Seniors are driving safer, driving longer

Oct 31, 2018News

Americans love to drive. More than 75 percent of adults carry a driver’s license, including 40 million who are 65 and older. But driving is more than just a passion or a pastime: It’s a lifeline. Studies show that giving up driving increases a person’s mortality risk and makes seniors more likely to land in nursing homes and suffer from depression. Yet the average American man outlives his ability to drive by six years; the average American woman, by 10 years.

So it’s not surprising that older people are reluctant to stop driving. “Seniors do not want to talk about or think about when they can’t drive,” says Sandi Rosenbloom, a professor of community and regional planning at the University of Texas at Austin. “I’ve done dozens of focus groups in seven different countries. If you ask seniors anywhere, ‘When do you think you won’t be able to drive?’ they will uniformly say about 10 years from whenever you ask. It doesn’t matter what age they are when you ask. They can be 80!”

Some of us do manage to drive well into what geriatricians call “oldest-old” age: More than 3.5 million Americans 85 and older currently hold a driver’s license. At 95, Eldon Bartlett is one of them. Bartlett, whose first car was a Model T, still pilots his 22-foot Gulf Stream motor home on annual trips between his home in Portland, Ore., and an RV park in Arizona, where he visits friends near Phoenix and plays cribbage.

It would be wonderful if everyone could count on Bartlett’s good fortune—and good genes. Eventually, though, physical or cognitive limitations (or both) make driving safely difficult or impossible for most older people, compelling them to hang up their car keys for good.

The problem is that most of them have no other way of getting around. Almost three-quarters of seniors live in areas with few—if any—transportation alternatives, which means their options for remaining mobile begin and end in their own driveway.

All of this amounts to a senior transportation predicament that will only grow more urgent with the arrival of the Silver Tsunami, a demographic monster wave that will swell the 65-and-older population to a projected 74 million in 2030 from 46 million in 2015.

Though it may at times seem effortless, driving is a complex task that requires, among other things, healthy cognition and good flexibility. (Think about craning your neck to check your blind spot.) A long list of medical conditions common to seniors may impair both. Fourteen percent of Americans ages 71 and older experience some type of dementia; Alzheimer’s disease affects about a third of the population 85 and older.

Many more common medical conditions can also limit the ability to drive, including chronic pain, diabetic neuropathy, failing vision, and osteoarthritis.

Even the drugs we use to treat medical conditions—painkillers, antidepressants, and sleeping pills, for example—can interfere with safe driving. Almost 30 percent of the seniors in one study were taking at least five prescription medications.

Defying the Stereotypes

All of the challenges that come with aging might lead you to assume that seniors represent a special menace behind the wheel. But data prove that this assumption is fundamentally wrong. Decades of statistics show that crash rates per mile driven are highest for the youngest drivers (ages 16 to 19), though they do begin to tick up steadily once drivers roll past age 70. But even at 85, senior drivers crash less often, per mile, than teens. And when they do, seniors are largely a danger to themselves.

Older adults don’t get enough credit for their safe driving habits, says Emmy Betz, M.D., M.P.H., an emergency room physician and associate professor at the University of Colorado School of Medicine who researches senior-driving safety.

“Older drivers are more likely to use seat belts and follow speed limits,” Betz says. “They are less likely to drive at night or while intoxicated, or to text while they drive.” Many seniors also regulate their driving behavior, limiting their trips at night, on highways, or during rush hour.

Public suspicion of older drivers isn’t based on facts or research but on a nonclinical factor: ageism. That’s the assertion—and that’s the word—put forward in a 300-page evidence-based handbook, “The Clinician’s Guide to Assessing and Counseling Older Drivers,” that was revised last year by the American Geriatrics Society and published by the National Highway Traffic Safety Administration.

This ageism extends all the way to our laws. Thirty-two states impose special registration burdens based on age, such as more frequent or in-person license renewals, and medical approval and vision tests. Maine requires vision screening for drivers once they reach 40; drivers 75 and older must pass a road test to renew their license in Illinois; and in Washington, D.C., drivers 70 and older need to have their physician sign off on their license renewal.

The effectiveness of these interventions, however, appears to be limited. A 2014 study in the journal Injury Epidemiology concluded that no policy it examined significantly reduced fatal crashes for drivers younger than 85.

Two policies did reduce fatality rates considerably for the most senior drivers: in-person renewals and additional vision tests in states without in-person renewal requirements. Researchers speculate that these policies work because they provide an opportunity to identify drivers with functional deficits and refer them to further screening (possibly leading to the denial of a license). Alternatively, some seniors who rightly fear they may not pass the screening may simply not renew their license and discontinue driving.

Researchers say that a quick and accurate doctor’s office screen has proved difficult to design. Though many people experience diminished vision, cognition, or motor skills as they age, those deficits occur at wildly different rates and degrees. Some 79-year-olds are hiking the Appalachian Trail; others find it impossible to climb a flight of stairs.

Testing these two populations the same way is futile, according to David Carr, M.D., who has been developing driver-screening tools at Washington University Physicians, where he’s the clinical director of geriatrics.

“The average older driver might crash or fail a road test less than 10 percent of the time,” Carr says, but the failure rate will be much higher for patients with dementia or a history of strokes. Which means that rather than relying on age, a worthwhile screening tool needs to start by assessing a driver’s individual health and risk factors.

Just six states require physicians to report potentially dangerous patients to state licensing authorities and medical advisory boards; the rest make such reporting voluntary. Last year Florida, which doesn’t require physician reporting, revoked almost 6,700 licenses for medical incapacity or failure to provide a requested medical form. It pulled almost 3,900 drivers off the road for failing a vision test or neglecting to supply a vision report.

Still, the case for stronger laws is a weak one. The latest study, in The Gerontologist, a medical journal, failed to find a corresponding reduction in emergency room admission rates in states that require doctors to report potentially dangerous older drivers.

Richard Marottoli, M.D., a professor and geriatrician at Yale University, counsels patients on driving cessation but understands why overtaxed general practitioners might shrink from the task. “The conversation is emotionally fraught,” he says. “It can put them in a different relationship. Instead of being a patient advocate, they become a patient adversary.” The bogeyman in a white coat coming for your keys.

Staying in the Driver’s Seat

Clues for ways to keep seniors on the road longer and safer could well come from a major new longitudinal study called LongROAD. The 5- to 10-year project, coordinated by the AAA Foundation for Traffic Safety, is following 3,000 seniors at five sites across the U.S. Volunteers submitted their full medical and driving records, were interviewed, and allowed tracking devices to be installed in their vehicles. Over time, these trip logs should provide researchers with insights on matters great and small. What time of the day do crashes occur, at what speeds, and on what types of roads? What medications were the drivers taking at the time? Do moving violations predict accidents?

But there’s plenty we already know. “You absolutely can help people drive longer,” says Betz, the Colorado emergency room doctor.

In terms of what you can do on your own, studies have found that cardiovascular exercise can slow cognitive decline, and that strength and flexibility programs can improve senior performance on driving metrics like neck rotation and response speed. Continuing-education programs probably can’t hurt. (See “How to Keep Driving Skills Sharp.”)

Senior drivers may also benefit from working with a driver rehabilitation specialist, a person trained to assess a driver’s abilities and recommend practical retraining, adaptive devices, and sensible driving restrictions. In shorthand, an occupational therapist with wheels.

Kathy Woods is a certified driver rehabilitation specialist who directs four colleagues at the Courage Kenny Rehabilitation Institute, a complex on the western border of Minneapolis. They see about 1,000 patients per year, most of them older adults. Many arrive with referrals from doctors or caregivers; some come on their own. Last winter her team assisted a client who was 101 years old.

The 3-hour evaluation is a daunting audit that begins with the same general cognitive and memory tests that a neurologist might administer, followed by a thorough vision screening.

A simulated-driving segment presents video road hazards, and multiple-choice questions assess the driver’s judgment and knowledge of traffic rules. A gas/brake apparatus gauges reaction time. At the end of the appraisal, Woods takes the client out on the streets.

What clues does she look for? “Going through a red light, going through a stop sign, weaving and drifting,” Woods says. “The more subtle ones might be stopping at a stop sign and not taking their turn when it’s time to go, or stopping at an intersection when they don’t need to.”

A 2010 observational study in the Journal of the American Geriatrics Society found that older drivers commit a greater number of minor errors (such as failing to signal) and dangerous ones (failing to stop at a red light) than middle-aged drivers do.

Prospective clients often ask Woods what the program’s “success rate” is. It’s not a term she likes. Success, as she defines it, can mean helping a client return to driving, continue driving—or never get behind the wheel again.

Shari Peterson, a 69-year-old professor who recently got a diagnosis of mild cognitive impairment, fell into the last category after being evaluated.

“I sobbed for 2 minutes,” Peterson recalls. “Then I said, I’m okay. My grieving lasted only about a day.”

Peterson’s grace is atypical, Woods says. Many seniors with dementia or other memory impairment reject the test results or demand another assessment. They’re skeptical; they’re angry.

“There is a grieving process with this major life change,” Woods says. “Some accept the outcome more quickly, while others struggle longer.”

Peterson’s son Brian, 39, says he was impressed that his mother “was willing to take the initiative to stop driving instead of making it a fight.” It took the pressure off him.

Adult children often see a driving “retirement” not only as a threat to a parent’s independence but also a threat to their own.

“Adult children tell me all the time, ‘I don’t want to do to my child what my parents have done to me,’” Rosenbloom says. “They get stressed; they often have to move their parent out of the home they’ve lived in for decades because there are no transportation services nearby.”

Peterson’s equanimity helped her adapt. Friends now pick her up for shopping trips. “I’ve been having a lot of lunches out—you can get around,” she says. She’d always considered herself an independent woman, but she recently concluded that “the people I love, they take joy from helping me.”

Now and again she still gets to ride in her car, a Mazda6. But now she sits in the passenger seat and her son drives. This reversal still feels “surreal” to him, he says. “One day you’re independent, and the next day you’re not.”

It would be a mistake to think of a driver rehabilitation specialist as someone whose job is to usher you away from your car. Plenty of seniors need to cease driving for a time after a major health event: a knee or hip replacement, for example, or open-heart surgery, chemotherapy, or a stroke. What may not be clear is when and how to get back on the road.

Mike Grein, 70, is another client of Woods’ practice. With her help he regained the confidence to drive after a serious collision (he wasn’t at fault) and a grueling series of surgeries kept him out of the driver’s seat for two years.

During his recovery period, Grein relied on his wife, Nancy, to get around town. When he said he wanted to start driving again, she arranged for him to meet with Woods.

Woods divides driving into different functions, and with Grein, she says, “the majority of them looked strong.”

“I was champing at the bit,” he says about his return to driving.

Now when the couple travel to visit their son, Nancy will be the one to pilot their car through Atlanta traffic. But during their vacation in Alaska, “I would just as soon get behind the wheel,” Grein says.

Driver rehabilitation specialists provide an urgently needed service. They’re also in short supply. States including Arkansas and Alaska have zero certified driver rehabilitation specialists, and Texas and California offer fewer than one for every 1.5 million people.

The Association for Driver Rehabilitation Specialists has a searchable database of specialists on its website, Insurance coverage for the service is limited, and seniors generally must pay out of pocket. A comprehensive driving assessment costs about $400 to $600.

When the time to retire from driving does come, most people discover that they have far fewer options than they had expected.

Some invest their hopes in the little white vans they see around the neighborhood: that is, paratransit. But what we know about paratransit—the federally mandated service for people with disabilities—is mostly wrong, according to Rosenbloom. It operates only near established public bus routes, which means it’s a limited resource in most suburbs. And its use is restricted to people who can’t reach regular public transportation because of a disability. Being unable to walk is a disability; being old is not. Neither is being unable to drive. Ultimately, Americans over the age of 70 make less than 0.5 percent of their trips on public paratransit.

Self-driving automobiles could one day help some seniors remain on the road for as long as they’re able to get into and out of a car, but that day is probably still years—maybe decades—away. And though ride services like Lyft and Uber have made finding transportation easier than ever for many, they still present serious limitations for seniors. (See “Not Taken for a Ride.”)

A City Full of Solutions

If senior transportation is a riddle, experts say that at least part of the solution can be found in Portland, Ore., at the headquarters of Ride Connection, a nonprofit “mobility manager.” Last year it provided 559,000 rides to seniors and people with disabilities.

“Mobility management” means different things in different locales. It can be little more than a website that posts the schedule of a neighborhood senior shuttle or a social worker in a healthcare facility who helps seniors make it to their chemotherapy appointments. The broader idea is to enable older people to find the transportation options that exist in their community and then help them get where they need to go.

Ride Connection is a groundbreaker in the field: a team of 96 employees in a new modernist office building (plus six satellite sites), all devoted to moving clients around metropolitan Portland. Documentary photo portraits, at a heroic scale, line the walls of the call center: a tattooed woman in a crowd with her service dog; a pair of elderly women embracing. These images are a constant reminder to the staff of the people they’re working for.

Each month more than 200 new customers call in to talk with a travel counselor. Over the course of a 30- or 60-minute call, the counselor will record where the customer regularly goes, describe what types of transit are available, and pass him or her along to a scheduler who books pickups and drop-offs on community shuttles across metropolitan Portland.

To the uninitiated, the logistics can be challenging. For example, a senior caller may need to travel to a doctor’s appointment from his daughter’s house in suburban Beaverton, then catch a ride to a mosque in southeast Portland before heading back home.

Fulfilling that itinerary demands close listening and careful networking. Some rides are fulfilled by staff, volunteers, or a partner social service agency. Or Ride Connection may reimburse a neighbor who regularly provides a lift to the grocery store. It also operates its own fleet of accessible vans, which volunteers can drive. Ultimately, the organization’s approach to mobility management is less like a silver bullet and more like buckshot. The staff members try whatever works.

It helps that Portland has mobility options to manage: TriMet, the regional transit agency, operates almost 80 bus lines, five light-rail lines, and a commuter rail system. The city has streetcar routes and an aerial tram that resembles an Airstream trailer on a ski-hill tow rope.

Ride Connection operates on an annual budget of about $9 million, including almost $2.3 million from TriMet. At the same time, diverting elderly and disabled passengers from pricey paratransit services saved TriMet $10 million in 2015-16.

“They move the masses. We move individual community members,” says COO Julie Wilcke, who started out 25 years ago as a volunteer driver. (Ride Connection had to turn down 35,000 valid ride requests last year for lack of funding.)

If those seniors can manage to take TriMet buses, all the better. The challenge is that a 76-year-old who has never ridden a bus in her life may not feel inclined to start. What changes someone’s mind, according to Dennis McCarthy, a senior transportation expert at Nova Southeastern University in Florida, is trying it.

One of Ride Connection’s programs is called Rider’s Club: It offers monthly field trips for seniors on the city bus line. They go for the cultural outings and return with practical travel training. After three such tours, more than 90 percent of participants say they would “consider the bus for everyday living activities,” Wilcke says.

Avonne Dressler first called Ride Connection after she saw one of its vans with the phone number on the side parked outside the senior center in Forest Grove, a farming community and college town on the route west from Portland to the Pacific Coast.

“My husband did all the driving,” Dressler said recently over lunch at the senior center with six of her friends. She married at age 18 when her husband returned from service in WWII and, like many of her contemporaries, never learned to drive.

After Dressler’s husband suffered a brain bleed in 1997, she became his co-pilot. This involved calling out objects on the right side, which he could no longer see, and acting as his navigator. The beginning of Alzheimer’s was the end of her husband’s driving.

Dressler and her husband struggled to adapt to their new life without a car. “I don’t think you ever are ready to lose an ability to be on your own,” she said.

Dressler, 89, has been a widow for eight years. “I don’t just wither on the vine,” she said. Daily service from Ride Connection helps make that possible. It shuttles her to the senior center for lunch and on Fridays to the Hair House, where she has kept a standing weekly appointment since 1981. On Saturdays she goes grocery shopping with her daughter and then to lunch.

Of the seven people at the table, the youngest was 77 years old, and everyone but Dressler was still driving. The oldest, at 95, was the Gulf Stream owner, Eldon Bartlett, who recalled that he once had a fender-bender.

“I ran into the side of a ’38 Ford and had to buy him a new hubcap,” Bartlett said. When lunch ended, he offered me a ride to the train station, 8½ miles away. I accepted with nary a hesitation.

Planning for the Future

Most of us understand that we need to plan for a time when we surrender our car. But very few of us actually prepare for that eventuality, says Marottoli, the Yale professor. “We should but we don’t,” he says. “It’s not unique to this situation or age group.”

It was all the more exceptional, then, to meet the future occupants of a new 27-unit development called PDX Commons in Portland’s Sunnyside neighborhood. One of the project’s planners, a retired documentary filmmaker named Jim Swenson, 73, walked me around the bohemian streetscape.

The number 15 bus stopped in front of the new residence every 7 to 15 minutes before rumbling downtown. This being Portland, the retail offerings down the street include a video-rental shop (90,000 titles), a bespoke hatter, and a storefront advertising children’s ukulele lessons. Swenson can also walk easily to a grocery store, a public library, and a pharmacy. Someone had counted 175 places to get a meal within a 1-mile radius. A future Commoner had already cashiered her Volvo and parked some of the proceeds in a new bike.

After its midyear opening, Swenson said, PDX Commons would become the first “co-housing” community in Portland dedicated to seniors. Each buyer will own a self-contained condominium, and some 5,000 square feet have been given over to shared amenities: a commercial kitchen, a 50-seat dining hall (which could double as a yoga studio), a wet bar, and suites for overnight guests that could also become rooms for healthcare attendants. Instead of driving to find a community, these seniors plan to build one under their own roof.

Co-housing communities were originally inspired by intentional communities in Denmark called bofaellesskaber (or “living together”). The Cohousing Association of the United States lists a dozen completed senior communities, with the greatest number being in California and New Mexico. Another two are under construction, and a dozen more hope to graduate from the planning stage.

The monthly potluck dinner Swenson and his wife, Janet Gillaspie, often attend is filled with a prosperous and progressive crowd in their late 50s, 60s, and 70s. Two midwives, an auto executive, and a Lutheran bishop were among the Commoners at a gathering last winter. When they talked about driving into old age, many had recently observed the trajectory of their senescent parents.

Gillaspie’s mother and father developed dementia in their early 80s. They had just built a new showpiece home. They had thought ahead, locating the master bedroom and a bathroom on the main floor.

What they seemingly hadn’t considered was that the house with the beautiful view would be isolated, an hour north of Portland. Without a car they would be stuck there. That’s what happened, and that’s where they remained until relocating last year to a residential-care facility.

“It doesn’t take a huge amount of personal experience to imagine what aging is going to be like,” Gillaspie said. “If you don’t make a plan, a plan will be made for you.”

At 61, she’s still working as an environmental consultant. She can’t predict how the experiment of PDX Commons will turn out. But it looks like a pretty good plan, she said. One that she has made for herself.

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