✘- Must not drive

! - May continue to drive subject to medical advice and/or notifying DVLA

✓- May continue to drive and need not notify DVLA

Excessive sleepiness – including obstructive sleep apnoea syndrome

‘Excessive sleepiness’ having, or likely to have, an adverse effect on driving includes:

• obstructive sleep apnoea syndrome of any severity
• any other condition or medication that may cause excessive sleepiness
• see also guidance on primary/central hypersomnias, including narcolepsy

Legislation states that objective sleep study measurements for driving assessment purposes should use the apnoea-hypopnoea index (AHI). Recognising that not all sleep services use AHI, DVLA will accept results of equivalent objective tests.

The ‘Tiredness can kill’ leaflet (INF159) is for drivers concerned about excessive sleepiness.

	Group 1 car and motorcycle	Group 2 bus and lorry
Excessive sleepiness due to a medical condition (see relevant section) including mild obstructive sleep apnoea syndrome (AHI below 15) or medication	✘- Must not drive. Driving may resume only after satisfactory symptom control. If symptom control cannot be achieved in 3 months DVLA must be notified.	✘- Must not drive. Driving may resume only after satisfactory symptom control. If symptom control cannot be achieved in 3 months DVLA must be notified.
Excessive sleepiness due to obstructive sleep apnoea syndrome – moderate and severe: ■ AHI 15 to 29 (moderate) ■ AHI 30 or more (severe) on the apnoea-hypopnoea index or equivalent sleep study measure	✘- Must not drive and must notify DVLA. Subsequent licensing will require: ■ control of condition ■ improved sleepiness ■ treatment adherence DVLA will need medical confirmation of the above, and the driver must confirm review to be undertaken every 3 years at the minimum.	✘- Must not drive and must notify DVLA. Subsequent licensing will require: ■ control of condition ■ improved sleepiness ■ treatment adherence DVLA will need medical confirmation of the above, and the driver must confirm review to be undertaken annually at the minimum.
Excessive sleepiness due to suspected obstructive sleep apnoea syndrome	✘- Must not drive. Driving may resume only after satisfactory symptom control. If symptom control cannot be achieved in 3 months DVLA must be notified. See ‘Excessive sleepiness due to obstructive sleep apnoea syndrome’ above when diagnosis is confirmed.	✘- Must not drive. Driving may resume only after satisfactory symptom control. If symptom control cannot be achieved in 3 months DVLA must be notified. See ‘Excessive sleepiness due to obstructive sleep apnoea syndrome’ above when diagnosis is confirmed.

Profound deafness

	Group 1 car and motorcycle	Group 2 bus and lorry
	✓- May drive and need not notify DVLA.	! - Must be assessed but may not need to notify DVLA. For licensing, the paramount importance is placed on a proven ability to communicate in an emergency by: ■ speech or ■ suitable alternative, for example SMS text Inability is likely to result in a licence being refused or revoked.

Cancers – not covered in other chapterssections

	Group 1 car and motorcycle	Group 2 bus and lorry
In both driving groups, fitness to drive is affected by the risk of seizure. All cases of eye cancer must meet the minimum requirements for vision (Chapter 6)..	! - Must be assessed but may not need to notify DVLA. If there is a likelihood of cerebral metastasis and seizure, DVLA must be notified. There must be no significant complication relevant to driving, such as: ■ specific limb impairment, for example due to bone tumour, primary or secondary ■ general impairment, for example due to advanced malignancy producing symptoms such as general weakness or cachexia that affects driving The effects of any cancer treatment must also be considered – the generally debilitating effects of chemotherapy and radiotherapy in particular.	! - Must be assessed but may not need to notify DVLA. Licensing requires specific consideration of the likelihood of cerebral metastasis and seizure, and there must be no complications, such as: ■ specific limb impairment, for example due to bone tumour, primary or secondary ■ general impairment, for example due to advanced malignancy producing symptoms such as general weakness or cachexia that affects driving The effects of any cancer treatment must also be considered – the generally debilitating effects of chemotherapy and radiotherapy in particular.

HIV and Advanced HIV

Living with HIV and receiving treatment

If there has been no development of an illness affecting the brain, vision, or a physical disability which may impair the ability to drive, people with HIV may drive and do not need to inform DVLA of their condition.

People living with HIV with complications such as illness or requiring a hospital admission may be considered to have more advanced HIV.

People with advanced HIV do not need to inform DVLA unless they:

• have been advised by a medical professional that they must inform DVLA about a specific medical condition
• develop any medical condition that may impact their ability to drive (check relevant chapterssections in AFTD guidance)

In these situations, DVLA must be notified.

Age-related fitness to drive

Older age is not necessarily a barrier to driving.

• Functional ability, not chronological age is important in assessments.
• Multiple comorbidity should be recognised as becoming more likely with advancing age and considered when advising older drivers.
• Discontinuation of driving should be given consideration when an older person – or people around them – become aware of any combination of these potential age-related examples:
  • progressive loss of memory, impaired concentration and reaction time, or loss of confidence that may not be possible to regain.
• Physical frailty in itself would not necessarily restrict licensing, but assessment needs careful consideration of any potential impact on road safety.
• Age-related physical and mental changes vary greatly between individuals, though most will eventually affect driving.
• Professional judgement must determine what is acceptable decline and what is irreversible and/or a hazardous deterioration in health that may affect driving. Such decisions may require specialist opinion.

DVLA has doctors ready to provide guidance to healthcare professionals.

	Group 1 car and motorcycle	Group 2 bus and lorry
Older age	! - When drivers reach the age of 70, they must confirm to DVLA that they have no medical disability. Drivers over 70 receive a licence for 3 years after fitness to drive has been declared, to include satisfactory completion of medical questions in the application.	! - Bus and lorry drivers: ■ must make fresh licence applications every 5 years from the age of 45 ■ annually from the age of 65 Each application must be accompanied by medical confirmation of satisfactory fitness to drive.

Transplant – not covered in other chapterssections

	Group 1 car and motorcycle	Group 2 bus and lorry
	! - May drive and need not notify DVLA. Except: there must be no other, or underlying condition that requires any restriction or notification to DVLA.	! - May drive and need not notify DVLA. Except: there must be no other, or underlying condition that requires any restriction. Failing this, DVLA must be notified and may require individual assessment.

Device or implants – not covered in other chapterssections

	Group 1 car and motorcycle	Group 2 bus and lorry
	! - May drive and need not notify DVLA. Except: there must be no other, or underlying condition that requires any restriction or notification to DVLA.	! - May drive and need not notify DVLA. Except: there must be no other, or underlying condition that requires any restriction. Failing this, DVLA must be notified and may require individual assessment.

Cognitive decline or impairment after stroke or head injury

There is no single simple marker for the assessment of impaired cognitive function relevant to driving, although the satisfactory ability to manage day-to-day living could provide a yardstick of cognitive competence.

In-car, on-the-road assessments are an invaluable way of ensuring, in valid licence holders, there are no features liable to present a high risk to road safety, including these examples:

• visiospatial deficits, notable distractibility, impaired multi-task performance

The following are also important in showing there is no impairment likely to affect driving:

• adequate performance in reaction times, memory, concentration and confidence

Cognitive disability

	Group 1 car and motorcycle	Group 2 bus and lorry
	✘- Must not drive and must notify DVLA. Impairment of cognitive functioning is not usually compatible with the driving of these vehicles. Mild cognitive disability may be compatible with safe driving – individual assessment will be required.	✘- Must not drive and must notify DVLA. Impairment of cognitive functioning is not usually compatible with the driving of these vehicles. Mild cognitive disability may be compatible with safe driving – individual assessment will be required.

Driving after surgery

Evaluating the likely effects of postoperative recovery.

Notwithstanding any restrictions or requirements outlined in other chapterssections of this document,guidance, drivers do not need to notify DVLA of surgical recovery unless it is likely to affect driving and persist for more than 3 months.

Licence holders wishing to drive after surgery should establish with their own doctors when it would be safe to do so.

Any decision regarding returning to driving must take into account several issues, including:

• recovery from effects of procedure
• anaesthetic recovery from the effects of the procedure
• any distracting effect of pain
• analgesia-related impairments (sedation or cognitive impairment)
• other restrictions caused by the surgery, the underlying condition or any comorbidities

Drivers have the legal responsibility to remain in control of a vehicle at all times.

Drivers must ensure they remain covered by insurance to drive after surgery.

Temporary medical conditions

Drivers generally do not need to notify DVLA of conditions for which clinical advice has indicated less than 3 months of no driving.

If the judgement of the treating clinician is that DVLA needs to be notified, the healthcare professional should advise the patient to contact DVLA.

Such a judgement may be necessary for any of a range of conditions that may temporarily affect driving, including, but not limited to:

• postoperative recovery (see Driving after surgery)
• severe migraine
• limb injuries expected to show normal recovery
• pregnancy associated with fainting or light-headedness
• hyperemesis gravidarum
• hypertension of pregnancy
• recovery following Caesarean section
• deep vein thrombosis or pulmonary embolism

Fractures

A driver does not need to notify DVLA of the fact of a fracture, but if recovery post-fracture is prolonged for more than 3 months, the treating clinician should offer advice on a safe time to resume driving.

Medication effects

It is an offence to drive or attempt to drive while unfit because of alcohol and/or drug use – and driving laws do not distinguish between illegal and prescribed drugs.

Drivers taking prescribed drugs subject to the drug-driving legislation will need to be advised to carry confirmation that these were prescribed by a registered medical practitioner.

Some prescription and over-the-counter medicines can affect driving skills through drowsiness, impaired judgement and other effects.

Prescribers and dispensers should consider any risk of medications, single or combined, in terms of driving – and advise patients accordingly.

Without providing an exhaustive list, the following drug groups require consideration:

• benzodiazepines – these may cause sufficient sedation to make driving unsafe
• antidepressants – sedating tricyclics have a greater propensity to impair driving than SSRIs, which are less sedating. Advice for individual driving safety should be considered carefully for all antidepressants
• antipsychotics – many of these drugs will have some degree of sedating side effect via action on central dopaminergic receptors. Older drugs (chlorpromazine, for example) are highly sedating due to effects on cholinergic and histamine receptors. Newer drugs (olanzapine or quetiapine, for example) may also be sedating; others less so (risperidone, ziprasidone or aripiprazole, for example)
• opioids – cognitive performance may be reduced with these, especially at the start of use, but neuro-adaptation is established in most cases. Driving impairment is possible because of the persistent miotic effects of these drugs on vision

Also refer to Chapterpsychiatric 4disorders, psychiatricand disorders,drug or alcohol misuse and Chapterdependence.

Hepatic 5encephalopathy

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Overt hepatic encephalopathy (OHE)	✘- Must not drive and must notify DVLA. Licence will be refused or revoked. Licensing may be considered 6 months following recovery from OHE and would be dependant upon a report from a specialist consultant hepatologist.* A formal driving assessment may be necessary (see Appendix G,). Compliance drugwith the clinical advice and follow up is required. Any other relevant standards for fitness to drive are satisfied (for example, alcohol-use disorders or alcoholexcessive misusesleepiness).	✘- Must not drive and dependence. must notify DVLA. Licence will be refused or revoked. Licensing may be considered 6 months following recovery from OHE and would be dependant upon a report from a specialist consultant hepatologist.* A formal driving assessment will be necessary (see Appendix G). Compliance with the clinical advice and follow up is required. Any other relevant standards for fitness to drive are satisfied (for example, alcohol-use disorders or excessive sleepiness).
Minimal hepatic encephalopathy (MHE) Refers to people without overt episodes but diagnosed with MHE on psychometric or neuropsychiatric testing	! - May drive but must notify DVLA. It is difficult to assess driving ability in people with MHE. DVLA acknowledges that there are varied presentations and rates of progression, and the decision on licensing is usually based on medical reports. Licensing consideration would be dependent upon a report from a specialist consultant hepatologist.* A formal driving assessment may be necessary (see Appendix G). A licence may be issued subject to review. Compliance with clinical advice and follow up is required. Any other relevant standards for fitness to drive are satisfied (for example, alcohol-use disorders or excessive sleepiness). Considerations include: ■ reversed sleep-wake cycle, poor short-term memory, disorientation, and lack of insight and judgement almost certainly mean unfit to drive ■ disorders of attention causing impairment	✘ - Must not drive and must notify DVLA. It is difficult to assess driving ability in people with MHE. DVLA acknowledges that there are varied presentations and rates of progression, and the decision on licensing is usually based on medical reports. There is a significant risk of MHE progressing to OHE (see below). Licensing consideration would be dependent upon a report from a specialist consultant hepatologist.* A formal driving assessment will be necessary (see Appendix G). A licence may be issued subject to review. Compliance with clinical advice and follow up is required. Any other relevant standards for fitness to drive are satisfied (for example, alcohol-use disorders or excessive sleepiness). Considerations include: ■ reversed sleep-wake cycle, poor short-term memory, disorientation, and lack of insight and judgement would mean unfit to drive ■ disorders of attention causing impairment
Liver transplantation	✘- Must not drive and must notify DVLA. If undertaken following episode of OHE licence will be refused or revoked. Licensing may be considered 6 months following successful transplantation. Licensing will be dependent upon cognitive function and a report from a specialist consultant hepatologist.* A formal driving assessment may be necessary (see Appendix G). Any other relevant standards for fitness to drive are satisfied (for example, alcohol-use disorders or excessive sleepiness).	✘- Must not drive and must notify DVLA. If undertaken following episode of OHE licence will be refused or revoked. Licensing may be considered 6 months following successful transplantation. Licensing will be dependent upon cognitive function and a report from a specialist consultant hepatologist.* A formal driving assessment will be necessary (see Appendix G). Any other relevant standards for fitness to drive are satisfied (for example, alcohol-use disorders or excessive sleepiness).

• Specialist report to include both clinician support for return or continued driving and likely risk of future episode of OHE