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Correspondence: Address correspondence to Anne E. Dickerson, PhD, OTR/L, FAOTA, Professor and Chair, Department of Occupational Therapy, East Carolina University, Health Sciences Building Room 3305, Greenville NC, 27858. E-mail: dickersona{at}ecu.edu
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Abstract |
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Key Words: Transportation • Aging • Mobility • Driving • Assessment • Rehabilitation
Compared with all other age groups except the youngest drivers, older drivers are at increased crash risk per mile driven (McKenzie & Peck, 1998; National Highway Traffic Safety Administration [NHTSA], 2000). It is predicted that by 2025, more than 40% of all fatal crashes may be associated with age-related frailties, with visual and cognitive impairments as major contributing factors (Staplin, Lococo, Gish, & Decina, 2003). Although there is mounting evidence that the older driver crash rate per mile driven may be biased upward as a result of the tendency of older drivers to drive shorter distances (e.g., Langford, Fitzharris, Newstead, & Koppel, 2004), older drivers are clearly at increased risk of death and serious injury, given a motor vehicle crash (Bédard, Guyatt, Stones, & Hirdes, 2002; Massie & Campbell, 1993), as a result of age-related frailty (Li, Braver, & Chen, 2003).
As older drivers have come under increased scrutiny, it has become apparent that it is not age, per se, that leads to problems with driving. Rather, declines in driving-related abilities are primarily the result of medical conditions (such as Alzheimer's disease and Parkinson's disease), other health problems, or the medications used to treat those conditions (Dobbs & Carr, 2005). Although these medical conditions can occur at any age, they are more likely to occur as one becomes older. At the same time, not all drivers experience these declines in the same way or even at all. Thus, research has increasingly focused on the functional declines that can affect driving rather than the medical conditions and medications used to treat them that lead to these declines.
Based on these insights, two complementary but interdependent goals have emerged with respect to older drivers: to help those who are able to drive safely continue to do so; and to identify and provide community mobility support to those who are no longer able to drive (Molnar, Eby, & Dobbs, 2005). Our purpose in this article is to review what we currently know about older driver safety and mobility, particularly in North America, and to highlight important research needs in a number of key areas that hold promise for achieving the safety and mobility goals for the aging baby boomers and future generations of older drivers. The framework for this article is presented in Figure 1. As shown in this figure, we view older adult transportation as a continuum. At one end of the continuum, mobility is enabled through independent driving, with crash or injury prevention being the main focus of research and programs. We chose the five areas in older adult driver safety that hold the greatest promise for reducing crashes and injuries for this age group: screening and assessment, remediation and rehabilitation, vehicle design and modification, technological advancements, and roadway design. On the other end of the continuum, mobility is provided through nondriving modes, in which the maintenance of older adult mobility is the focus of research and programs. Here we review the main topic in this area: alternative transportation. Between the two ends of the continuum, older adults are transitioning from being drivers to being nondrivers, with the focus of research and programs being the maintenance of both driver safety and mobility for the older adult. In this article, we review what is known about each of these topics, which were chosen to span the transportation continuum for older adults.
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Screening and Assessment |
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According to guidelines published by NHTSA and the American Association of Motor Vehicle Administrators (Staplin & Lococo, 2003), the critical abilities for driving that need to be detected for functional loss as early as possible can be clustered loosely into visual abilities, mental abilities, and physical abilities. Screening activities are needed to assess these three areas and may lead to more in-depth, diagnostic assessments to determine the extent, etiology, and implications for the observed functional loss. It must be understood that a screening tool is a defining attribute: a screening outcome by itself does not support a decision to stop driving. However, the results of a functional screening may provide valuable additional information to be considered by a qualified professional in a fitness-to-drive evaluation, or it may serve as a trigger for further evaluation.
The most extensive and rigorous research to date that links crash risk to age-related functional decline (Staplin, Gish, & Wagner, 2003) highlights the basic abilities that are most important for safe driving. In addition to having good vision under both high- and low-contrast conditions, certain aspects of physical fitness are also important, including sufficient head–neck flexibility to quickly check to the sides and rear of the vehicle and enough leg strength to control the pedals effectively in routine situations and when one is reacting to emergencies. A cluster of cognitive abilities are also highlighted, including working memory to retain and apply traffic rules and regulations and remember directions while driving; visual search, especially under divided attention conditions, to spot all manner of signs, signals, hazards, landmarks, and other elements in or near the road; visualizing missing information, to help drivers anticipate and recognize threats even when only partial information is in view; and visual information processing speed, which makes it possible to pay attention to what is happening directly ahead while still perceiving threats at the edge of the "useful field of view."
Functional screening may be conducted by a qualified test administrator in an office or clinical setting that offers a reasonable degree of privacy as well as absence from distractions. A variety of manual and computer-based driver screening tools are available. What is most important is that screening encompasses the full range of key safe driving abilities, and that it applies measures that are scientifically validated as predictors of motor vehicle crashes by using test procedures that are standardized and reliable.
Self-screening
Home-based self-screening can play an important role in maintaining safe mobility by providing older drivers with information about driving-related declines so that they can make informed decisions about their own driving behavior. Although there is much greater potential for measurement error in a home setting, there are benefits to self-screening: (a) the assessment can be completed in the privacy of one's own home, which is less threatening; (b) the tool may be an early intervention warning that can benefit drivers before the onset of serious health concerns or decrements in abilities; (c) self-screening instruments can be easily distributed, resulting in more people using them; and (d) self-screening can facilitate planning for future transportation needs (Eby & Molnar, 2005). However, individuals must be free of serious cognitive impairment to self-screen, and they must be motivated to answer questions honestly and be able to follow through on recommendations. Inaccurate responses, for any reason, may lead to inappropriate feedback. Further, an important research question concerns how often users consult with an appropriate health care professional or voluntarily modify their driving habits in a manner consistent with screening outcomes.
Two recently developed and complementary self-screening instruments show promise. Both instruments are intended to provide drivers with information about changes in safe driving abilities that occur with aging, and make recommendations about driving compensation and remediation strategies to extend safe driving, as well as further evaluation that might be indicated. The Driving Decisions Workbook (Eby & Molnar, 2001; Eby, Molnar, & Shope, 2000; Eby, Molnar, Shope, Vivoda, & Fordyce, 2003) is a paper-and-pencil instrument and the American Automobile Association's (AAA) Roadwise Review: A Tool to Help Seniors Drive Safely Longer is an interactive CD-ROM instrument based on the Clinical Driving-Health inventory program (Staplin & Lococo, 2003). Preliminary testing found that the Driving Decisions Workbook correlated with an on-road driving test and several clinical tests of functional ability, and older drivers found it to be useful and intended to change their driving as a result of its completion (Eby et al., 2003). To date, no published evaluation results are available for AAA Roadwise Review, but AAA reports that users enjoy the program and state their intent to follow the recommendations provided.
Driver screening and assessment is especially challenging for drivers with dementia, who are affected not only by physical changes that may accompany aging but also by intellectual and cognitive impairment (Kapust & Weintraub, 1992). Because drivers with dementia generally lack insight into their impairments in driving-related abilities, they are not good candidates for self-screening and may be resistant to other screening and assessment efforts. Drivers with dementia and the special challenges they present are discussed more fully in the section on transitioning to nondriving.
Where Do We Go From Here?
Functional Capacity Screening
Current priorities for research in this area are to seek additional data describing the validity and reliability of driver screening tools, while demonstrating their administrative feasibility when they are taken out of the laboratory for application in health care–rehabilitation, educational–training, insurance, licensing, or other real-world settings. It will also be of interest to compare the crash-prediction value of performance on single screening measures versus a full battery of tests.
Self-screening
Although early self-screening results are encouraging, there is clearly a need for further research to evaluate the effects of self-screening on driver behavior. In particular, objective data are needed about the actual changes in behavior made by drivers as a result of self-screening, including seeking out further assessment and evaluation, participating in driver education or training activities, and modifying or reducing actual driving. Ultimately, what is needed is an examination of whether driving safety has been positively impacted by self-screening and how self-screening can be used to facilitate effective communication and action within the families of older drivers. This might be achieved by analyzing driver history or crash records to try to detect changes in crashes or citations, or monitoring actual driving under natural conditions (e.g., through instrumented vehicles) to detect changes in driving performance. Both approaches are not without challenges and would require relatively large samples of older drivers, as well as the ability to follow study participants over time.
The development of validated assessment tools, as opposed to screening tools, is also needed, especially for drivers with dementia. The tools must be sensitive, easy to administer, and cost efficient. At present, professionals disagree on what constitutes an acceptable assessment of driving fitness, and consensus guidelines are only now beginning to emerge (Dubinsky, Stein, & Lyons, 2000; Wang & Carr, 2004). An individualized commonsense assessment from a professional is often used (Meuser, Carr, Berg-Weger, Niewoehner, & Morris, 2006), although an on-road assessment from a driver-rehabilitation specialist can provide more definitive data regarding driver capability to aid in the decision-making process.
Research is also needed to determine the appropriate reassessment intervals for drivers with dementia as their driving skills are monitored. At this point in time, the literature reports varying intervals of 3 to 12 months with little acknowledgment of varying levels of the disease process. Currently, the body of research and practice literature provides only guidance regarding the need for health professionals to assess driving competence of an older driver with dementia. Several organizations have provided consensus statements and recommendations for the facilitation of driving retirement.
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Rehabilitation |
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To be effective, education and training efforts for older drivers have to build on what is known about functional impairments, how they affect driving, and what can realistically be done to address the impairments (Molnar, Eby, & Miller, 2003). In many cases, the focus of education and training is not so much on individual impairments but on general driving skills that must be improved because of lack of knowledge about new traffic laws or safe driving practices (e.g., stopping distances on wet vs. dry pavement). The goal of training in these cases is to provide the necessary information and practice opportunities to improve driving skills. Training in regard to specific functional impairments may mean teaching older people to do new things or to do things in a different way (e.g., learning to do stretching and strengthening exercises, or improving visual attention or processing).
Unfortunately, until recently there has been little published research on this topic and some past training programs have been shown to be of limited efficacy (e.g., Bédard, Isherwood, Moore, Gibbons, & Lindstrom, 2004). However, recent evidence suggests that training may be beneficial for improving visual attention and processing speed in certain situations (Stephens et al., 2005). In addition, preliminary work suggests that a combination of in-class education and on-road training may lead to improvements in some important driving-skills components.
Where Do We Go From Here?
Much remains to be accomplished regarding training options for older drivers, and there are key issues to address. First, a clear theoretical framework must be delineated that identifies the necessary components of successful training programs. To optimize safe driving, the focus should include the following: (a) four components, namely, the driver, the driving environment, the automobile, and their interactions (Wang & Carr, 2004); (b) the fact that safe driving is achieved at different levels (Michon, 1979); (c) the self-beliefs that play a critical role in driving decisions (Anstey, Wood, Lord, & Walker, 2005); and (d) the larger societal influences, such as federal and state policies and regulations, that are relevant to a system's perspective on driving safety (Classen, Garvan, et al., 2006). Second, best practices relevant to older adult education have to be identified and adopted by practitioners. Third, target groups for intervention must be clearly identified. Our focus may be different when we are dealing with different subgroups of drivers (e.g., healthy vs. nonhealthy, or urban vs. rural). By increasing the focus on these issues, it may be possible to further increase safe driving among older drivers.
In addition to the development of training programs that would meet the needs of older drivers, research is needed to identify the impact of such programs over time on older drivers' driving confidence, travel patterns, safety awareness, and crash risk (e.g., near crashes, convictions, and collisions), as well as the cost effectiveness of the programs. More generally, research is needed to examine older driver compliance with professional recommendations for driver rehabilitation.
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Vehicle Modifications |
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Some vehicle modifications, such as easy-locking seat belts, visor extenders, steering-wheel covers to improve grip, and seat and back support cushions to relieve back pain or improve line of sight, do not require special training. Many of these features are available through automobile supply stores or other popular venues. However, Silverstein, Gottlieb, and Van Ranst (2005) note that although individuals with disabilities may be aware of such vehicle modifications, that information has not yet transferred widely to older adults themselves or to the network of aging-related professionals who serve them.
Other modifications require special training. These include: large panoramic rear and side mirrors; pedal extenders; leverage handles to assist in opening the car door; hand controls, directional signal crossovers to shift operation to the opposite side or foot; extra loud turn-signal "clickers" or a relocated or brighter turn-signal indicator; left-foot accelerator for those with limited or no use of the right foot; touch pads or voice-scan activation systems for car controls and electronic joystick controls for steering, gas, and brake; seat lifts to aid in getting out of a car seat; car lifts and carrying devices for a wheelchair; or a steering device to aid in grabbing the wheel and making turns easier or more efficient.
Before making any modifications to their vehicle, older drivers should be evaluated by an occupational therapist or certified driving-rehabilitation specialist to ensure that they get the right equipment, have it installed properly, and receive training on how to use it. Because each driver has unique needs and preferences, there is no one set of equipment that is right for everyone. In fact, some older drivers (such as those with dementia) may not be appropriate for rehabilitation intervention because they lack insight into their impairments and do not have the capacity to learn new strategies and techniques (Stephens et al., 2005).
Where Do We Go From Here?
Although vehicle modifications are recommended for many drivers with driving-related functional impairments, there is limited research on the effectiveness of these modifications in improving safe driving. Studies are needed to evaluate the impact of various vehicle modifications on actual driving performance and crash risk. In addition, research is needed to examine the training that individuals receive for driving with vehicle modifications to identify what works well and what does not, and how the process might be improved.
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Advanced Technology |
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All of these technologies, and many others, would seem to be beneficial to older drivers. Until recently, however, little of this technology was developed to take into account the unique requirements of older drivers. In an excellent review of older adult drivers and advanced technology, Caird (2004) concludes that although older drivers are the group most likely to find advanced technologies beneficial, they are also the group most likely to have an increased risk of crash through the introduction of advanced technology. Poorly designed technology applications could increase distractions for older users, leading to a higher risk of crash. However, systems designed for optimal use by older drivers would also be beneficial to drivers of all ages.
Studies show that older drivers use advanced technologies in a different way than do younger drivers (Caird, 2004; Eby & Kostyniuk, 1998; Stamatiadis, 1998). For example, in an evaluation of navigation-assistance applications, Kostyniuk, Streff, and Eby (1997) found that older drivers used the system more frequently than young people did, entered a greater number of destinations into the system, and utilized the technology with a "co-pilot." Understanding these patterns of use for the various technologies that are being developed is crucial for optimizing the benefits of ITS and advanced technology for all users. Such research is lagging (Caird).
Research has also found that older drivers take much longer to learn how to use ITS technology (Caird, 2004; Kostyniuk, Streff, & Eby, 1997). Whether this is a cohort effect of people who did not grow up using computer technologies or an effect of aging per se is not known. Understanding the concepts behind advanced technologies, in particular those that take over partial control of the vehicle, is crucial to the success of the technology for increasing safety and mobility. Thus, it is clear that acceptance of advanced technology by older drivers will be largely dependent upon the quality of training received.
Where Do We Go From Here?
An important topic of future research is the development and testing of educational materials and a curriculum about advanced transportation technologies designed for older adult audiences. This training should take into account how older adults learn and recognize the declines in abilities that they may be experiencing, such as decreased visual acuity or slowed information processing. The research should also determine the proper venue for training to take place.
Other research needs include optimizing the use of advanced technologies by older adults by developing a better understanding of how this age group uses various ITS applications. Improvements in the design of advanced technologies to take into account the special needs of older adults have the potential to benefit users of all ages.
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Roadway Design |
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Because wholesale changes to the entire roadway infrastructure would be cost prohibitive, design improvements recommended in the Handbook are keyed to new construction; reconstruction of existing facilities; regularly scheduled maintenance activities; and "spot treatments" where there are crashes or other demonstrated safety problems, or where a proactive approach to avert future problems is desired by state or local transportation authorities. In consideration of the sensory, perceptual, cognitive, and physical limitations of older adult drivers, design improvements broadly prescribe increases in the size and brightness or contrast of painted markings and sign messages, reduced complexity in traffic-control information, and more extensive use of advance-warning treatments. More specifically, engineering "best practices" are targeted where crash data analyses indicate the most significant safety problems exist and where data show that the mobility of seniors is most affected: urban and suburban intersections, operations at pedestrian crossings, violations of expectancy at highway work zones, and nighttime driving difficulties across a variety of settings.
The Handbook provides its most extensive set of recommendations for urban and suburban intersections, where the greatest safety problems are associated with left-turn movements. Removing conflicts between turning and through vehicles by providing "protected" signal phasing (turn arrows) is most desirable. Where capacity requirements dictate the use of "permissive" phasing, and left-turning drivers must choose safe gaps in oncoming traffic, Handbook recommendations focus on practices that improve sight distance. These include the consistent use of a 2.5-second perception-reaction time value in formulas for intersection design, and a positive offset of opposing left-turn lanes to ensure that a driver's view of oncoming traffic is not blocked by vehicles waiting to turn left across the intersection. Additional recommendations highlight the need for better delineation and channelization practices to indicate the proper paths for designated movements at intersections; overhead lane-use control signs and advance (midblock) street-name signing to reduce driver uncertainty; limiting the angle with which intersecting roads meet to no more than a 15° "skew" from perpendicular, because reduced head–neck flexibility makes scanning to the sides a great deal more difficult; eliminating right turn on red where any skew exists; implementing more prominent signing to reduce wrong-way movements at intersections; and the use of larger stop signs and backplates for traffic signals to improve the conspicuity of these devices.
Where Do We Go From Here?
Continuing research priorities with regard to intersection improvements and other roadway design enhancements are twofold. First, the safety effectiveness and cost effectiveness of countermeasures such as those included in the Handbook must be demonstrated at the local, regional, and state level, to accelerate their implementation; and, the associated benefits of preserving and extending mobility for older adults must somehow be factored into these assessments. Recent findings from a study of safety impacts of improved intersections using kinematics measures from an instrumented vehicle and on-road evaluations show promise but must be replicated and expanded (Classen et al., 2006, 2007). Second, even when there is solid evidence that a design change is beneficial, older motorists may resist its use; a prime example is using a modern roundabout in preference to a conventional intersection. Researchers must identify the best strategies to educate older road users about upgrades in roadway design and traffic control technology, and to promote their use.
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Transitioning to Nondriving |
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Research has shown that decisions to stop or reduce driving are influenced by a variety of factors. One of the most important factors is the status of an individual's health. The physiologic changes of aging (Coughlin, 2001), the pathological effects of various diseases, and the medications used to treat them may affect one's ability to drive (Ray, Thapa, & Schorr, 1993). Older adults experiencing health declines typically resist giving up driving as long as they possibly can, although many do self-regulate their driving patterns (e.g., do not drive at night) in what has been called a "driving cessation continuum" (Dellinger, Sehgal, Sleet, & Barrett-Connor, 2001). However, ultimately, medical problems are often the reason older adults stop driving (Dellinger et al.). Some of the medical factors associated with giving up driving include age-related eye disease, Parkinson's disease, and stroke-related paralysis (Campbell, Bush, & Hale, 1993). In fact, poor vision is the most commonly cited reason older adults give for regulating or stopping driving (Dellinger et al.; Rabbitt, Carmichael, Jones, & Holland, 1996), and visually impaired older adults say that giving up driving is one of the most devastating consequences of their impairment (Horowitz, Boerner, & Reinhardt, 2002).
Research has also focused on the sociodemographic factors associated with driving cessation. Evidence of social influences on driving cessation is mixed, with some studies reporting an influence of friends and family on older drivers' decisions (Johnson, 1995, 1999) and another reporting no such influence (Persson, 1993). Financial resources may have an impact on driving decisions; for example, for those older adults living on fixed incomes, the costs of owning, maintaining, and operating a motor vehicle can be prohibitive.
An emerging line of research is beginning to examine the mental health consequences of driving decisions (Johnson, 1999; Persson, 1993; Yassuda, Wilson, & von Mering, 1997). An increasing number of epidemiological studies are showing that driving cessation may be associated with increased depression over time and declines in general psychological well-being (Fonda, Wallace, & Herzog, 2001; Marottoli et al., 1997; Ragland, Satariano, & MacLeod, 2005).
The issue of driving reduction and cessation is especially challenging in regard to people with dementia (see Vanderbur & Silverstein, 2006, for review of the literature on community mobility and dementia). Studies indicate that up to 25% of older adults continue driving after a physician recommendation for driving cessation (Dobbs, Carr, & Morris, 2002). Unlike older adults who have sustained a stroke, suffer from arthritis, or experience declining vision, drivers with dementia cannot be retrained or have modifications made to the car to correct for their deficits. Although many drivers cease or restrict their own driving when they experience changes in their driving abilities, people with dementia do not always make the appropriate decisions on their own with regard to driving modification or cessation because of their lack of insight, poor judgment, and loss of reasoning ability (Adler & Kuskowski, 2003). It has been shown that compared with most of the general driving population, drivers with dementia are at an increased risk for unsafe motor vehicle operation and crashes (Fox, Bowden, Bashford, & Smith, 1997). In addition, several studies have revealed that people with dementia become lost while driving (Rowe, Feinglass, & Wiss, 2004; Silverstein, Flaherty, & Tobin, 2002). For these reasons, drivers with dementia ultimately must stop driving. In most cases, driving retirement becomes a question of not "if" but "when." A smooth and safe transition to nondriving status is especially important for this group.
Because driving requires cognitive abilities such as memory, recognizing images (visual processing), attention, and decision making, driving concerns often are first noted by others following a disturbing incident (i.e., becoming lost, a motor vehicle accident or driving citation). Currently, a "wait and see" posture has developed among respected professionals suggesting that the family knows best or the litmus test of until the first accident is a sufficient response. In response to a crisis, family or friends often request the immediate help of a professional to facilitate driving retirement, thus creating a difficult family dynamic. To avoid such a crisis, professionals should integrate driving fitness into routine assessment and intervention planning, recognizing that the transition to nondriving is an individualized process (Dobbs et al., 2002).
Experts in alternative transportation note that individuals move toward driving retirement over a process that takes years or even a decade. Decreasing driving destinations is observed with increasing physical and cognitive frailty (Marottoli, Mendes de Leon, Glass, Williams, Cooney, & Berkman, 2000). Thus, there is often ample time to discuss this issue, as appropriate, when older adults meet with health professionals. An interdisciplinary approach to mobility counseling that includes a physician, social worker, and occupational therapist may facilitate driving retirement and enable the older adult and the family to plan for a healthy transition into retirement. Unfortunately, clinicians are usually called in during a time of crisis, making the transition to driving cessation more difficult than it has to be.
Where Do We Go From Here?
Although it is clear that "giving up the keys" can be traumatic and changes the lives of older adult drivers, very little is known about the driving-cessation process or the shift to transportation dependence. Nearly 1 million drivers will stop driving because of poor health within the next year. Considering the growth in the older adult population and the dependence people have on the automobile for transportation, it is important to more fully understand factors that influence driving decisions and the effects those decisions have on older adults. Such information may help to develop strategies for continued mobility in light of changing needs and capabilities.
Given the link between driving and personal independence, introducing driving retirement can be a difficult and emotional event for both the older driver and the support network. Therefore, it is especially important that the transition to nondriving be approached as a process rather than as a single directive or event, given that driving is important not only for accomplishing daily tasks but also as a means to maintain one's socialization, and given that it is imbued with a host of psychological meanings, including a sense of autonomy, independence, and self-worth (Burkhardt, 2000; Owsley & McGwin, 1999; Yassuda et al., 1997).
Although it has been suggested that the decision to change driving behaviors and stop driving completely is complex and motivated by a range of factors (Dellinger et al., 2001), there has been surprisingly little research addressing the psychosocial influences on this decision, including the role that family, friends, and professionals play in this process. Further, prospective studies are needed to identify the factors that mediate the impact of driving self-regulation and cessation on the individual's mental health and psychological well-being (Johnson, 1995, 1999; Marottoli et al., 1997). Other fruitful areas of continuing and future research include investigation of social and psychological antecedents and consequences of driving cessation, and identification of adaptive strategies and pathways to effective driving self-restriction.
Historically, the focus of older driver safety has been on identifying at-risk drivers and when to cease driving. Although issues related to driver screening and assessment are important, attention should also be devoted to cessation counseling and helping older drivers transition to nondriving. However, there is little if anything known about what can be done to ease the shift to transportation dependence. One potentially fruitful avenue of inquiry is to explore whether findings from the broader literature on managing life transitions can be applied to the driving arena. There is a need to better understand the transition process for older drivers to determine what opportunities it might present and what strategies might be useful in managing the process more smoothly.
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Alternative Transportation |
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Among the alternate transportation options available for seniors are public and paratransit services, private and specialized transportation services, and senior transportation services known as STPs (which stands for supplemental transportation programs). Current best practices for meeting older driver travel needs by transit operators have already raised quality of service and harnessed the use of information technology. Real-time notification of time of arrival or departure of paratransit services, door-through-door services, and the training of seniors how to use transit services are some examples. Alternatives to traditional transit services include initiatives such as ITNAmerica, which provides "dignified and sustainable transportation services" using the automobile to assist older adults. These services advertise that they enable seniors to get where they need to go, offer seniors what some call "a modicum of independence," and enable older adults to stay in their homes as long as possible while making it possible for people to stop driving.
Unfortunately, these options are typically common in urban areas and minimally available in rural communities. Furthermore, for the vast majority of older adults who stop driving as a result of poor health, their poor health precludes them from using public mass transit services as an option even if it is available. For example, older adults may be unable to walk to the bus stop, climb the stairs to a van, go to activities beyond their jurisdictional boundaries, or pay for the transportation services. This last barrier is especially true for low-income older adults with limited financial resources (Carp, 1988).
Research by the Beverly Foundation (2004) has identified five attributes of alternative transportation services that determine whether they are "senior friendly," including availability, acceptability, accessibility, adaptability, and affordability. The need for senior-friendly transportation services is more than just a convenience; many older adults in need of alternative transportation services are unable to use the currently available services because the services do not meet the requirements for being senior friendly.
Thus, it is not surprising that many older adults consider public transportation to be inadequate and not responsive to their needs (Kostyniuk & Shope, 2000), and when they can no longer drive they report relying on family and friends for transportation (Kostyniuk & Shope, 2003). This helps explain why the presence of transportation alternatives does not necessarily ensure the well-being of those who give up driving (Legh-Smith, Wade, & Hewer, 1986), and few who live in areas with practicable transportation alternatives actually use them (Burkhardt, 2000), with one study showing that only 1% of trips made by older adults were made by transit (Collia, Sharp, & Giesbrecht, 2003).
Where Do We Go From Here?
Despite some attempts by researchers to estimate the market for alternative transportation services (e.g., Foley et al., 2002; Staplin & Freund, 2005), a definitive methodology for estimating future numbers of drivers who will be reducing their driving or stopping altogether is lacking. The challenge in fully understanding the market potential for transit services is further complicated by the need to understand other issues. These include where seniors will be residing (i.e., in an urban, suburban, or rural environment), their household context, how health and technology will influence driving cessation, and the cultural and economic considerations that will influence driving cessation and the need for alternative transportation services.
Longitudinal data sets may provide a resource for deriving future numbers of drivers who gradually reduce their driving exposure or cease driving altogether. However, many of the current data sets are focused only on senior health or morbidity issues. There is a need for an increase in the number of variables that focus on mobility and other lifestyle issues. This need must be coupled with the analysis, financial support, and dissemination of results emanating from these data sets by and to professionals from a variety of disciplines. With this potential collaborative initiative in mind, we think that facilitating the diverse future travel needs of older adults will require a substantial amount of mobility planning (entailing an intimate understanding of older adult travel needs), increasing numbers of proactive and specialized mobility providers, and dedicated financial resources.
Given the importance of providing alternative transportation services that are senior friendly, research is needed to better understand how these attributes map to older adults' functional abilities as well as to transportation service providers' capabilities. When particular services are not able to meet the criteria for friendliness, it is important to identify ways to adapt the services or to create linkages with other services that do meet the criteria. Further, there is a need to develop and evaluate community models that demonstrate the continuum of services that are friendly to older adults.
Several research needs in the area of alternative transportation have particular importance for drivers with dementia, although there are broader implications as well. Identifying alternative transportation resources that correspond with individual support networks is critical and must "fit" with the retiring driver's needs and capabilities (Taylor & Tripodes, 2001). Transportation options must be available and practicable, and they must provide access to business, health-related, and social activities. Ongoing follow-up is essential. Transportation plans and life situations can change, resulting in the situation in which the driver continues or resumes driving. It could be argued that alternative modes of transportation are not very senior friendly, let alone "dementia friendly." For example, arm through arm rather than curb to curb might define one criterion that would be critical for a dementia-friendly service. The key criterion for assessing community mobility options for the person with dementia ultimately is this: Can they use it? A note of caution is that arm through arm is extremely expensive, time consuming, and probably not something most volunteer drivers would be willing to do for a long period of time.
Other questions remain that have to be answered about older adults and their needs for alternative transportation. With the growth in the older adult cohort, can we expect a concomitant increase in transit use? Are there some tactics and strategies that can help overcome the historical tendencies of older adults who have ceased to drive to be too frail to avail themselves of transit services or to rely on riding with family members and friends? How will a challenged transit industry continue serving their primary "commuter" markets while attempting to offer innovative services that will be attractive to older adults and subsequently used by them?
Research in this area could also benefit by focusing more broadly on how to facilitate the transition for older adults and their family members from one stage of mobility to the next. Currently, efforts related to older adult driving safety (e.g., assessment and rehabilitation) are quite disconnected from efforts to develop and support alternative transportation options. That is, driver safety professionals pursue research, assessment, and rehabilitation activities on one track while the transportation options professionals do research, develop models, and support transportation services for older adults on a parallel track. The most frequent overlap appears to be the agenda of giving up the keys, which both sectors deal with on a daily basis. Unfortunately for older adults, neither group appears to address the transition from one sector to the other in a coordinated manner. The current link between these parallel tracks appears to be information or referral services that help older adults who are no longer able to drive get in touch with transportation options. There is no question that identifying options is important, but what is also needed is the development and testing of a transportation transitions model that links the driver safety and transportations options sectors to help support older adults and their families as they make the transition from driving to transportation dependence.
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Discussion and Conclusions |
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Although the areas included in this review are diverse, four cross-cutting themes emerged as important for all areas. The first theme is the importance of safe transportation for older adults. Safe mobility is essential to continued engagement in civic, social, and community life, and to the human interactions necessary for health, well-being, and quality of life. When safe driving is no longer possible for older adults, safe and practicable alternative transportation must be available. A second theme is that older adults are individuals, with specific needs, abilities, and resources. Not all older adults will have difficulty meeting their transportation needs and no single transportation solution will work for all people. A third theme is that research and countermeasures intended to help meet the transportation needs of older adults will likely also benefit younger users of the transportation system, particularly those with disabilities. Thus, improvements in areas such as roadway design and advanced technology to meet the needs of older adults will likely have benefits for road users of all ages. A final theme is that the issues surrounding the maintenance of safe transportation for older adults are multifaceted and will require an interdisciplinary research approach if we are to make significant progress in the next decade as the baby boomers begin to reach age 70. The research agenda outlined in this article provides an opportunity for researchers in transportation safety, gerontology, engineering, social work, occupational therapy, psychology, sociology, public health, urban planning, medicine, and pharmacology to work together to help achieve the goals of safety and mobility for older adults and drivers of all ages.
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Footnotes |
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We thank Kathrin Boerner, David B. Carr, Jane Hardin, Thomas M. Meuser, Steven E. Mock, Patricia M. Niewoehner, Joann Reinhardt, and Elin Schold Davis for their valuable contributions to this article. We also thank the interest group membership at large for its collective insights and wisdom about safe mobility for older adults. Finally, we thank GSA for its ongoing support of the interest group. The opinions, findings, and conclusions expressed in this article are those of the authors and not necessarily those of GSA. For more information about the Transportation and Aging Interest Group, please contact its primary convener, Lisa Molnar (ljmolnar{at}umich.edu).
1 Department of Occupational Therapy, East Carolina University, Greenville NC.
2 University of Michigan Transportation Research Institute, Ann Arbor.
3 Graduate College of Social Work, University of Houston, TX.
4 Public Health Program, Lakehead University, Thunder Bay, Ontario, Canada.
5 Saint Louis University School of Social Work, MO.
6 Department of Occupational Therapy, College of Public Health and Health Professions, Gainesville, FL.
7 Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Rockville, MD.
8 Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY.
9 The Beverly Foundation, Pasadena, CA.
10 Center for Urban Transportation Research, University of South Florida, Tampa.
11 College of Public and Community Service, University of Massachusetts, Boston.
12 TransAnalytics, LLC, Kulpsville, PA.
Decision Editor: Linda S. Noelker, PhD
Received for publication December 18, 2006. Accepted for publication March 16, 2007.
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This article has been cited by other articles:
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  B. Mezuk and G. W. Rebok Social Integration and Social Support Among Older Adults Following Driving Cessation J. Gerontol. B. Psychol. Sci. Soc. Sci., September 1, 2008; 63(5): S298 - S303. [Abstract] [Full Text] [PDF]
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Abstract
Screening and Assessment