The Driving Dilemma

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By Elizabeth Dugan

Even though I am a baby boomer who affectionately calls my mother “Crash,” I should confess that she wasn’t the inspiration for my book The Driving Dilemma. Ironically, it wasn’t until I was nearly finished with the project that my mother became a case study. She provided an example of the kind of accident that is becoming more and more common as our population ages: an older person, driving on a weekday, close to home, involved in a crash while making a left turn. Lucky for us no one was seriously injured in her accident – but it sure was a wake-up call for my family. After more than five decades of accident-free driving, my mother was providing an unwanted and all-too-personal case study to use to explain the problem facing older drivers and their families.   

One good thing to come out of the experience is that I can personally attest that the steps outlined in my book. After her accident, my mother, my siblings and I assessed the situation, talked over the issues threatening her driving fitness and safety, and explored possible alternative transportation options and assistive devices to help. We began talking and working together to prepare for her eventual retirement from driving.

While that may sound easy, don’t be mislead – confronting a driving problem (or even a potential problem) isn’t simple or pleasant. The easiest and most comfortable solution is to have family members provide needed transportation. But adult children are often busy with other family and career responsibilities, and many do not even live close enough to help. So finding and using local transportation options becomes a huge challenge. Driving retirement may be the first major late life issue we confront and it can be incredibly unsettling and upsetting. But I know that with information, communication skills, and confidence you will be better prepared to tackle this difficult issue with grace.

The golden age wave
It’s no secret that our population is aging. The number of older drivers will double in less than 20 years, and it won’t be long before one out of four drivers is age 65 or older. This golden age wave is caused by unparalleled medical and public health achievements. It’s simply amazing to think that never before in human history have most people lived to old age. We have an extra two or three decades of life compared to Americans who lived just 100 years ago. As a gerontologist I view this as an exciting human development. Yet my wonder at this demographic change is tempered by the fact that many institutions (e.g., regulatory, medical, social) haven’t “caught up” with this new reality yet.  

What's the problem?
The good news is that older drivers, on average, tend to be safe drivers. Compared to younger drivers they drive fewer miles per year, almost always wear seatbelts, and rarely get ticketed for speeding or driving under the influence. However, the bad news is that when involved in a crash -- an older driver is much more likely to be killed or seriously injured compared to a younger driver. Per-mile-driven the fatality rate is more than nine times higher for drivers 85 and older compared to younger drivers (aged 25- 69). 

These trends are combining to create a new – and often disturbing – milestone in life: the moment you hang up the keys for good. Recent research suggests that we’ll outlive our ability to drive by seven to ten years. For most of us driving retirement will become a pivotal life event (like marriage, parenthood or retirement). Unlike those transitions however, we don’t have established traditions surrounding it, nor much experience for making the passage easier on us.

Thus a problem with driving fitness is likely to be a sentinel event in a person’s life -- and may foreshadow other changes that threaten independence. Many of the strategies that I describe to help you with conversations about driving are perfectly applicable to other sensitive topics. I hope that being prepared for this first issue will help you to better deal with other later-life issues as well.

What the facts about older drivers?
Driving fitness is determined by our mental and physical function – in lay terms, how well we can see, think and move. Obviously, vision is vitally important to driving fitness. The incidence of many vision impairments increases with age. Not only do we have to see stimuli, we have to cognitively process a tremendous amount of information quickly and clearly to drive safely.  Physically we have to be able to get in and out of the vehicle, manipulate the steering, acceleration, and braking systems. Finally, we have to know and follow the rules of the road.

Crashes. As noted, older drivers actually have relatively low rates of accidents. But they are more likely to be injured or die as a result of those crashes, and more likely to recover more slowly from any injuries sustained. The most deadly type of crash, the side impact, occurs more characteristically with older drivers (particularly on left turns). Among older drivers, men are two times as likely as women to die in a crash. Most traffic fatalities involving older drivers occurring during the daytime, on weekdays, and involve another vehicle.

Driving modification. Many older drivers modify their driving to avoid risky situations such as driving in bad weather, heavy traffic, or at night. Many drivers intuitively know when to limit their driving and do so very successfully. Unfortunately, some do not. And sometimes even self- regulation is not enough to compensate for accumulating threats to driving fitness.

Chronic disease. Nearly three out of four older adults have one or more chronic illnesses. Nearly 50 percent have two or more conditions. The conditions themselves or the medications used to treat them can impair driving fitness.

Age.  Driving fitness is not determined by age. Just because someone is 65, 75 or even 95 does not automatically mean they should give up driving. It isn’t age that determines driving fitness but how well the person can see, think, and move. Decades of research have proven that we age at different rates. We all know people who are healthy and active well into their 90s, while others may become debilitated or die in their 50s or 60s.  

Assess driving fitness
It’s important to base your discussions about driving fitness on objective information and not just a vague sense of worry. The easiest, least expensive, and unfortunately -- least accurate -- assessment is to take a driving quiz or to review a driver checklist (see www.drivingdilemma.com for a free copy). These self-assessments list warning signs of driving impairment that indicate whether further assessment or action is needed.

Another good assessment is the AAA Foundation Roadwise Review CD-Rom program. This program is based on solid research, is affordable (about $15), can be completed at home, and has a very positive approach. The only drawbacks are that the older driver has to be comfortable with computers (especially a mouse) and needs someone to help with the testing procedures. 

Driving fitness requires the ability to see, think, and move – so the clinical assessment of these key functions is the next step in assessment. The National Highway Transportation Safety Administration and the American Medical Association partnered to create clinical practice guidelines to provide guidance to healthcare providers on the assessment of older drivers. It is available online (at www.nhtsa.dot.gov/people/injury/olddr ive/OlderDriversBook). I recommend an assessment by a board-certified geriatrician, if possible, because they are experts in assessing and treating the many complex conditions associated with aging.  

Finally, the most comprehensive type of assessment is a multidisciplinary assessment conducted at a driving rehabilitation clinic. These types of assessments include:
 

  • an interview with a geriatric social worker to determine a person’s driving history, resources, and needs
  • a cognitive assessment by a neurologist or geropsychologist
  • a physical assessment by a geriatric nurse practitioner or geriatrician
  • an actual road test with a certified driving rehabilitation specialist

Unfortunately this type of assessment is not yet covered by most health insurance plans and the out-of- pocket expense (typically about $400) may be prohibitive for some.

Assistive devices
There are a number of assistive devices that may help compensate for some threats to driving fitness. Low vision specialists, occupational therapists, and driving rehabilitation specialists can all be excellent resources when seeking to find out more about obtaining and using assistive devices.

Before you start talking
If you are worried about a client or loved one’s driving, here are some things to think about before you start a conversation on the subject.

Consider what driving represents to his/her identity. Put yourself in his or her shoes. What difficulties might arise without a car? Will he or she be able to keep up with important activities?

Anticipate emotions. The process of change in driving status can be scary and complicated.  Will your loved one be sad? Angry? Afraid? Many people start to worry: Am I losing control?  Will I become a burden?  Am I dying?

Plan ahead. Start the conversation at a time and place when you will not be interrupted or have to rush. Sit comfortably where everyone is at the same eye level. Avoid rehashing old arguments. This should be a conversation about your love and concern for the driver’s safety and the facts relating to the person’s driving fitness. If you acknowledge that you both have the same goal, that is keeping the older driver as independent, socially integrated, and safe as possible – whether they are driving or not – many fears and hard feelings can be avoided.

Talking about change
Many of us are squeamish about talking about a topic as important and sensitive as driving fitness and retirement. Every state has established clearly defined rules about the medical fitness standards that are required to maintain a license to drive. If one of the clinical or multidisciplinary assessments described above identifies a deficiency – the time to talk is now.  One thing to keep in mind is that it may not be a dichotomous choice (drive vs. cease driving).  There are graduated steps (don’t drive at night, avoid highways, etc.) that may extend driving fitness. The challenge then shifts to closely monitoring driving fitness during the graduated steps and being prepared for when driving is no longer possible.

I have a number of colleagues and friends who have offered me piles of money to talk to their parents and to get them to stop driving. But honestly, the conversations can be very positive. I recommend using the strategies from a counseling approach called motivational interviewing (see www.motivationalinterview.org for more information). This approach stresses:

  • using open-ended questions
  • seeking to understand the older driver’s perspective
  • recognizing that the ultimate responsibility for change rests with them
  • recognizing that there are pro’s and con’s to every change in behavior
  • being prepared to roll with resistance
  • supporting the person’s self-efficacy
  • using reflective listening techniques

You’ll find that using this approach takes enormous pressure off you. If you approach the conversation with the goal of getting mom to hand over the keys you are setting yourself up for conflict, frustration and failure. 

Instead, I recommend that you approach the discussions with the twin goals of 1) keeping the person as safe and independent as possible, and 2) understanding how he/she sees the issue. This approach frees you from having to “persuade” the driver to see things your way, which nearly always leads to attack/denial, point/counterpoint arguments. This communication style puts you and the driver on the same team -- working together to understand and resolve the problem. If you give the older driver permission to think about and express both the pro’s and con’s of making a change (e.g., retire from driving) you’ll find that it opens up communication and helps move the person closer to changing.

When talking is not enough
Unfortunately there are times when an assessment indicates a loss of driving fitness and despite your best efforts, talking about driving retirement is not sufficient. In some instances you’ll have to work with the regulatory system to get an unfit driver off the road. Check with the California Department of Motor Vehicles Senior Driver Program (www.dmv.ca.gov/about/senior/senior_top.htm ) for information.

 

Elizabeth Dugan, PhD, is a noted researcher on geriatric issues. She studies how older patients and their doctors communicate, especially about sensitive topics (like driving retirement). Dr. Dugan teaches at the University of Massachusetts Medical School and also has an adjunct faculty appointment at the Wake Forest University School of Medicine. She is the author of The Driving Dilemma (Collins of HarperCollinsPublishers, 2006; www.drivingdilemma.com) and can be reached at elizabethdugan@drivingdilemma.com.

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