Go to your Nvidia control panel. Under "3D settings" click "Adjust image settings with preview" Now make sure "Let the 3D application decide" is checked.
I use to have horrible slow downs outside in the wasteland. Especially in populated areas like the Crimson Caravan Company. This trick increased performance by 100%.
Using the "advanced 3D image setting" or using the falloutNV nvidia profile brings back the horrible lag.
my Nvidia card
Geforce 9800 GT
Sorry, but I'm calling placebo. Mainly because your 'fix' involves using the "driver settings for dummies" option in the nvidia control panel. If you do a google search for nvidia control panel driver options and actually put some time to read in what each manual option is capable of doing then you will be smart enough to manually adjust profiles to suit each game you play. It's not rocket science, it is actually quite simple to navigate. Here, I'll make it easy:
Ambient Occlusion only works in a few select games and enhances shadow detail but can cause artifacts. Best left off
Anisotropic filtering should be application controlled unless the application has no controls. Otherwise crank it up to 16x, the performance trade off is negligible even on weaker modern cards in most cases
AA gamma correction only works with opengl, turn it off or leave it on since even in open gl games there is no performance hit
if the game has built-in AA (like NV) leave AA mode at enhance and no matter what level it is at in game, choose whatever level (ex- 4x) you want here
Transparency AA at the very basic turn on at mulisampling. the SS options decrease performance depending on your setup
Ignore Cuda for NV
leave max pre rendered frames at 3
change multi display to single display perf. mode
change power management to perfer max perf
leaave the next few settings at their default except if using AF above or in game, change the negative LOD to clamp. If you want the best texture filtering with no optimizations, change it to high quality. quality plus at least anisotropic sample optimizations is default and relatively good. Triple buffering only effects opengl games here and vsync doesn't matter since NV enables by default. Use d3doverrider to turn on d3d triple buffering