Transportation mobility is the modes of movement of individuals from one place to another for purposes of meeting personal, social, employment or recreational needs and desires. Transportation mobility is important to the well being of older adults. Driving is an important component of transportation mobility. Yet, aging and age-related condition places older adults at increased risk of injury and death from automobile accidents.
A substantial proportion of the older population in the United States and Canada continue to drive into their eighth and ninth decades of life (Chipman, Payne & McDonough, 1998; Jette & Branch, 1992). A majority of these older drivers feel that driving is "vitally important" to their well being (Coughlin & Straight, 1998). For example, in many areas of North America, the ability to drive is essential for grocery shopping and obtaining health care. In addition, the maintenance of social, family, and community relationships is fostered by being able to drive. Also, driving may help in warding off the stigma of an old-age identity by helping older adults maintain a sense that they may be old, but not that old, because they still drive (Persson, 1993). Driving an automobile is a source of independence, freedom, socialization, and self esteem for manv older individuals.
Unfortunately, the older driver is at increased risk for death and injury because of motor vehicle collisions. The leading cause of accidental death for older individuals is a car crash (National Highway Traffic Safety Administration [NHTSA], 1999). In 1998, people age 70 and older accounted for 9% of the U.S. population, but accounted for 14% of all traffic fatalities. Drivers 85 years old or older are 9 times as likely to die in a crash than are drivers 26 to 69 years old (NHTSA, 1998). They are also likely to suffer more serious injuries.
These higher mortality and morbidity rates of those older than age 85 are caused by increased fragility. Although older drivers account for a lower proportion of motor vehicle collisions than any other age group, older drivers have a much higher incidence of mishaps per mile driven and a much higher rate of fatality (NHTSA, 1993). By 2020, approximately 22 million people older than age 75 will be eligible for a driver's license and 7 million of these individuals will be age 85 or older (American Association of Motor Vehicle Administrators, 1998). As the U.S. population ages, more individuals will be at risk.
The purpose of this article is to examine the age-related physiologic changes and health conditions affecting older adult driving performance. Older adult driving behavior will also be discussed. Guidelines for decreasing risk while maintaining transportation mobility will be offered.
CONDITIONS AFFECTING DRIVING
Age-Related Physiologic Changes
Three broad categories of age-related physiologic changes that may effect driving are visual, cognitive or psychomotor, and muscular skeletal function. Ninety percent to 95% of the information input used during driving is visual (Hills, 1980; Laux ¿5c Brelsford, 1990). Age-related visual changes that affect driving are visual processing speed, dim illumination, dynamic vision (i.e., the ability to see moving objects), near vision, and visual search (i.e., the ability to find what one is looking for in a cluttered scene). Being "surprised" by other vehicles when merging and the unexpected appearance of vehicles in their peripheral vision are related to visual changes. In addition, problems in seeing the instrument panel at night and in dealing with haze and sun-caused glare on the windshield are caused by changes in vision. Lastly, older drivers have problems reading signs in time for an appropriate driving response (Kline et al., 1992).
A combination of visual- and cognitive-processing domains, known as useful field of view (UFOV), is reduced with aging. The UFOV includes visual sensory function (i.e., acuity and contrast visual sensitivity), visual processing speed, and divided and selective attention (Marottoli et al., 1998; Sims, Owsley, Allman, Ball & Smoot, 1998). With decreased UFOV, older individuals experience difficulty in judging their own speed. Other vehicles are viewed as moving too fast (Kline et al., 1992).
Cognitive changes, which may affect driving, include distraction by irrelevant stimuli, decline in spatial orientation, decreased visual searching, and decreased visuomotor integration (Laux & Brelsford, 1990). More time is required to process available visual information by the older driver. Psychomotor slowing is a common experience of aging. After a movement is initiated, the older individual takes longer to execute the activity (Graca, 1986; Stelmach & Nahom, 1992). Consequently, older drivers may have trouble with situations requiring quick decision-making. Older individuals drive slower than younger drivers. The slower speed, however, may be a compensatory action for age-related psychomotor limitation (Perryman & Fitten, 1996).
Changes in muscular skeletal function such as decreased strength and flexibility may affect driving ability. Age-related changes in height, grip strength, and neck flexibility are correlated with driver performance (Laux & Brelsford, 1990). Joint flexibility is found somewhat predictive of driving skills (McPherson, Ostrow & Shaffron, 1989). After reviewing the results of several studies, a National Highway Traffic Safety Administration report concluded that older drivers with reductions in physical flexibility and range of motion of arms, legs, and neck are at increased crash risk (NHTSA, 1999). Backing and changing lanes requires the ability to turn the head, neck, and upper torso. Therefore, the task of backing and changing lanes may be impaired by changes in musculoskeletal function.
The prevalence of chronic health conditions increases with age. For example, cardiac disease, diabetes, seizure disorders, Parkinson's disease and stroke have been linked to driving ability or crashes (Koepsell et al, 1994; Waller, 1992). In recent studies of older drivers, no significant association was found between different disease histories, with the exception of the association between dementia and crashes (Foley, Wallace & Eberhard, 1995; Marottoli, Cooney, Wagner, Doucette & Tinetti, 1994). Dementia almost certainly increases the risk of motor vehicle crashes (Lundberg, Hakamies-Blomqvist, Almkvist & Johannson, 1998; Reuben, 1991)- the greater the dementia severity, the greater the likelihood of poor driving ability (Hunt, Morris, Edward & Wilson, 1993). However, Marottoli et al. (1994) report that even borderline cognitive impairment is a predictor of crashes and traffic violation.
Predictors of crashes are back pain, muscular skeletal dysfunction (Foley et al., 1995), foot abnormalities (Marottoli et al., 1994), and limitation in neck rotation (Marottoli et al., 1998; McPherson et aL, 1989). Individuáis who are unable to walk at least a block are at increased risk of crashing (Marottoli et al., 1994). A history of falling is thought to be a risk factor for crashes (Koepsell et al., 1994; Sims et al., 1998). The functional consequences of health problems affect driving ability rather than the diagnosis of a particular disease.
Many drugs such as antihistamines, ophthalmic agents, skeletal muscle relaxants, antihypertensives, antipsychotic agents, analgesics, barbiturates, anti-anxiety agents, hypnotics, narcotics, and alcohol are thought to have the potential to affect driving (Carr, 1993; Ray, Gurwitz, Decker & Kennedy, 1992). However, data related to the affect of central nervous system medications on driving safety is limited. Use of long half-life benzodiazepines is associated with an increased risk of crash (Hemmelgarn, Suissa, Huang, Boivin & Pinard, 1997). However, older drivers involved in fatal crashes in 1998 have the lowest proportion of ethanol intoxication of all adult drivers (NHTSA, 1998).
Use of nonsteroidal anti-inflammatory agents (NSAID) is associated with increases in crashes (Foley et al., 1995). Back pain and musculoskeletal dysfunction are often treated with NSAIDs and may explain this finding. In other words, NSAIDs themselves do not influence driving. It is musculoskeletal dysfunction that impairs the other adults' driving ability. The use of adrenergic blocking drugs is associated with a decreased risk of crashes (Sims et al., 1998). Beta-blockers may reduce performance anxiety and tremor, which may enhance vehicle control in some older drivers (Sims et al., 1998).
Older Driving Behavior
Age-related physiologic changes and the prevalence of chronic health conditions affect driving behavior. Older drivers have a slower acceleration and turning time as compared with younger drivers. This behavior increases their risk of crashes when entering traffic or crossing a main road. Older drivers take significantly longer executing the left turn, thus increasing exposure to on-coming traffic and a crash (Cox & Cox, 1998; Keskinen, Ota & Katila, 1998). Older drivers make more errors at signed or signalized intersections (McGwin & Brown, 1999; NHTSA, 1993). Older adults report that merging onto a freeway is a difficult driving maneuver (Lerner, Morrison & Ratte, 1990).
Older drivers compensate for their limitations in what appears to be an appropriate manner. Drivers with visual or attentional impairments often avoid situations they believe to he difficult such as rain, night, heavy traffic, and rush-hour traffic (Ball et al., 1998; Stutts, 1998). With increased age and disability, there tends to be a decline in the number of miles driven. The frequency of trips, however, does not decline (Marottoli et al., 1993). Older adults drive for essential reasons, such as shopping and trips to the physician, rather than for pleasure.
The major reasons to stop driving are poor health and increased age, which in turn reduce safe driving (Hakamies-Blomqvist & Wahlstrom, 1998; Johnson, 1995; Marottoli et al., 1993). Driving cessation is associated with comorbidity (Campbell, Bush & Hale, 1993; Forrest, Bunker, Songer, Coben & Cauley, 1997). Gender and regional patterns of driving cessation have been noted. Women are much more likely to stop driving than are men of the same age (Campbell et al., 1993; Johnson, 1998a).
Because of lack of alternative transportation, drivers in rural areas tend to continue driving to a more advanced age than those in urban areas (Forrest et al., 1997). Retirement, deceased income, and the availability of alternative sources of transportation are associated with driving cessation in urban areas (Kington, Reuben, Rogowski & Lillard, 1994; Marottoli et aL, 1993). In contrast, feelings of insecurity on the road after being involved in a crash leads to driving cessation in rural older adults (Johnson, 1995).
Driving cessation is either gradual or sudden (Persson, 1993). The following is an example of a gradual trajectory. An older individual at age 70 may no longer drive in rush-hour traffic or at night. At age 75, trips may be limited to familiar places and only for grocery shopping, visiting close neighbors, the physician, or attending church. By age 80, only short trips of several blocks to visit family are attempted. The trips are planned where only right hand turns are necessary. At age 90, the person no longer feels confident to drive and stops. The sudden trajectory is triggered by a health event, such as a severe cerebral vascular accident. The consequences of the health event are so great the person is no longer able to drive.
The decision to stop driving is made with great reluctance and viewed as a final rite of passage. For many older adults, it is "like cutting off a hand" (Perrson, 1993) or "a leg" (Johnson, 1995). Many older adults regret having made the decision (Johnson, 1995). Not only is the cessation of driving difficult for the older adult, it is also a problem for family members. Family members view the restriction or cessation of driving as one of the most emotionally charged decisions with which they must struggle (Adler, 1997). One resource families may find helpful is the American Automobile Association (AAA) Foundation (1991) guide "Concerned About an Older Driver? A Guide for Families and Friends." The guide indicates how families of older drivers can help them maintain their independence and mobility without sacrificing safety.
Driving cessation is associated with an increase in depressive symptoms, sorrow, loneliness, and isolation (Johnson, 1995; Marottoli et al., 1997; Reuben, Silliman & Traînes, 1988). Driving cessation often results in social isolation leading to loneliness and ultimately depression. Marattoli et al. (1997) found driving cessation was one of the strongest predictors of depressive symptoms in older adult.
Older adults are more likely to discuss their driving with a family member or friend than with a health professional. In a study of rural older drivers, Johnson (1998b) reports 52% of the older adults had discussed their driving with a best friend and 48% had discussed the problem with a family member. A majority of rural older adults did not discuss driving cessation with any health care provider (Johnson, 1998a).
DRIVING BEHAVIOR QUESTIONS
The same was true in the urban retirement community (Perrson, 1993). In a study of Finnish ex-drivers, only 6.9% had received professional advice to stop driving (Hakamies-Blomqvist & Wahlstram, 1998). Although health care providers believe they have a responsibility to assess driving ability, they are uncertain about how to assess driving competence (Johnson, 1998b; Miller &Morley, 1993).
Injury prevention and health maintenance are important objectives in nursing practice. The nurse's goal is to identify treatable causes while preserving the older adult's mobility and independence. Driving should be viewed as an aspect of this independence. At this time, no reliable, valid assessment instruments to identify driving risk are available. Based on the association suggested by the research literature cited above, the following guidelines to decrease risk while maintaining transportation mobility are suggested.
DECREASING RISK WHILE MAINTAINING TRANSPORTATION MOBILITY
Driving behavior is viewed as a sensitive topic, and clients may not be willing to discuss driving as a health concern. More likely, a family member or friend will mention the issue with a nurse. If nurses do not discuss the issue of driving, older adults may perceive it is unimportant (Johnson, 1998b). Nurses can initiate discussions about driving with their older clients by assuring them that the goal is to keep them driving safely as long as possible.
A review of driving behavior should be part of health assessment data. Questions about lifestyle, driving, and functional ability can be integrated into the interview. The frequency, length of trips, type of traffic patterns frequently encountered, and use of seat belts should be elicited. Questions about driving difficulties, such as problems driving at night, near misses, crashes, or violations should be included (Table 1). A history of change in visual acuity, functional status, falls, ability to rotate the neck with a full range of motion, and ability to react quickly to situations requiring an immediate response are important to be aware of because they are key indicators of increased risk.
Current medications can be reviewed, as well as the presence of comorbidity. A general cognitive status test such as the Mini-Mental State Exam (Folstein, Folstein, & McHugh, 1975) is useful in identifying individuals at risk. Information about family and social support is useful when planning interventions. A self-assessment tool available from AAA Foundation. (1994) tided, "Drivers 55 Plus: SelfRating Form." Although the reliability and validity of this instrument is not known, the self-assessment tool may be useful to increase older adults' awareness of their driving abilities. Physical assessment should include near vision testing and evaluation of neck and back flexibility. The feet should be examined for deformities and sensory neuropathy.
COMMON DISABILITIES, THEIR EFFECTS ON DRIVING, AND SUGGESTED ADAPTIVE AIDS
Clients with decreased near vision should be referred to an ophthalmologist for further evaluation and treatment. Two common eye conditions, glaucoma and cataracts, can be successfully treated to improve vision. Treatment for macular degeneration with a loss of central vision is limited. However, the ophthalmologist can determine the degree of vision loss and counsel the client regarding driving restrictions or possible driving cessation. Clients with questionable cognitive impairment should be referred to a geriatric assessment center for evaluation. The multidisciplinary teams at such a center can diagnosis dementia and can plan for future care with the person and family. This planning is a way to explore the older individual's ability to drive safely.
The fit between driver and car may need to be modified. If the client's height has decreased, seat cushions that raise the height or pedal extenders may be useful. The use of wide angled rear view and side view mirrors will increase the visual field. Glasses, windshields, and headlights can be cleaned to improve visibility. An occupational therapist can be helpful in suggesting necessary modifications to the car (NHTSA, 1999). Table 2 lists common disabilities, their affect on driving, and suggested driving aids.
Decreased head and neck mobility affects the older individual's ability to complete driving tasks. Range-ofmotion exercise training can, therefore, prove beneficial because it improves trunk rotation and shoulder flexibility. A pamphlet available from the AAA Foundation (1989) for traffic safety contains an outline of a flexibility fitness program to improve older driver performance. Senior centers often provide exercise programs to improve strength and flexibility.
Clients can be referred to driver improvement courses such as the "Mature Operator Course" offered by The American Automobile Association, the "55 Alive Course" offered by The American Association of Retired Persons (AARP) or the "Coaching the Mature Driver" offered by the National Safety Council (NHTSA, 1999). Course content includes a description of the relationship between age and driving skills, review of current rules of the road, and specific safe driving techniques. These courses are often offered at local senior citizen centers. Many insurance companies offer a discounted rate for automobile insurance to individuals who have completed such a course.
Evaluation of the AARP driving course by the California and New York Department of Motor Vehicle and the New York Department of Insurance have demonstrated fatal injury crash and violation reductions among program participants (AARP, 19%). The effectiveness of the Mature Operator Course or Coaching the Mature Driver has not been reported in the literature. Table 3 lists driver improvement courses.
DRIVER IMPROVEMENT COURSE
Clients can also be counseled to modify their driving. Together the counselor and older adult can plan the safest route to their most frequent destinations. With some thought, a route with effective iUumination, right turn instead of left turn intersections, less dense traffic, clear signs and signals, and well-marked lanes can be devised. In addition, making shorter trips and fewer trips during non-rush hour traffic are useful suggestions. As with any lifestyle modification, the older driver should be an active participant in the plan. Various organizations publish educational material which can augment counseling (Table 4).
The preferred method to identify the unsafe drivers is a road test (Carr, 2000). Programs offering testing of visual, cognitive, and motor skills in addition to performing a road test by an occupation therapist who specializes in assessing driving skills are available at rehabilitation centers and university hospitals. Referral may be made by physicians, nurses, hospital discharge planners, courts, clergy, and concerned family members and friends (NHTSA, 1999).
EDUCATIONAL MATERIALS FOR OLDER DRIVERS
If driving cessation is the only alternative, maintaining the older adult's dignity and finding alternative modes of transportation are priorities. Friends and family members have been found to be significant factors in the decision to forfeit a driver's license (Johnson, 1995; 1999), and their support can be helpful in this difficult decision. Supportive, compassionate communication can provide older individuals the opportunity to discuss the meaning of driving cessation. Such communication can help the older individual to retain self-control and normalize the situation. Family and friends can be encouraged to visit and call the older individual to prevent loneliness and isolation.
Alternative sources of transportation such as family, public transit, taxis, buses, state-sponsored organizations, and church groups must be explored with the older individual (Table 5). Some older adults who need transportation are reluctant to ask without this mutual exploration. Using the money saved by not operating an automobile to pay for a driver or taxi can be suggested. A network of transportation opportunities needs to be developed for each individual. This network may include friends, family members, the church, and formal organization such as Dial-a Ride and public transit. Nurses can advocate for change in transportation systems to meet the needs of the older population.
Valid and reliable screening instruments to identify older adults at risk of crashes need to be developed. Development of such an instrument would require an interdisciplinary approach, including physician, ophthalmologist, and physical and occupational therapists. Limited research has been conducted to evaluate the effectiveness of various driver education programs in decreasing crashes. Is classroom instruction as effective as simulated driving or actual road driving instruction? The effectiveness of the AAA Foundation's self-evaluation tool needs to be studied. In addition, the effectiveness of the nursing interventions suggested in this article need evaluation.
ALTERNATIVE TRANSPORTATION SOLUTION
Being able to drive contributes to the well-being of large numbers of older individuals. Age-related conditions, however, put older adults at risk of injury and death from automobile crashes. Nurses have a role in the assessment of older drivers. The goals of interventions are to assist the older adult to continue safe driving as long as possible. And when driving is no longer safe, nurses need to assist in finding alternative modes of transportation so the well-being of older adults is maintained.
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DRIVING BEHAVIOR QUESTIONS
COMMON DISABILITIES, THEIR EFFECTS ON DRIVING, AND SUGGESTED ADAPTIVE AIDS
DRIVER IMPROVEMENT COURSE
EDUCATIONAL MATERIALS FOR OLDER DRIVERS
ALTERNATIVE TRANSPORTATION SOLUTION