To screen or not to screen

Blog — by Dr Jo Scott-Jones

You may have seen recent headlines such as Routine cognitive tests on older drivers on the way out after NZTA review’[Hawkes Bay Today 12 August 2026] and Grey Power NZ asking members, "Please keep us informed if you do encounter GPs still insisting on a mandatory cognitive test with all senior drivers seeking to renew their driving licence". 

It is acknowledged there has long been an inconsistent approach to the issue of screening for cognitive impairment as part of an older person’s driver's licence medical examination.     

The review was commissioned by the NZ Transport Agency (NZTA) Waka Kotahi and the Office for Seniors to support health professionals in understanding the utility of cognitive assessment within the medical office-based driving assessment process. 

The report notes there is no universally accepted protocol for a general practice medical office-based driving assessment or for the use of cognitive tests in fitness to drive assessment. There is also no universally accepted cognitive test for the purpose of assessing fitness to drive. 

The RNZCGP has recently released guidance on implementing recommendations arising from the report.

What does this all mean for practices?

• For older people who are considered to be physically and mentally healthy, current evidence does not support the routine use of cognitive assessment as part of fitness to drive assessment.

• Global cognitive assessments (e.g. Montreal Cognitive Assessment (MoCA), MiniAddenbrooke’s Cognitive Examination (mini-ACE)), while giving an indication of general cognitive ability, do not accurately predict on-road driving performance.

• Trail Making Test (TMT), Maze assessment and reaction time tests are moderately associated with on-road driving performance. 

• When the assessor has concerns about cognitive ability, the Trail Making Test (TMT) could be an alternative to more global cognitive assessment tools, such as the Mini-Mental State Examination (MMSE), MoCA or Mini-ACE to reflect driving performance. Consideration of a test of reaction times may aid prediction of on-road driving safety. Trail Making Test administration and scoring references are available online.

• Recognising there is no perfect office-based test, if there is uncertainty of cognitive or functional ability to drive, an On Road Safety Test or, if appropriate, an Occupational Therapy Driving Assessment will add useful information.

Practices should note the RNZCGP recommendation that if there are concerns about possible cognitive impairment, initial screening should be with a recognised tool relevant to the patient (eg mini-ACE, MANA or RUDAS). If some impairment is detected, they should then consider using a test more relevant to driving performance (eg TMT).

Many practices are using registered nurses to either do the majority of a DLM or complete the whole process. This is fine, and a good use of the multidisciplinary team, but having a clear, documented process for escalation of any concerns to a GP / NP is an essential safety net.

We will all have patients who were found to have a degree of cognitive impairment on screening that was not suspected prior to administering the test, but cognitive testing is not part of any screening programme (when the pre-test probability is low). The tools we have are designed for case finding (when the pre-test probability is high).

Major international groups such as the US Preventive Services Task Force do not currently support routine screening for cognitive impairment, stating that the current evidence is insufficient to assess the balance of benefits and harms. The recommendation applies to community-dwelling adults aged 65 years and older without recognised signs or symptoms of cognitive impairment.

It is important that practices currently using routine cognitive screening as part of older patients’ driver’s licence medical examinations review the NZTA report and RNZCGP guidance, and consider their recommendations when updating practice policy.