to the editor: The recent article¹ that reviews the medical evaluation of the elderly for automobile driving provided information of practical value to primary care physicians; however, I would like to furnish additional sources of information that also may be of benefit to readers.

I agree with the author that individualized decisions are necessary in assessing the ability of patients with dementia to drive safely, notwithstanding a 1994 consensus conference conclusion that patients with moderate dementia are considered sufficiently impaired to preclude safe driving.² For forced cessation of driving, a particularly helpful document can be downloaded from the Alzheimer's Association Web site that describes steps to take away the car keys (http://www.alz.org).

The author also correctly points out that comorbid conditions in the elderly may have an effect on their ability to drive. When treating patients with comorbid conditions, primary care physicians can access several guidelines available in the literature. The American Medical Association released a guideline document in 1986, but it may be difficult to access because it is not widely available at medical libraries³; moreover, it has not been revised since its original publication. A more recent document is available from the Canadian Medical Association and can be downloaded from its Web site at http://www.cma.ca/cpgs/drivexam/index.htm.⁴ Many states in the United States also have their own medical criteria that can be obtained from the medical review section, division of driver's license, department of transportation. The Web site http://www.carbuyingtips.com/driver-licenses.htm serves as a portal to access 48 of the 50 Division of Motor Vehicles, State Department of Transportation's Web sites. These sites contain considerable information, and many of them also list important telephone numbers. As of this writing, Delaware and Oklahoma do not have corresponding Web sites.

It should be noted that the above guidelines represent expert opinions that are usually not supported by scientific data. Nonetheless, the availability and access of these guidelines allow primary care physicians to provide counseling using the most current information.

Finally, as Dr. Carr points out, in the United States, the legal responsibility of physicians to report medical conditions to the state authorities varies from state to state. I believe there is an urgent need to have uniform standards or driver's license requirements and guidelines for physicians to report medically unfit drivers. One mechanism for accomplishing this goal is to enact uniform laws that are adopted by the legislatures of all 50 states. Perhaps a federal commission can be created to bring about this change.

in reply: I appreciate Dr. Kakaiya's comments about additional resources that could be of benefit to readers. I would also add to these resources the nice summary in the Canadian Journal of Neurological Sciences¹ that addresses ethical issues.

Dr. Kakaiya also points out the difficult situation when many primary care physicians are faced with patients with comorbid conditions. Currently, the Association for the Advancement of Automotive Medicine has formulated a medical advisory steering group that will update medical standards for driving and hopefully be a resource for primary care physicians. I wholeheartedly agree that there is an urgent need to adopt uniform standards across the country. Nothing short of federal legislation would be required to accomplish this goal.