Background Cognitive impairment caused by illness or injury, or neurodegeneration associated with ageing is likely to increase with an ageing population. There is a need for clear policy and practice in order to support the safe mobility of people with cognitive impairment.

Methods A narrative review of research evidence and current policy in the UK was conducted. This covered evidence on the road safety risk associated with cognitive impairments, research on screening tools and their effectiveness, and clinician’s knowledge of guidelines and their confidence in decision making.

Results The assessment of fitness to drive is problematic because there is little good evidence of the safety risk of those who drive with cognitive impairment partly because drivers self-regulate, taking themselves out of the system before they are at risk. Research evidence suggests that universal screening at a given age would not be cost effective because age is not a functional criterion given the variation of cognitive impairment caused by age related diseases in older people. Neuropsychological test batteries for other illnesses and injuries affecting the brain have shown inconsistent results and so their validity for clinical decision making remains questionable. There is a lack of confidence among clinicians about how to advise patients about fitness to drive and few specialist driving assessment centres for them to refer patients to.

Conclusions There needs to be more evidence on the safety risk of people driving with injury or illness affecting the brain. A standard care pathway would help to manage the safe mobility of people with cognitive impairment. A protocol for general practitioners and other health professionals is needed to guide how to discuss fitness to drive with their patients. Research is needed to develop a clinically viable desk based assessment of driving safety. Given the growing number of older drivers there is a need for more specialist driving assessment centres.