You hear it all the time: It’s an accident waiting to happen! The statistics are troubling and increasing each year. According to a recent article in AARP’s The Magazine, there are now more than 45 million U.S. citizens sixty-five years old and older, with that number estimated to reach 70 million by 2030. Currently, approximately 36 million older drivers still hold a drivers’ license (No Driver, No Problem, David Stanley, AARP The Magazine, Dec. 2014/Jan. 2015).
What is most startling is that about 80 percent of these older drivers live in “car-dependent” suburbs—not cities with public transit. Ninety percent of those older drivers say they don’t want to move, and their independent living is closely tied to their ability to drive safely (www.aarp.org/home-family/personal-technology/info-2014/google-self-driving-car.html).
But another insight to the problem is that more than 35,000 people were killed in automobile accidents in 2013—an overwhelming percentage at least partially due to human error (www.nsc.org/NewsDocuments/2014-Press-Release-Archive/2-12-2014-Traffic-Fatality-Report.pdf). Statistics for the elderly driver are troubling, as after age seventy the involvement in fatal crashes climbs sharply, and by age eighty the rates are the same as rookie teenagers, according to the Insurance Institute of Highway Safety. It is interesting that these rates would be worse if it were not for elders’ ability to self-regulate: no driving at night, shorter trips, and an ability to contract their lives (www.clark.wa.gov/sites/default/files/CHAPTER_3_TRANSPORTATION.pdf).
This may describe part of the problem, but it does not recognize the impact on the independence and potential quality of life for those who are disenfranchised from driving. Loss of vision and hearing can affect anyone, so it is important to note that the health of the driver is the focus, not the chronological age. Despite this, there may come a time in life when physical or mental frailties make it no longer possible for safe driving, constituting the voluntary surrender of one’s license appropriate. Even so, there are ways that this can be delayed, allowing for a prolonged period of safe driving. When the time comes to surrender a license, every effort should be made to provide alternative transportation that meets the individual’s needs.
The ever-increasing number of older drivers is caused by many factors. In addition to the general aging of the population occurring in all developed countries, many more females are driving into advanced age than have in the past. Furthermore, buoyed by the large ranks of baby boomers and increased life expectancy, the U.S. senior population is growing nearly twice as fast as the total population (Physician’s Guide to Assessing and Counseling Older Drivers, 1 NHTSA, www.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/Contents.html). Within this cohort of older adults, an increasing proportion will be licensed to drive. It is expected that these license-holders will drive more miles than older drivers do today.
In addition, the United States has become a highly mobile society, and older adults are using automobiles for volunteer activities, gainful employment, social and recreational needs, and cross-country travels. Recent studies suggest that older adults are driving more frequently, while transportation surveys reveal an increasing number of miles driven per year for each successive aging cohort (Physician’s Guide, 2). As the number of older drivers with medical conditions expands, however, patients and their families will increasingly turn to physicians for guidance on safe driving. Physicians will have the challenge of balancing their patients’ safety against their transportation needs and the safety of society.
Driving can be crucial for performing necessary chores and maintaining social connectedness, with the latter having strong correlations with mental and physical health (Physician’s Guide, 1). Many older adults continue to work past retirement age or engage in volunteer work or other organized activities. In most cases, driving is the preferred means of transportation, while in some rural and even suburban areas, driving may be the sole means of transportation. Reliance on driving as the sole available means of transportation can result in an unfortunate choice between poor options. In the case of dementia, drivers may lack the insight to realize they are unsafe to drive (Physician’s Guide, 3).
Just as the driver’s license is a symbol of independence for adolescents, the ability to continue driving may mean continued mobility and independence for older drivers, with great effects on their quality of life and self-esteem (Physician’s Guide, 2). Studies of driving cessation have noted increased social isolation, decreased out-of-home activities, and an increase in depressive symptoms. These outcomes have been well documented and represent some of the negative consequences of driving cessation. It is important for healthcare providers to use the available resources and professionals who can assist with transportation to allow their patients to maintain independence.
Micromanaging is crucial in prolonging elderly driving. Older drivers not only drive substantially less but also tend to modify when and how they drive. When they recognize loss of ability to see well after dark, many stop driving at night. There are data that suggest older women are more likely to self-regulate than men. Despite all these self-regulating measures, motor vehicle crash rates per mile driven begin to increase at age sixty-five (Physician’s Guide, 5).
Older driver crashes tend to be related to inattention or slowed speed of visual processing. They are often multiple-vehicle events that occur at intersections and involve left-hand turns. The crash is usually caused by the older driver’s failure to heed signs and grant the right-of-way. At intersections with traffic signals, left-hand turns are a particular problem for the older driver. At stop sign–controlled intersections, older drivers may not know when to turn (Physician’s Guide, 3–4). These driving behaviors indicate that visual, cognitive, and motor factors may affect the ability to drive in older adults. It is believed that further improvements in traffic safety will likely result from improving driving performance or modifying driving behavior (Physician’s Guide, 4).
Although older drivers believe that they should be the ones to make the final decision about driving, they also agree that their physicians should advise them. In many cases, physicians can keep their patients on the road longer by identifying and managing diseases, such as cataracts and arthritis, or by discontinuing sedating medications (Physician’s Guide, 4).
Physicians must abide by state reporting laws (see www.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/Chapter8.html). While the final determination of an individual’s ability to drive lies with the driver licensing authority (DMV), physicians can assist with this determination. Driving licensing regulations and reporting laws for older drivers vary greatly by state. Some state laws are vague and open to interpretation; therefore, it is important for physicians to be aware of their responsibilities for reporting unsafe patients to the local driver licensing authority (Physician’s Guide, 4).
Thus, physicians can play a more active role in preventing motor vehicle crashes by assessing their patients for medical fitness to drive, recommending safe driving practices, referring patients to driver rehabilitation specialists, advising or recommending driving restrictions, and referring patients to state authorities when appropriate (Physician’s Guide, 4).
A Growing Public Health Issue
Motor vehicle injuries are the leading cause of injury-related deaths among those sixty-five to seventy-four year olds, and are the second leading cause among those seventy-five to eighty-four-year-olds. By age eighty, male and female drivers are respectively 4 and 3.1 times more likely than twenty-year-olds to die as a result of a motor vehicle crash (Physician’s Guide, 5).
Age-related changes in vision, cognition, and motor ability may affect an individual’s ability to enter/egress a motor vehicle with ease, access critical driver information, and handle a motor vehicle safely (Physician’s Guide, 190). We encourage vehicle manufacturers to explore and implement enhancements in vehicle design that address and compensate for these physiological changes.
In particular, vehicle designs based on the anthropometric parameters of older persons—that is, their physical dimensions, strength, and range of motion—may be optimal for entry/egress; seating safety and comfort; seat belt/restraining systems; and placement and configuration of displays, mirrors, and controls. Improvements in headlamp lighting to enhance nighttime visibility and reduce glare, as well as the use of high-contrast legible fonts and symbols for in-vehicle displays may help compensate for age-related changes in vision. In addition, prominent analog gauges may be easier to see and interpret than small digital devices. Computers have revolutionized the motor vehicle industry by managing airbag safety systems, anti-lock brakes, and global positioning systems. In-vehicle assessment tools to assess for high-risk conditions may be developed in the future (Physician’s Guide, 190).
In terms of road and traffic engineering, the Federal Highway Administration (FHWA) has recognized and addressed the needs of older road users in its “Highway Design Handbook for Older Drivers and Pedestrians,” a supplement to existing standards and guidelines in the areas of highway geometry, operations, and traffic control devices. This handbook explains deficits older drivers may have both physically and mentally, and offers suggestions on how best to design or alter existing roadways for the betterment of older drivers.
Alterations made to roadways that benefit all drivers, not just those who are older, have been shown to improve the lives of drivers. Recent positive news is a trend in reduction of highway deaths for the first time since 1992, which in part has been attributed to installation of median guard cables on busy highways, building better roads, and the addition of rumble strips to the shoulders of roads. The FHWA handbook will soon be updated to incorporate the latest research on the effectiveness of design and engineering enhancement to accommodate older road users.
The problem facing older drivers is the challenge—we must allow our seniors to drive as long as it is safe, but no longer, and continue to develop affordable alternatives that minimize the impact of the loss of freedom, independence, and mobility that driving has provided to individuals. Further discussion of the problem as well as proposed solutions and alternatives will be discussed in the ensuing articles.