Lewis Morgenstern has made up his mind. When he turns 65 in four years, he’s going to sign an advance directive for driving.

The directive will say that when his children want him to stop getting behind the wheel, Morgenstern will follow their advice.

“I recognize that I might not be able to make the best decision about driving at a certain point, and I want to make it clear I trust my children to take over that responsibility,” said Morgenstern, a professor of neurology, neurosurgery, and emergency medicine at the University of Michigan.

His wife, 59, intends to sign a similar document at 65.

Morgenstern has given a lot of thought to the often-divisive issue of when to stop driving. He co-authored a recent article in the Journal of the American Geriatrics Society that found 61% of older adults with cognitive impairment continued to drive even though 36% of their caregivers were concerned about their performance.

Many of these seniors probably adapted by exercising caution and drawing on extensive experience behind the wheel, Morgenstern said. But, he noted, “there is undoubtedly a group of people who are driving and shouldn’t be because they’re a risk to themselves and to others.”

Relatively few studies have looked at how many older adults with mild cognitive impairment or dementia continue to drive, and there aren’t any national standards on when people should hand over the car keys. But the issue is a growing concern as the ranks of seniors in their 70s, 80s, and 90s — the age group most likely to have cognitive impairment — expand.

Nearly 50 million people 65 and older held driver’s licenses in 2021, a 38% increase from 2012, according to data compiled by the American Automobile Association. Almost 19 million were 75 or older, a rise of 31%. During this period, motor vehicle deaths for people 65 and older increased 34%, reaching 7,489 in 2021. The number of seniors injured in vehicle crashes that year exceeded 266,000.

For the most part, older adults drive safely. They use seat belts more often, are intoxicated less often, and are less likely to speed than younger adults. Compared with younger and middle-aged adults, they’re involved in fewer fatal car crashes each year. And they’re more likely to restrict where and when they drive — following familiar routes, avoiding heavily trafficked streets, and not driving at night.

Still, risks for older drivers rise with advancing age and the onset of medical conditions such as arthritis, glaucoma, and Parkinson’s disease. And when crashes occur, seniors are more likely to be severely injured or die because they’re more vulnerable physically.

Cognitive impairment and dementia pose especially worrisome challenges because decision-making, attention, judgment, and risk assessment are compromised in people with these conditions.

“This is a big challenge when it comes to driving, because people don’t react appropriately and self-regulate,” said Emmy Betz, a professor of emergency medicine at the University of Colorado School of Medicine who has studied advance driving directives.

This was the case for Morgenstern’s beloved father-in-law, who developed moderate Alzheimer’s disease in his 70s but remained convinced he was fit to drive. After he got badly lost one day, Morgenstern’s mother-in-law took away the car keys, and “he didn’t understand why. He was very unhappy,” Morgenstern said.

Morgenstern’s interest in advance directives for driving, an option he recommends in his paper, springs from this experience.

Several types of directives exist. One asks a person to name a family member or friend who will talk to them about whether it’s safe to continue driving. AAA and the American Occupational Therapy Association have endorsed a directive of this kind, which is not legally binding.

Obligations also run in the other direction, with family members agreeing to help the person explore ways to keep driving, if possible. If not, family members agree to help the person find other ways to get out and about by offering rides and helping them use public transportation, carpooling services, or volunteer-driver programs. Uber and Lyft, which have created programs for seniors, are newer options frequently used.

Another nonbinding directive, endorsed by the Alzheimer’s Association, recognizes that people with dementia will not be able to drive as their illness progresses. It, too, names people who should raise concerns about driving when it becomes important. But it goes further by stating: “I understand that I may forget that I cannot drive anymore and may try to continue driving. If this happens, please know that I support all actions taken, including removing or disabling my car, to help ensure my safety and the safety of others.”

At the University of South Florida Health, Lori Dee Grismore, an occupational therapist and certified driving rehabilitation specialist, said up to 75% of the seniors she evaluates have some type of cognitive impairment.

This becomes evident during the first part of Grismore’s comprehensive evaluation: an interview about the person’s driving habits and recent problems; a review of their medical history; a vision exam; a physical assessment; and a battery of six cognitive tests. “If someone doesn’t have insight, which is common, they don’t understand why these tests have anything to do with driving,” she told me.

If she thinks it’s safe, Grismore then takes older adults out on the road, checking their ability to follow directions, make turns, stay in their lanes, maintain appropriate speeds, and interpret signs, among other performance measures.

While most older adults with mild cognitive impairment pass these tests, Grismore usually recommends retesting at regular intervals and imposing restrictions such as driving only close to home and staying off highways. But she acknowledged there’s no guarantee seniors will remember these restrictions.

Grismore’s three-hour assessment costs $420. Medicare doesn’t pay — a barrier to seniors with low or fixed incomes. Older adults and families interested in finding a driving rehab provider can consult an American Occupational Therapy Association directory at https://myaota.aota.org/driver—search/.

Elin Schold Davis, who coordinates the Older Driver Initiative at the occupational therapy association, recommends getting an evaluation of this kind when someone is diagnosed with cognitive impairment or when family members begin to notice problems.

“We should all be planning for our changing transportation needs in our 70s, 80s, and 90s,” she said. “The hard part is that driving is associated with independence, and this is such an emotional issue. But the more people look ahead, the more choice and control they can have.”

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Steering Older Drivers to Resources

Many people with cognitive impairment continue to drive and don’t want to stop. There are no standards for when they should give up their car keys, but planning ahead is recommended. Here are some resources that offer guidance.

For basic information: Alzheimer’s Association: “Dementia and Driving” National Highway Traffic Safety Administration: “Driving and Alzheimer’s Disease”

Hitting the milestone: Healthwise: “Is It Time to Stop Driving?”

A conversation guide: The Hartford Center for Mature Market Excellence: “At the Crossroads: Family Conversations About Alzheimer’s Disease, Dementia and Driving.”

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(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)