driving preferably should be raised at the early stages of such conditions, when an individual has sufficient cognitive and reasoning ability to make decisions about their driving future, such as selling their vehicle. It will often be necessary to enlist the early help of the family to ensure that an individual does not drive.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

Driving may be permitted in cases of early dementia, provided that the medical practitioner is satisfied that there is no significant loss of insight or judgement and an individual does not show signs of disorientation or confusion. Standard tests of cognitive function should be used in assessment. Where the medical practitioner is not in a position to undertake formal testing, individuals should be referred to a geriatrician, psychogeriatrician or other suitable specialist for further assessment.

When driving may resume or may occur

A driving assessment with an occupational therapist is recommended in all cases where there is some doubt about driving ability, especially should family members have concerns. The Agency is likely to place a condition on an individual's licence that regular medical assessment is required.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Individuals with confirmed dementia or cognitive impairment from whatever cause should not drive.

2.9 Intracranial tumours

Individuals with an intracranial tumour can show dangerous errors of judgement. A full assessment of driving skills with an occupational therapist trained in driving assessment will often be a valuable way of determining whether an individual should continue to drive.

2.9.1 Non-cerebral tumours

This group of tumours includes such conditions as acoustic neuroma, meningiomas of the posterior fossa and pituitary tumours. Adequate treatment of these conditions is not usually associated with problems likely to impinge on driving capabilities, other than visual field defects associated with pituitary tumours. In these circumstances, the guidelines in section 6(external link) should be considered.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

Problems may occur with individuals who have had pituitary tumours removed through a craniotomy. Individuals should not drive for a minimum period of six months.

When driving may resume or may occur

In other non-cerebral tumour situations, including transphenoidal pituitary surgery, driving may resume as soon as there has been satisfactory recovery, provided that there are no residual disabling symptoms. Regular medical follow-up is advisable.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Individuals who have had pituitary tumours removed through a craniotomy should not drive for a minimum period of 12 months.

When driving may resume or may occur

In other situations, including transphenoidal pituitary surgery, driving may resume as soon as there has been satisfactory recovery, provided that there are no residual disabling symptoms. Regular medical follow-up is advisable. The Agency is likely to place a condition on an individual's licence that regular medical assessment is required.

2.9.2 Cerebral tumours

Cerebral tumours, whether benign or malignant, carry a significant risk of associated epilepsy, both before and after surgery. For this reason, restrictions will generally be applied. In addition, associated motor or sensory dysfunction and visual defects may coexist, which could affect the safety of driving.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

Once such a condition has been diagnosed, driving should cease for a minimum of 12 months. In advanced malignant tumours (such as Grade 3 or 4 gliomas) or in cases of cerebral secondary tumours (eg from lung cancer), driving should cease for a minimum period of three years following treatment, depending on circumstances.

When driving may resume or may occur

Driving may resume 12 months after surgery or other forms of treatment if there is no evidence of epileptiform seizures or other problems likely to affect an individual's ability to drive safety.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Individuals with such conditions are generally considered unfit to drive.

When driving may resume or may occur

Individuals who had a tumour diagnosed in childhood and who have survived to adulthood without recurrence and with no significant functional deficits may be able to drive. In such cases, the Agency may consider a licence application on the basis of a satisfactory medical assessment, usually including an appropriate specialist report.

2.10 Structural intracranial lesions and head injuries

2.10.1 Structural intracranial lesions - cerebral abscess, arteriovenous malformations and intracranial aneurysms

Conditions such as cerebral abscess, arteriovenous malformations and intracranial aneurysms pose risks for driving. The major risks are in respect of epilepsy, particularly with cerebral abscess, and also spontaneous bleeding in the case of untreated arteriovenous malformations and aneurysms. Damage to the brain is also a possibility arising from intracranial bleeding and/or compression as well as from surgical treatment. Functional deficits may therefore require assessment.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

Driving should cease for a minimum period of six months following a craniotomy for intracerebral lesions, depending on the circumstances and the range of post-traumatic problems. All individuals who have conditions such as cerebral abscess, arteriovenous malformations, intracranial aneurysms or structural intracranial lesions should stop driving until the medical practitioner permits a return to driving.

When driving may resume or may occur

A full neurological assessment and an occupational therapist's assessment may be necessary before considering whether an individual is fit to resume driving. An on-road driving test will often be required if there are post-traumatic or post-surgical functional deficits. Visual assessment will also be necessary to ensure the absence of any significant visual field defects. Frontal lobe injuries may present particular difficulties in assessment. Licences may be subject to the requirement of regular medical assessments.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Individuals with intracranial lesions such as aneurysms, arteriovenous malformations and cerebral abscess would normally be considered permanently unfit to drive because of the risks of epilepsy and further bleeds.

2.10.2 Minor head injuries

Medical standards for all licence classes and/or endorsement types

A minor head injury should not impair driving ability for more than a few hours. An individual who sustains a minor head injury without loss of consciousness or any other complication should not drive for three hours. An individual who sustains a minor head injury but does lose consciousness should not drive for 24 hours and should have a medical assessment before returning to driving.

An extension of the recommended periods that an individual should refrain from driving may be necessary if an individual exhibits loss of good judgement, decreased intellectual capacity, post-traumatic seizures, visual impairment or loss of motor skills. They should not be allowed to drive until cleared as fit to drive by a medical practitioner, having referred to the appropriate section of this guide.

2.10.3 Serious or significant head injuries

Serious head injuries, such as acute intracerebral haematoma requiring surgery or compound depressed fracture or dural tear or with more than 24 hours of post-traumatic amnesia, present a number of problems with respect to driving safety.

Serious head injuries carry a risk of post-traumatic epilepsy, which is much more common after penetrating (open) head injuries, particularly with dural penetration, injuries complicated by intradural (not subdural) haemorrhage and depressed fractures of the cranial vault. In addition, associated post-injury cognitive and behavioural problems may make it unsafe for an individual to drive, and post-traumatic physical disabilities may make driving difficult or require vehicle modifications.

It is imperative that all cases are fully and properly assessed before there is any suggestion of a return to driving. Most individuals with severe head injuries, including those with post-concussion syndrome, should not drive within six months of the event, and a return to driving should be subject to medical practitioner assessment.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

When driving should cease

Driving should cease for a minimum period of six months following severe head injuries, depending on the circumstances and the range of post-traumatic problems. The existence of post-traumatic epilepsy will require the application of the same rules as for tonic clonic epilepsy. The only exception is the occurrence of immediate seizures (normally in the first 24 hours after injury) that are considered part of the acute process.

When driving may resume or may occur

A full neurological assessment and occupational therapist's assessment may be necessary before considering whether an individual is fit to resume driving. An on-road driving test will often be required if there are post-traumatic or post-surgical functional deficits. Visual assessment will also be necessary to ensure the absence of any significant visual field defects. Frontal lobe injuries may present particular difficulties in assessment, and a neuropsychological assessment should be considered.

Occupational therapist's assessments may also be required in respect of vehicle modifications or other driving aids that may be needed. Licences may be subject to the requirement of regular medical assessments.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Driving should cease for a minimum period of 12 months following severe head injuries, depending on the circumstances and the range of post-traumatic problems.

The existence of post-traumatic epilepsy will require the application of the same rules as for tonic clonic epilepsy. The only exception is the occurrence of immediate seizures (normally in the first 24 hours after injury) that are considered part of the acute process.

When driving may resume or may occur

Most severe head injuries will result in the driver being considered unfit to drive. Individuals with severe head injuries may drive after a minimum period of 12 months, provided there has been adequate evidence of a recovery sufficient to allow for safe driving relative to an individual's occupation. A specialist neurological assessment is required. In addition, an occupational therapist's assessment is recommended.

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