Should elderly drivers be tested in the United States

Drivers Test/Elderly

Due to the population change in the United States, or what is called the "graying of America," the next couple of decades will significantly increase the number of individuals over the age of 65 who are driving on the country's roadways. Because a variety of physical and psychological conditions either become worse or arise after the age of 50, especially as the years progress, and because older individuals are involved with a greater number of motor vehicle accidents, it would seem practical that proactive measures be taken at this time. Special examinations should be developed and administered prior to re-licensing that test for the conditions that are most prevalent with aging so that the safety of older individuals and others on the road will be protected.

The United States is entering the era of "The Graying of America." Increased life expectancy is creating record numbers of people aged 65 and older. In less than a century, the country has added 25 years to the life span. Those aged 65 and older represented 13% of the population in 2000 and will be about 21% of the population in 2030. The group expected to grow most rapidly in the next 30 years is the one aged 85 years and older. As this shift occurs, the U.S. can expect myriad of changes from family structure to health care to cultural values.

Because of the variance in demographics, more drivers on the roadways will be over 65, as well. In the next 20 years the number of elderly drivers (persons 70 & over) is predicted to triple in the United States. What impact will this have on accident statistics?

A study was initiated to forecast the number of older drivers and passengers who may be fatally injured in traffic crashes in future years (Bedard, 2001, 751). The research was based on data from the United States. Fatality Analysis Reporting System that covered the time period from 1975 to 1998. The results showed that about 35,000 drivers and passengers died in traffic crashes each year from 1975 to 1998. Older adults, or those 65 and up, accounted for 10% of all fatalities in 1975, 17% in 1998, and a projected 27% by 2015, the same proportion predicted for drivers and passengers younger than the age of 30. On the basis of these projections, the number of fatally injured women and men above the age of 65 will increase respectively by 373% and 271% between 1975 and 2015. The researchers thus concluded if present trends continue, the number of fatalities among older drivers and passengers and those aged younger than 30 may be equivalent early in this century. These projections call for further research into conditions that may lead to crashes involving older drivers and for the development and implementation of initiatives to curb traffic-related fatalities among older adults

Across the country, states are thus assessing the need for drivers tests for elderly. Pennsylvania law requires a doctor to report any condition that impairs a patient's ability to drive. Of 21,000 reports on questionable drivers filed with Pennsylvania officials in 2004, nearly 6,000 resulted in license suspensions, with 181 of the suspensions because of neurological disorders like Alzheimer's disease. In Canada, drivers over 80 are required to take medical examinations before renewing driver's licenses in British Columbia. Ontario drivers over 80 may have to take a road test every two years. Florida, the state with the largest percentage of seniors, issues licenses for six years, but drivers over 79 must pass a vision test. Illinois and New Hampshire require drivers 75 and older to take a road test. The American Association of Retired People (AARP) recommends a refresher driving course for individuals over the age of 50.

Given the health changes that people undergo as they become older, such decisions as these are not wrong. It would be unwise to wait until the year 2010 and then react to the situation, rather than be proactive today.

HISTORICAL BACKGROUND

Ten years ago, it became very clear that the future held both great promise and extreme mobility challenges for the aging population. Today the evidence for both possibilities appears even more clear. By almost any measure, in the coming decades the elderly will have longer, happier, fulfilling lives than their peers today and definitely than the elderly of just a few decades ago. However, a 1996 Organization for Economic Co-operation and Development (OECD) study surveyed the implications of global aging and commented:

The basic news is good. Increased longevity, good health and independence are key values in their own right. They are also a reflection of the underlying strength of social and economic issues... [but] there will be difficult transitional problems before that good news is fully realized. (5-6).

One of these challenges will be automobile driving by an aging population. Older people in 2005 have much more active, eventful, and mobile lives. Mobility, defined principally as the trip rate by all forms of transportation, includes walking and biking as well as driving and using the various other moving vehicles. An important part of their active lives is efficient, convenient, and flexible access to a variety of desired services and facilities. In the future when aging individuals lose the ability or resources to engage in such activities, the drop in their well-being may be substantial and could have profound physical and psychological impact. A direct source of decline in the elderly in coming decades will be decreasing mobility, or the inability to drive or to find satisfactory travel alternatives to gain needed services and facilities. No evidence exists that older people's desire to travel will decline simultaneously with their ability to drive or to find other alternatives. Many elderly may eventually find themselves cut off from the very aspects of life that made their early retirement years so much better than those of older people only a few decades ago.

The number of Americans over age 65 has greatly exceeded the growth rate of the population as a whole, but this amount of older individuals goes hand-in-hand with a significant shift in the population structure. According to the U.S. Census, Population Profile of the United States. (1998), the American elderly now comprise a major proportion of the entire population. There are two major causes for the growth in both the number and percentage of older people. People are living longer due to increased income, better education, and enhanced healthcare. The Central Intelligence Agency Fact Book indicates that in 1998, the average American life expectancy was just over age 76. When America first became a nation, it stood less than half of that. Even at the start of this century, the average U.S. life expectancy was below 50 years (U.S. Census, Statistical Brief). Older Americans are better educated and housed than similar older Americans from just a few decades ago. They are more likely to be well-off economically and less likely to be poor. Until 1974, for example, the poverty rate of the elderly was greater than that of children. In the U.S., the median income for elderly people more than doubled between 1957 and 1992, while the poverty rate was cut in half (Hobbs, 1996, 64). At the same time, chronic disability and institutionalization rates among the aging have continued to drop, and death rates from heart disease, the major killer of the elderly, have fallen substantially since 1960 (ibid). Another reason for older populations is that individuals of childbearing age are having fewer children. Fertility rates have continued to fall for the last 40 years.

Since the 1950s, Americans have become increasingly dependent on the automobile as more people moved into the suburbs, federal highways began dissecting the country and national and city transportation systems started declining. Older people have also become more dependent on the private car. Automobiles have given them more personal choices, a greater range of possible activities, and independence. According to the report Transportation in an Aging Society (2004, 18), driver licensing among the elderly is very high and continuing to grow. Licensing rates increased for all individuals over age 50 from 1992 to 1997 but was faster among women than men, especially among those over age 70. This trend does not include people suddenly deciding to become drivers but instead younger, active adults aging into their retirement years. As a result, in 1997 almost 92% of all men and 70% of all women over 60 years old had a driver license. Licensing is nearly universal among those becoming 65 years of age in the next 15 years. By 2012, almost every American man and close to 9 out of 10 women will enter their retirement years as drivers. Presently, there are about 18.5 million licensed drivers aged 71 and over.

While the socio-economic and health conditions and mobility of this aging population is better than ever before, it does not mean that there are no problematic areas.

As one ages, specific functions related to driving skills may be impaired such as vision, hearing, sensation, and cognitive and motor abilities. For instance, a decline in peripheral vision may impact the ability to pass approaching vehicles safely, and the decreased range of motion in an older person's neck may impair the ability to look behind when backing up. Also, reaction time decreases by almost 40% on average from age 35 to 65 (Jackson, 1999).

It also appears that the aging process may affect cognitive skills. Short-term memory loss, for instance, can decrease driving skills by interfering with an individual's ability to process information effectively when merging onto a highway into traffic or changing lanes. Such issues are magnified when driving under stressful situations. The higher incidence of cognitive impairment, particularly dementia, among older men and women leads to an increased risk of accident involvement (Jackson, 1999).

According to AARP, as a group, persons age 65 and older are relatively safe drivers. Although they represent 14% of all licensed drivers, they are involved in just 8% of police-reported crashes and 11% of fatal crashes. In comparison, drivers age 16 to 24 are involved in 26% of police-reported crashes and 26% of fatal crashes, but represent only 14% of licensed drivers. Individuals over 65 also drive fewer miles on average than any other age group.

However, when they crash, the situations and reasons are normally different from younger drivers. Older drivers' crashes occur most often when are turning left, whereas younger drivers crashes usually take place while they are driving straight ahead. Older drivers fail to yield right of way or not respond properly to stop signs and traffic lights. Younger drivers speed follow too close. Among all drivers age 65 and older, it is the oldest ones who pose more risk to themselves and to public safety. For all adults age 25 to 64, and for adults age 65 to 69, the rate of crashes per miles driven is relatively constant. The rate begins to rise at age 70, and increases rapidly at age 80.

In addition, the aging may not be aware of their decreasing driving ability. Seniors who are experiencing cognitive or physical decline shouldn't be the ones to judge their own driving abilities. Bonnie Dobbs, an assistant professor at the University of Alberta in Canada, found that 98% of elderly drivers with impairments severe enough to hinder driving ability think they are average or above-average on the road (Corcoran, 2003, 16).

A common consequences of aging is a decline in motoric function and the ability to learn new motor skills. These declines in motoric function and motor learning are associated with increased risks of falling and mortality in older individuals. Also, musculoskeletal impairments often can impact driving safety in the elderly. Conditions such as rotator cuff tendinitis may make turning a steering wheel more difficult. Under emergency conditions, the older adult driver may have trouble avoiding an accident or reducing its severity by avoiding a direct impact. Recently, a study suggested that elderly drivers are more likely to be involved in accidents that involve angles or turning. Arthritis in the neck or shoulders may result in a limited ability to turn the head, reducing the ability to scan efficiently for traffic at an intersection. Finally, reflexes often begin to diminish in the elderly, which puts them at greater risk for a traffic accident.

It is well recognized that the occurrence of impaired vision and hearing increases with age. Driving is a complex task that depends on sensory acuity, ability to process a large number of environmental stimuli simultaneously, cognitive capacity to recognize correct inferences from incoming data and to formulate a correct response, and motor ability to operate the vehicle's controls (McCloskey, 1999, 267). Although impairments in any of these faculties may higher the risk of crash, some investigators propose that the presence of sensory impairments is particularly important. Common visual deterioration occurs through cataracts, glaucoma, age-related macular degeneration, diabetic retinopathy, optic atrophy, corneal dystrophy, and effects of stroke.

As humans age, the ability to see details at a distance declines and they have a harder time focusing on nearby objects. This presbyopia is an age-related process that results from the loss of flexibility in the eye's lens and is different from near- and farsightedness. As it progresses, presbyopia can pose safety problems for drivers such as greater difficulty reading dashboard control panels and instrumentation (Industrial Engineer, 2004). Aging is associated with a progressive deficit in the resolution of fine visual details. Acuity for high-contrast targets, approximately 20/18 at age 20, falls to about 20/30 by age 70. In addition, failure to meet a 20/40 acuity cutoff under nighttime testing occurs with disproportionate frequency among older drivers.

The reduction in the size of an elder's visual field has been implicated as a major cause of automobile accidents involving drivers of advanced age. Drivers with peripheral visual deficits have collision rates twice as high as those with normal peripheral vision. (Beer, 2000, 233). Neuron loss to the peripheral retina can also lead to limited visual acuity in the periphery. This is why driving at twilight may present the most difficulty: The peripheral retina is extremely sensitive to decreased light. Another study out of the Department of Ophthalmology and Visual Sciences of the University of Illinois, Chicago Eye Center noted evidence of compensation for visual impairment in an age-related macular degeneration group, as compared to similar-age subjects with normal vision, in four major areas: (1) not driving in unfamiliar areas, (2) traveling at low speeds, (3) self-restricting nighttime driving, and (4) taking fewer risks while driving (e.g., not changing lanes) (Szlyk, 1995, 1033). Millions of elderly people experience vision loss as a result of age-related macular degeneration. Although these people rarely become blind, they do experience difficulty performing daily activities that require central vision such as reading or driving a motor vehicle

Numerous older adults suffer visual impairment due to cataracts more often than any other single cause. More than half of adults older than age 65 have cataracts, which is slightly more frequent in African-Americans. Retrospective reviews have shown that among older drivers, presence of cataracts was associated with an increased frequency of a recent motor vehicle accident (MVA) when compared with persons free of this eye condition. The per capita MVA rate in older licensed drivers (40/1000) is substantially less than in persons younger than 25 (140/1000), but this is largely a result of the many fewer miles driven by older persons than younger. Hence, the per-mile driven rate of MVA among older drivers is actually comparable to that of the highest risk younger drivers (Kuritzky, 2002, 23).

In 2001, the states of Alabama and Kentucky tested about 300 drivers with an eye examination that went beyond the standard eye chart to assess "useful field of view," which included visual processing, the ability to filter out visual distractions, and other factors. Three years later, the drivers whose test results showed they had an impaired useful field of view were more than twice as likely to have been in an accident than those who showed no impairment. Standard eye tests did not predict accident risk (Harvard Health Letter, 2002, NA).

A significant percentage of the elderly suffer hearing loss. This presbycusis is characterized by a decline in the ability to hear sounds at certain frequencies and at low decibel levels. To determine how diminished hearing might increase the risk of motor vehicle collision injuries in older drivers, McCloskey et. al conducted a population-based case-control study at a large Health Maintenance Organization (HMO). All study subjects were HMO members who were licensed drivers age 65 or over. They found that owners of hearing aids and those who used a hearing aid while driving were at increased risk of having an injury collision.

A number of other medical illnesses may possibly hinder the elderly driver. One of the most serious areas of concern with aging is dementia or, in the extreme, Alzheimer's disease. Individuals with Alzheimer's disease or a related disorder become steadily more impaired in their ability to handle such functions as driving. They can exhibit symptoms such as memory loss, disorientation, and alterations in visual and spatial perception that often lead to their getting lost, forgetting driving rules or having slowed-down reaction times. Although an individual with early dementia may not appear to have such problems, the disease may eventually affect his or her motor coordination, judgment and concentration. In addition, at all steps of hindrance driving ability is likely to worsen during times of high stress.

Normally, it is not unusual for individuals with dementia and their families to have different opinions on the older persons' driving ability. However, while respecting that person's desire to drive, family members must put safety first. Because they do not want to lose their independence, some people with dementia may insist on continuing to drive even when their licenses are revoked. Unfortunately, as a last resort, caregivers and family members may need to prevent access to the vehicle.

In 2000, the American Academy of Neurology issued guidelines to help determine whether individuals with Alzheimer's disease should continue driving. Previously, restriction or cessation of driving was recommended only for those persons with moderate to severe dementia. In their new guidelines, however, the American Academy of Neurology recommends even men and women with minor Alzheimer's disease should be advised not to drive. Such patients frequently have cognitive impairment that may seem as simple forgetfulness, as well as subtle difficulties in the areas of visual-spatial processing and reasoning. The Academy also appears to recognize that merely advising people not to drive will not be sufficient. In this regard, they also recommend that when mild cognitive impairment is diagnosed, the patient should undergo a driving performance evaluation. They further advise that such individuals need to be reassessed twice a year to determine whether their condition has worsened. If so, reassessment of driving performance is advised.

Other medical problems that can impact driving capacity include Parkinson's disease and stroke. Strokes occurring in the right posterior brain often lead to a left neglect syndrome. Affected persons normally ignore input from the left half of their world. At the same time, they could have normal language skills, which tend to mask their underlying visual impairment. These patients are at risk for accidents and serious injury (Craig, 2001, 22).

Mental status deterioration can also affect the ability to drive safely, and routine screening for such changes is recommended for elderly patients. Declines in cognitive skills that accompany aging may include a reduction in the speed of processing information as well as difficulty in handling multiple input as efficiently as previously. In other words, elderly persons as a group show some decline in mental flexibility and attention. This, combined with problems with vision, hearing, and perception, puts them at greater risk for accidents.

Conditions such as cardiac disease or diabetes, including hypoglycemic reactions associated with diabetes, are frequently found in the elderly and often are linked with sudden changes in their status. In such situations, older drivers pose considerable traffic risks. In fact, a study showed that the medical illness most predictive of an increased risk for injury in an automobile crash was diabetes (Koepsell, 1994, 695). This finding was even greater for older drivers using insulin or hypoglycemic agents.