Excerpt: 'The Driving Dilemma'

More aging men and women in America means more elderly drivers on the road. It won't be long before one in every four drivers in the country is over the age of 65.

With the increase in older drivers comes safety issues. Dr. Elizabeth Dugan answers many of the questions older drivers and their loved ones have about the effects of age, medical conditions and medications on driving in her new book, "The Driving Dilemma."

Read an excerpt from "The Driving Dilemma" below:

Assessing Fitness to Drive

Your aunt is 86 and has just returned from a care facility where she had stayed to recover from a fall. She walks very slowly and has diffi culty with stairs, but she insists she is a safe driver and hasn't had any kind of traffi c accident in more than 20 years. Still, you wonder, should she be driving?

Your father is 72 and is in relatively good health, but while driving with you recently on the highway, he strayed to the left-hand shoulder, then overcorrected with a sudden jerk of the wheel. This left you frightened and him defensively arguing that it wasn't a big deal. Is he at risk?

Your mother is 75 and you've noticed that in the past couple of years she has been repeating herself -- sometimes telling you the same story twice in a conversation. You notice some dings on the bumpers of her car, and a scratch on the right side. When you ask her about them, she seems surprised and says they must be from other people bumping into her car while it was parked at the grocery store. Should you be worried about her driving?

These very common situations all confront you with a similar challenge: How do you know if an older adult is fi t to drive? Since age alone is not a reliable indicator, what should you be looking for? And, if you are an older driver, what should you be looking for in your own driving habits that might signal a need for some kind of change?

This chapter describes the most common warning signs of driving risk and gives you some tools to assess whether a real driving problem exists. Specifi cally, I explain what the indicators of driving fi tness are, what signals a problem, how to categorize the severity of problems, how to conduct a home assessment, and what's involved in a professional assessment. Appendix 1 includes assessment forms that can be used either by an older driver for self-assessment or by a family member or friend. Appendix 2 contains forms to help you to implement changes by talking with your physician about specifi c functional concerns related to driving that may need some medical intervention.

Driving safety involves factors related to the vehicle, the roadways, the weather and other conditions. Above all, driving safety involves the driver. This chapter focuses primarily on drivers and on determining their fi tness for driving. Although it is important to ensure that a vehicle is in proper mechanical condition, that issue is beyond the scope of this book. I'm working from the assumption that the vehicle is in good working condition. Also, other factors play a role in how safely a person can operate a vehicle: the conditions of the roads and a driver's familiarity with them, the weather, and the time of day all can affect driving safety. Obviously, all possible conditions can't be addressed here, but they should be taken into account when determining driver fi tness. If you are concerned about a driver's fi tness, you will want to observe his or her driving fi rsthand and keep a written record of your concerns. The forms in Appendix 1 should help you.

Driving Fitness and Age

At the most basic level, driving requires that we have the ability to properly see, think, and move. Limitations in any of these three key functions may signal a worrisome threat to driving fi tness. Illness, age, and even signifi cant life events can all impair your ability to see, think, and move. Signifi cant life events, such as the loss of a spouse, may be so distressing that they contribute to physical changes that, in turn, affect driver safety. For example, the physical symptoms of fatigue and slowed thinking are common in grief. While these symptoms are perfectly normal, they can impair your ability to drive safely. See Chapter 2 for more information about common age-related changes and medical conditions that may impair driving fi tness.

Contrary to what many people believe, age, by itself, does not determine driving fi tness. What matters in driving are three fundamental functions: the ability to see, think, and move. These abilities change at different rates for different people. Some people in their 90s and beyond are more healthy and fi t for driving than some people in their 50s or 60s. Thomas Perls, M.D., M.P.H., a professor at the Boston University School of Medicine, became interested in this phenomenon when he noticed that some of his oldest patients were some of his healthiest. Dr. Perls directs the New England Centenarian Study and is widely regarded as one of the world's leading experts studying adults aged 100 years or older. His research shows that centenarians age relatively slowly, and seem to have delayed or entirely escaped diseases associated with aging such as heart disease, stroke, cancer, and Alzheimer's disease.

I spoke with one of Dr. Perl's study participants, Ms. Nedinne Parker, aged 104. Ms. Parker is a devoted baseball fan (she roots enthusiastically for the Kansas City Royals), still lives independently, and drives once a week to her volunteer job at a local hospital. She is a remarkably healthy, active, witty woman who is still able to see, think, and move well enough to drive safely. Ms. Parker is modest about the fact that she still maintains her driving fi tness. She also realizes that she has some limitations and that others may be skeptical of her driving skills. During our conversation, she quipped that she doesn't have many friends or relatives clamoring for a ride: "Well, to be honest, I don't know if I would be too quick to jump in a car with a 104-year-old gal!" She has limited herself to driving only on local, familiar roads and only during daylight hours. As a result of these self-imposed limits she has been able to maintain her driving fi tness. Similarly, Mr. Edward Rondthaler still lives independently and is driving around upstate New York at 100 years of age. Mr. Rondthaler doesn't drive as much as he did when he was 80 (he drove across the country then), but he still enjoys driving around town and is doing so safely. These drivers remind us that it is not age but function that determines driving fitness.

Warning Signs of Driving Risk

If driving fi tness isn't determined by age, then what are the signs of impaired driving fi tness? Listed below are warning signs of impaired driving fi tness based on research and guidelines developed by advocacy groups such as the American Association of Retired Persons (AARP), the American Automobile Association (AAA), and the American Medical Association (AMA).

To help you remember them, I have categorized the warning signs by level of risk into red, yellow and green. "Red" signs point to the highest level of safety risk. Having one of the red risks is a signal to immediately begin the conversation about driving and to seek a professional assessment. "Yellow" signs point to a somewhat lower, but still signifi cant safety risk. Having one yellow risk is cause for concern, and having two or more is cause for concern and should prompt further assessment. "Green" signs point to safety risks that are usually easily corrected and, if corrected, can allow a person to continue to drive safely. If you are concerned about your driving or the driving of a loved one, the time to start talking is now. I can't stress this enough -- being proactive and informed helps everyone. Honest and open communication is the best way to develop a plan that respects the needs, wants, and safety of all involved.


One or more auto accidents in the past fi ve years. A recent history of accidents is a strong predictor of future mishaps. Did the accident involve another moving vehicle? Was it a single car accident? Did it involve hitting a stationary object? The details of the accident(s) are important in evaluating the overall risk of the accident.

Recent traffic tickets or police warnings. This is a serious indicator of suboptimal driving performance. Insurance companies raise their rates after a ticket or accident because such events tend to predict future problems.

Severely impaired vision, cognition, or mobility.


Recent near misses or close calls while driving. Sometimes a near miss isn't our fault, but sometimes it is a symptom of declining driving performance. It's important to know which is the case in order to evaluate the risk for the driver.

Having friends or relatives say they don't want to ride with the driver, or having them say they don't want their children driving with that person.

Since people are often reluctant to speak up about their concerns for a person's driving, such expressions should be taken seriously as a sign that something is wrong. If concerns are raised, get the details and follow the guidelines presented later in this book for initiating a conversation and taking action.

Accumulation of vehicle dents and dings. Backing into things or scraping walls or other objects may indicate vision, mobility, or navigational problems. Minor fender benders also signal that driving fi tness is slipping.

Feeling uncomfortable, stressed, or exhausted when driving. Stress and exhaustion are signs that a driver may not be feeling fully competent behind the wheel and, thus, can be a signal that driving skills are diminishing.

Having other drivers honk, gesture, or seem annoyed at you when driving.

Unless you live in a city that is famous for rude drivers, honking, yelling, or other "impolite" actions are probably a clue that a person's driving is either erratic or outside the norm, both of which can be a sign of trouble.

Diffi culty judging gaps in traffi c at intersections and on highway entrance and exit ramps.

Age-related changes in the eyes may impair depth perception.

Failing to notice vehicles or pedestrians on the sides of the road when looking straight ahead.

Being surprised by the sudden presence of pedestrians or cars could indicate a diminished fi eld of view, which is vital to safe driving.

Not seeing lights, signs, signals, or pedestrians soon enough to respond to them smoothly.

Getting lost more often than in the past, especially in familiar areas.

This could signal memory problems or other cognitive defi cits. Trouble paying attention to traffi c signals, road signs, and pavement markings.

This could be a sign of a problem with the cognitive ability to divide attention and to respond to multiple cues simultaneously.

Slow response to unexpected situations. This could signal impaired thought processes related to recognizing stimuli and attaching meaning to them or a delay in physical reactions.

Becoming easily distracted or having diffi culty concentrating while driving.

New or worsening medical conditions. Chapter 2 explores medical conditions and driving in detail. The worsening of a condition may require adaptations.

Taking medications with side effects that can impair driving safety. Many medications carry warnings about operating machinery or driving while taking them. In Chapter 3, many common medications and their effects on driving safety are discussed.

Not using the safety belt. Forgetting to take advantage of the safety belt could signal problems with memory. If it isn't that the driver forgets to use the safety belt, but that he or she can't operate it because of physical limitations, there are seat belt extenders that can lengthen the receptacle and strings or ribbons that can make it easier to pull the belt over the shoulder and torso.

Diffi culty negotiating sharp turns and intersections. These may refl ect problems with seeing or moving, both of which impair safety.

Hesitating over right-of-way decisions. This may signal an important problem with cognitive processing speed.

Diffi culty keeping the car in the proper lane. A driver who straddles lanes, drifts into lanes without realizing it, or changes lanes without signaling could have a vision or movement problem.


Trouble seeing over the steering wheel. The driver's eye level should be between the top of the wheel and the level of the rear-view mirror, approximately 10 inches away from the air bag. Short drivers should use a seat cushion or pillow to achieve the correct position.

Diffi culty looking back over one's shoulder. Commonly caused by neck stiffness or pain, this can cause real problems. See a driver rehabilitation specialist to fi nd out if getting the car fi tted for adaptive mirrors will help, and consult with a healthcare provider to see if there are treatments that can improve fl exibility and range of motion.

Trouble physically moving the steering wheel or looking out mirrors. Again, while relatively minor, these signal problems with movement. Talk to a physician about exercises that may help the driver maintain the strength and fl exibility required to operate a vehicle. Correcting such problems and improving fi tness may help avoid more serious problems down the road.

Diffi culty getting in or out of the vehicle. Improving your total fi tness may help improve this. In addition, consider putting something slick, such as a plastic trash bag or a silk scarf over the seat to make it easier to slide in and out of the car.

The Consequences of Ignoring Warning Signs: a Case Study It seems that you only have to open the newspaper to fi nd an example of an older driver having problems. The consequences of ignoring the kind of risk signals just described range from minor to catastrophic. Unfortunately, catastrophic results do happen. I present the case study below not to sensationalize the issue, but to hammer home the importance of paying attention to even minor warning signs. I reviewed dozens of local and national news accounts, the National Transportation Safety Board reports, and data released from the Santa Monica Police Department to tell the following story, using three perspectives, that of the driver, witnesses, and investigative report.


It was an ordinary day. Despite hip replacements, chronic leg pain, and arthritis, George still got around pretty well with a cane and regularly walked around the neighborhood for exercise. He and his wife lived in a modest, comfortable home and were members of a supportive church. After breakfast he ran a few errands before it got too hot -- the week before temperatures had hovered near 100 degrees. He was home for lunch, fi nished writing a letter, and then drove to the post offi ce. It was a Wednesday afternoon, so traffi c wasn't bad. He pulled up to the mailbox in the parking lot, slid across the seat, and dropped the letter into the box. Sliding back to the driver's seat, he put the car back in gear and headed out of the post offi ce parking lot for home. His route home would take him by the popular Santa Monica farmer's market.


Witnesses were frozen by the sound and motion of it all, likening it to a tornado, tidal wave, and earthquake all hitting at the same time. Bodies and stands were fl ying like pins in a bowling alley. A crowd rushed the car when it fi nally came to a stop. They pulled the driver, an elderly man, from the car. Then they lifted the '92 Buick off the woman trapped underneath and disabled the horn, which allowed the other, haunting sounds to take over. Screams of pain and confusion, and calls for help fi lled the air, as did sirens and, a bit later, the sounds of helicopters coming to transport the injured to hospitals. The Police Chief, James T. Butts, Jr., said it was the single most horrifi c, devastating scene of tragedy he had ever seen in thirty years of law enforcement. By the end of the week, 10 people were dead and 63 injured. The dead ranged in age from 7 months to 78 years; death came painfully and indiscriminately.


On July 16, 2003, about 1:46 p.m. Pacifi c Daylight Time, a 1992 Buick LeSabre driven by an 86-year old male was westbound on Arizona Avenue, approaching the intersection of Fourth Street, in Santa Monica, Los Angeles County, California. At the same time, a 2003 Mercedes Benz S430 sedan was also westbound on Arizona Avenue and had stopped for pedestrians in a crosswalk. The Buick struck the left rear corner of the Mercedes, continued through the intersection, and drove through a farmers' market, striking pedestrians and vendor displays before coming to rest. The Buick proceeded through the farm- ers' market for approximately 2 blocks (750 feet) and came to rest near the intersection of Ocean and Arizona Avenues. As a result of the accident, 10 people died and 63 people were injured, some seriously. The Buick driver stated to police that he tried to stop the car as it went through the market, stepping on the brake, taking his foot off the accelerator, and ultimately trying to put the car's transmission in "park". Police offi cers were on the scene within one minute and by the end of the afternoon a total of 400 municipal employees (fi re, ambulance, police, etc.) responded to the accident. He indicated he might have confused the brake and accelerator pedals.

The results of the National Transportation Safety Board investigation excluded many potential causes of the accident: weather; driver's experience and familiarity with his vehicle and area; alcohol; illicit medications; insuffi cient sleep or fatigue; pedal placement or vehicle failure. The report concluded that the driver unintentionally accelerated his vehicle. The driver made an error in response execution, inadvertently accelerating when he intended to brake, that resulted in the collision with the Mercedes. The driver failed to detect his error in response execution, thereby inadvertently accelerating his vehicle and propelling it through the Santa Monica farmers' market. The driver most likely reverted to the habitual response of hard braking or "pumping" the brakes as his stress level increased and the vehicle failed to slow, but because his foot was on the accelerator instead of the brake pedal, this response led to increased acceleration. The ineffectiveness of the driver's efforts to stop his vehicle and the realization that he was striking objects in his path very likely increased the already high level of stress affecting him, thereby impeding his ability to quickly detect and correct his earlier error in response execution.


The accident at the Santa Monica Farmers' Market remains nothing less than a personal and national tragedy. On that perfectly ordinary summer day, an intelligent, grandfatherly 86-year-old man was involved in a horrifi c auto accident. Although no one can ever predict an accident, it turns out that a trained eye might have detected enough warning signs to raise concern about his driving fi tness. He exhibited several of the warning signs detailed earlier in this chapter. The investigative reports of the accident noted: vision impairment (corrected with glasses); mobility issues (history of bilateral hip replacement, spinal stenosis, arthritis of such severity that a disabled parking placard was issued; pain in the right thigh, and cane required for walking); and medication (prescription and overthe- counter) use. Perhaps most striking of all the warning signs was a recent history of minor auto accidents (3 in 10 years). Three weeks after the crash, a cardiologist diagnosed a serious heart problem in George and implanted a dual chamber pacemaker.

Admittedly, hindsight is always 20/20. But in retrospect, it seems that George clearly had enough warning signs to at least raise concerns about his driving fi tness. The truth is that predicting future accident risk is not yet an exact science. It is not clear who is responsible for assessment, either. If an older driver cannot or does not heed warning signs, who should? A state's department of motor vehicles? The police? Physicians? Family members? Neighbors? Research and vigorous debate about these fundamental policy questions is lacking and yet never more urgently needed. Because you are reading this book, I assume that you have more than a passing interest in the topic. I hope that you will push these questions toward the front burner for decision makers.

Determining Driving Fitness: Ability to See, Think, and Move

This section reviews the main skills and functions needed to safely operate a vehicle. As I've mentioned, in order to drive safely, a person must be able to see, think, and move well and with ease. If any of these abilities is limited, the driver could be at risk.


The ability to see is essential to safe driving. For example, we need to be able to read the gauges and dials in the car, see street signs, recover our focus at night, recognize and respond to brake lights, and correctly judge the speed and location of other vehicles around us. Nearly every key task in driving involves detecting, processing, and responding to visual cues. Eye doctors can evaluate visual acuity, which is needed to read road signs and to see objects, such as pedestrians or other cars, in the driving path. The useful fi eld of view, or visual fi eld, has to do with our peripheral vision, or the ability to see off to the sides without moving our head or eyes. A reduced visual fi eld means that it is harder to see cars and people off to the side. The ability to recover from glare changes with age, and older eyes need more time to recover than younger eyes. Sensitivity to light is needed to see the taillights of other cars at night. Depth perception is the ability to judge the distance between objects, such as oncoming cars, and us.


Not only do we need to see all the stimuli that surround us, but we also need to make sense of it all by thinking quickly and clearly. Memory, attention, visual attention, and executive function are all high-level skills needed to drive safely. Divided attention is used when you are doing two things at once, such as talking to a passenger and navigating a turn. Selective attention is the ability to tune out or ignore what is not important in order to focus on what is important. The speed of thinking and decision making is critical to driving safety and tends to decrease with aging. Slowed or hesitant responses to situations such as merging or changing lanes are often causes of accidents for older drivers. Memory is vital to safe driving. You've got to be able to remember where you are going, the rules of the road, and how to make decisions.


In order to drive safely, you need to be able to move without much restriction. Moving in this way requires fl exibility and muscle strength. Flexibility is the ability to stretch or move a joint or muscle. Being fl exible enough to turn to look behind you when backing up or being fl exible enough to get in and out of your car are key functions. Muscle strength is needed to open the door, change gears, turn the steering wheel, and press the brake and gas pedals.


A brief mention of general driving profi ciency is warranted. You have to know and follow the rules of the road in order to be a safe driver. A lifetime of bad driving habits will catch up with an older driver suddenly faced with problems stemming from health-related changes. A history of aggressive or careless driving does not bode well for future safety. A refresher course should defi nitely be taken to learn new, safer driving habits.

Assessments of Driver Safety Below is a description of the range of assessment options available to help you or your loved one to assess driving fi tness.


The easiest, most affordable, and comprehensive do-it-yourself home assessment is the Roadwise Review™ program, available from the American Automobile Association (AAA) for a small fee (approximately $15.00). The Roadwise Review™ program is not an assessment of actual driving performance, but it does provide an easy way for you to measure important functional abilities directly related to driving in the comfort of your own home. The program is on CD-ROM and can run on most home personal computers. The only drawback is that it requires access to a computer, and some of us are not experienced or comfortable computer users. If a person's unfamiliarity with computers would lead to results that aren't a valid refl ection of his or her abilities, then don't use this program. However, if the older person is familiar with computers, or is interested in learning about them, the Roadwise Review™ gives you an opportunity to generate concrete results about driving fi tness that can make your conversations easier.

Driving safely requires complex visual processing, quick and clear thinking, and fl exibility and strength. A change or loss in any of these functions (seeing, thinking, moving) could endanger you. The Roadwise Review™ program identifi es specifi c impairments that may pose a risk in many common driving situations and provides a good general discussion of driving fi tness. Eight areas are reviewed:

1. Leg strength and general mobility: you need these functions to accelerate and brake under regular conditions and to respond quickly in emergencies.

2. Head/neck fl exibility: this allows you to check blind spots when you back up, change lanes, and merge into traffi c.

3. High-contrast visual acuity: this helps you detect pavement markings, read road signs, and spot hazards in or near the road.

4. Low-contrast visual acuity: this enables you to maintain lane position and drive safely in rain, dusk, haze, and fog.

5. Working memory: this allows you to follow directions, remember traffi c rules and regulations, and make good decisions as you drive.

6. Visualizing missing information: this enables you to recognize and anticipate a threat or hazard even when part of it is hidden from view.

7. Visual search: this enables you to scan the driving environment and recognize traffi c signs, signals, navigational landmarks, and hazards.

8. Visual information processing speed: this allows you to pay attention to what is in front of you while also detecting threats at the edge of your fi eld of view.

This assessment requires two people, the driver and a helper. It also requires a stable, straight-back chair that does not roll, tilt, or swivel; a measured 10-foot path near the computer; and about an hour to complete. The results are completely private and available for your review after completing the program. I recommend it as an excellent fi rst step in determining your driving fi tness.


If an in-home assessment suggests a problem, the next step would be to consult with the older person's physician or another healthcare provider in order to do a more thorough evaluation. This typically will not involve an actual road test, which is the fi - nal and most defi nitive level of assessment.

Recognizing the growing importance of evaluating driving ability among older adults, the American Medical Association created an assessment guideline for physicians called the Assessment of Driving-Related Skills (ADReS). This is a set of brief tests, conducted in a doctor's offi ce, which measures the three key functions for safe driving (vision, cognition, and motor function). Some physicians may use other systems or they may have developed their own strategies for assessing function. If your physician is not familiar with the ADReS, it can be freely accessed via the internet from the professional resources section (Public Health: Geriatric Health) of the AMA Web site (www.ama-assn.org or via the National Highway Transportation Safety Administration at www.nhtsa.dot.gov/ people/injury/olddrive/OlderDriversBook). Here's a brief overview of the ADReS evaluation and what you or a loved one can expect.


Aspects of vision that are important for safe driving can be assessed by most primary care physicians. Far visual acuity is assessed using the standard Snellen E Chart. With the chart hung at the proper distance the patient reads the smallest line of text possible. The visual acuity score is based on the lowest full-row read. One's fi eld of view is measured by what is called confrontational testing. The examiner sits or stands 3 feet in front of the patient, at the patient's eye level. The patient is asked to close his or her right eye, while the examiner closes his or her left eye. Each fi xes on the other's nose. The examiner then holds up a random number of fi ngers in each of four quadrants and asks the patient to state the number of fi ngers. The process is repeated for each eye.


General cognitive function is measured with the Trail- Making Test (Part B), in which the person is asked to draw a line between small circles on a page in a specifi ed order. Research indicates that poor performance on the test is associated with poor driving performance. Another simple evaluation of memory, visual perception, and executive skills is the Clock Drawing Test. In this test the examiner gives the patient a piece of paper and a pencil and asks him/her to draw a clock, including the face and numbers, and to indicate the time as specifi ed.


The Rapid Pace Walk is used to measure lower limb strength, endurance, range of motion, and balance. A 10-foot path is marked and the patient is asked to walk the path, turn around, and walk back to the starting point as quickly as possible. The Manual Test of Range of Motion and Manual Test of Motor Strength are simple subjective tests of resistance to an examiner's pressing or of measurements of the range of motion of the head or extremities.


An assessment by a driving rehabilitation specialist or geriatric driving clinic is the most comprehensive test of driving fi tness, but it's also the most time-consuming and expensive. An assessment at a program like the DriveWise program at Beth Israel Deaconess Medical Center in Boston, Massachusetts, takes two patient visits to complete. Visit One, the actual multidisciplinary assessment, takes four hours and involves a social worker, a neuropsychologist, a nurse, an occupational therapist, and a certifi ed driving rehabilitation specialist. First, an assessment conducted by a social worker determines driving needs and driving history, driving-related knowledge, license status, and a complete medical and medication history. Then a neuropsychological evaluation is done to assess cognitive status, followed by an evaluation with an occupational therapist to examine refl exes, vision, and mental status. Finally, an actual road test assessment is conducted by a certifi ed driving rehabilitation specialist. In Visit Two about two weeks later, the fi ndings are reviewed with the driver and family. Driving assessment clinics are often based in academic medical centers (teaching hospitals) or at outpatient rehabilitation clinics. This type of assessment tends to be the most expensive (around $400 or so) and is not yet covered by health insurance. However, many older drivers and family members have reported that the peace of mind afforded by such a comprehensive assessment is worth every penny.