Excerpt: 'The Driving Dilemma'

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Nov. 1, 2006 — -- 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."

Assessing Fitness to Drive

Your aunt is 86 and has just returned from a care facility whereshe had stayed to recover from a fall. She walks very slowly and hasdiffi culty with stairs, but she insists she is a safe driver and hasn'thad any kind of traffi c accident in more than 20 years. Still, youwonder, should she be driving?

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

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

These very common situations all confront you with a similarchallenge: How do you know if an older adult is fi t to drive? Sinceage alone is not a reliable indicator, what should you be lookingfor? And, if you are an older driver, what should you be looking forin your own driving habits that might signal a need for some kindof change?

This chapter describes the most common warning signs of drivingrisk and gives you some tools to assess whether a real drivingproblem exists. Specifi cally, I explain what the indicators of drivingfi tness are, what signals a problem, how to categorize the severity ofproblems, how to conduct a home assessment, and what's involvedin a professional assessment. Appendix 1 includes assessment formsthat can be used either by an older driver for self-assessment or by afamily member or friend. Appendix 2 contains forms to help you toimplement changes by talking with your physician about specifi cfunctional concerns related to driving that may need some medicalintervention.

Driving safety involves factors related to the vehicle, the roadways,the weather and other conditions. Above all, driving safetyinvolves the driver. This chapter focuses primarily on driversand on determining their fi tness for driving. Although it is importantto ensure that a vehicle is in proper mechanical condition,that issue is beyond the scope of this book. I'm workingfrom the assumption that the vehicle is in good working condition.Also, other factors play a role in how safely a person canoperate a vehicle: the conditions of the roads and a driver's familiaritywith them, the weather, and the time of day all can affectdriving safety. Obviously, all possible conditions can't beaddressed here, but they should be taken into account when determiningdriver fi tness. If you are concerned about a driver'sfi tness, you will want to observe his or her driving fi rsthand andkeep a written record of your concerns. The forms in Appendix1 should help you.

Driving Fitness and Age

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

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

I spoke with one of Dr. Perl's study participants, Ms. NedinneParker, aged 104. Ms. Parker is a devoted baseball fan (she rootsenthusiastically 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 stillable to see, think, and move well enough to drive safely. Ms.Parker is modest about the fact that she still maintains her drivingfi tness. She also realizes that she has some limitations and thatothers may be skeptical of her driving skills. During our conversation,she quipped that she doesn't have many friends or relativesclamoring for a ride: "Well, to be honest, I don't know if I wouldbe too quick to jump in a car with a 104-year-old gal!" She haslimited herself to driving only on local, familiar roads and onlyduring daylight hours. As a result of these self-imposed limits shehas been able to maintain her driving fi tness. Similarly, Mr. EdwardRondthaler still lives independently and is driving aroundupstate New York at 100 years of age. Mr. Rondthaler doesn'tdrive as much as he did when he was 80 (he drove across thecountry then), but he still enjoys driving around town and is doingso safely. These drivers remind us that it is not age but functionthat determines driving fitness.

Warning Signs of Driving Risk

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

To help you remember them, I have categorized the warningsigns by level of risk into red, yellow and green. "Red" signs point tothe highest level of safety risk. Having one of the red risks is a signalto immediately begin the conversation about driving and to seek aprofessional assessment. "Yellow" signs point to a somewhat lower,but still signifi cant safety risk. Having one yellow risk is cause forconcern, and having two or more is cause for concern and shouldprompt further assessment. "Green" signs point to safety risks thatare usually easily corrected and, if corrected, can allow a person tocontinue to drive safely. If you are concerned about your driving orthe driving of a loved one, the time to start talking is now. I can'tstress this enough -- being proactive and informed helps everyone.Honest and open communication is the best way to develop a planthat 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 futuremishaps. Did the accident involve another moving vehicle?Was it a single car accident? Did it involve hitting a stationaryobject? The details of the accident(s) are important in evaluatingthe 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 accidentbecause 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 asymptom of declining driving performance. It's important toknow which is the case in order to evaluate the risk for thedriver.

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

Since people are often reluctant to speak up about their concernsfor a person's driving, such expressions should be takenseriously as a sign that something is wrong. If concerns areraised, get the details and follow the guidelines presented laterin 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 indicatevision, mobility, or navigational problems. Minor fenderbenders 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 feelingfully competent behind the wheel and, thus, can be a signalthat driving skills are diminishing.

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

Unless you live in a city that is famous for rude drivers, honking,yelling, or other "impolite" actions are probably a cluethat 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 highwayentrance and exit ramps.

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

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

Being surprised by the sudden presence of pedestrians or carscould indicate a diminished fi eld of view, which is vital to safedriving.

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

Getting lost more often than in the past, especially in familiarareas.

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

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

Slow response to unexpected situations.This could signal impaired thought processes related to recognizingstimuli and attaching meaning to them or a delay inphysical reactions.

Becoming easily distracted or having diffi culty concentratingwhile 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 drivingsafety.Many medications carry warnings about operating machineryor driving while taking them. In Chapter 3, many commonmedications and their effects on driving safety are discussed.

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

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

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

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


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

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

Trouble physically moving the steering wheel or looking outmirrors.Again, while relatively minor, these signal problems withmovement. Talk to a physician about exercises that may helpthe driver maintain the strength and fl exibility required tooperate a vehicle. Correcting such problems and improvingfi 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 trashbag or a silk scarf over the seat to make it easier to slide in andout of the car.

The Consequences of Ignoring Warning Signs: a Case StudyIt seems that you only have to open the newspaper to fi nd an exampleof an older driver having problems. The consequences ofignoring the kind of risk signals just described range from minorto catastrophic. Unfortunately, catastrophic results do happen. Ipresent the case study below not to sensationalize the issue, but tohammer home the importance of paying attention to even minorwarning signs. I reviewed dozens of local and national news accounts,the National Transportation Safety Board reports, anddata released from the Santa Monica Police Department to tellthe 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 regularlywalked around the neighborhood for exercise. He and his wifelived in a modest, comfortable home and were members of a supportivechurch. After breakfast he ran a few errands before it got toohot -- the week before temperatures had hovered near 100 degrees.He was home for lunch, fi nished writing a letter, and then drove to thepost offi ce. It was a Wednesday afternoon, so traffi c wasn't bad. Hepulled up to the mailbox in the parking lot, slid across the seat, anddropped the letter into the box. Sliding back to the driver's seat, heput the car back in gear and headed out of the post offi ce parking lotfor home. His route home would take him by the popular Santa Monicafarmer's market.


Witnesses were frozen by the sound and motion of it all, likening itto 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 crowdrushed 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 thewoman trapped underneath and disabled the horn, which allowed theother, 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 soundsof helicopters coming to transport the injured to hospitals. The PoliceChief, James T. Butts, Jr., said it was the single most horrifi c, devastatingscene 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 painfullyand indiscriminately.


On July 16, 2003, about 1:46 p.m. Pacifi c Daylight Time, a 1992Buick LeSabre driven by an 86-year old male was westbound on ArizonaAvenue, approaching the intersection of Fourth Street, in SantaMonica, Los Angeles County, California. At the same time, a 2003Mercedes Benz S430 sedan was also westbound on Arizona Avenueand had stopped for pedestrians in a crosswalk. The Buick struck theleft rear corner of the Mercedes, continued through the intersection,and drove through a farmers' market, striking pedestrians and vendordisplays before coming to rest. The Buick proceeded through the farm-ers' market for approximately 2 blocks (750 feet) and came to restnear the intersection of Ocean and Arizona Avenues. As a result of theaccident, 10 people died and 63 people were injured, some seriously.The Buick driver stated to police that he tried to stop the car as itwent through the market, stepping on the brake, taking his foot off theaccelerator, 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 ofthe afternoon a total of 400 municipal employees (fi re, ambulance,police, etc.) responded to the accident. He indicated he might haveconfused the brake and accelerator pedals.

The results of the National Transportation Safety Board investigationexcluded many potential causes of the accident: weather; driver'sexperience and familiarity with his vehicle and area; alcohol; illicitmedications; insuffi cient sleep or fatigue; pedal placement or vehiclefailure. The report concluded that the driver unintentionally acceleratedhis vehicle. The driver made an error in response execution, inadvertentlyaccelerating when he intended to brake, that resulted in thecollision with the Mercedes. The driver failed to detect his error in responseexecution, thereby inadvertently accelerating his vehicle andpropelling it through the Santa Monica farmers' market. The drivermost likely reverted to the habitual response of hard braking or "pumping"the brakes as his stress level increased and the vehicle failed toslow, but because his foot was on the accelerator instead of the brakepedal, this response led to increased acceleration. The ineffectivenessof the driver's efforts to stop his vehicle and the realization that hewas striking objects in his path very likely increased the already highlevel of stress affecting him, thereby impeding his ability to quicklydetect and correct his earlier error in response execution.


The accident at the Santa Monica Farmers' Market remainsnothing less than a personal and national tragedy. On that perfectlyordinary summer day, an intelligent, grandfatherly 86-year-old manwas involved in a horrifi c auto accident. Although no one can everpredict an accident, it turns out that a trained eye might have detectedenough warning signs to raise concern about his driving fi tness.He exhibited several of the warning signs detailed earlier inthis chapter. The investigative reports of the accident noted: visionimpairment (corrected with glasses); mobility issues (history of bilateralhip replacement, spinal stenosis, arthritis of such severity that adisabled parking placard was issued; pain in the right thigh, andcane required for walking); and medication (prescription and overthe-counter) use. Perhaps most striking of all the warning signs wasa recent history of minor auto accidents (3 in 10 years). Three weeksafter the crash, a cardiologist diagnosed a serious heart problem inGeorge and implanted a dual chamber pacemaker.

Admittedly, hindsight is always 20/20. But in retrospect, itseems that George clearly had enough warning signs to at leastraise concerns about his driving fi tness. The truth is that predictingfuture accident risk is not yet an exact science. It is not clearwho is responsible for assessment, either. If an older driver cannotor does not heed warning signs, who should? A state's departmentof motor vehicles? The police? Physicians? Family members?Neighbors? Research and vigorous debate about these fundamentalpolicy questions is lacking and yet never more urgently needed.Because you are reading this book, I assume that you have morethan a passing interest in the topic. I hope that you will pushthese 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 tosafely 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, seestreet signs, recover our focus at night, recognize and respondto brake lights, and correctly judge the speed and location ofother vehicles around us. Nearly every key task in driving involvesdetecting, processing, and responding to visual cues.Eye doctors can evaluate visual acuity, which is needed to readroad 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, hasto do with our peripheral vision, or the ability to see off to thesides without moving our head or eyes. A reduced visual fi eldmeans that it is harder to see cars and people off to the side.The ability to recover from glare changes with age, and oldereyes need more time to recover than younger eyes. Sensitivityto light is needed to see the taillights of other cars at night.Depth perception is the ability to judge the distance betweenobjects, 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 andclearly. Memory, attention, visual attention, and executive functionare all high-level skills needed to drive safely. Divided attentionis used when you are doing two things at once, such astalking to a passenger and navigating a turn. Selective attentionis the ability to tune out or ignore what is not important in orderto focus on what is important. The speed of thinking and decisionmaking is critical to driving safety and tends to decreasewith aging. Slowed or hesitant responses to situations such asmerging or changing lanes are often causes of accidents forolder drivers. Memory is vital to safe driving. You've got to beable 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 withoutmuch restriction. Moving in this way requires fl exibility andmuscle strength. Flexibility is the ability to stretch or move ajoint or muscle. Being fl exible enough to turn to look behindyou when backing up or being fl exible enough to get in andout of your car are key functions. Muscle strength is needed toopen the door, change gears, turn the steering wheel, andpress 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 tobe a safe driver. A lifetime of bad driving habits will catch upwith an older driver suddenly faced with problems stemmingfrom health-related changes. A history of aggressive or carelessdriving does not bode well for future safety. A refresher courseshould defi nitely be taken to learn new, safer driving habits.

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


The easiest, most affordable, and comprehensive do-it-yourselfhome assessment is the Roadwise Review™ program, availablefrom the American Automobile Association (AAA) for a small fee(approximately $15.00). The Roadwise Review™ program is not anassessment of actual driving performance, but it does provide aneasy way for you to measure important functional abilities directlyrelated to driving in the comfort of your own home. The programis on CD-ROM and can run on most home personal computers.The only drawback is that it requires access to a computer, andsome of us are not experienced or comfortable computer users. Ifa person's unfamiliarity with computers would lead to results thataren't a valid refl ection of his or her abilities, then don't use thisprogram. 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 drivingfi tness that can make your conversations easier.

Driving safely requires complex visual processing, quick andclear thinking, and fl exibility and strength. A change or loss inany of these functions (seeing, thinking, moving) could endangeryou. The Roadwise Review™ program identifi es specifi c impairmentsthat may pose a risk in many common driving situationsand provides a good general discussion of driving fi tness. Eightareas are reviewed:

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

2. Head/neck fl exibility: this allows you to check blindspots when you back up, change lanes, and merge intotraffi c.

3. High-contrast visual acuity: this helps you detect pavementmarkings, read road signs, and spot hazards in ornear the road.

4. Low-contrast visual acuity: this enables you to maintainlane 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 gooddecisions as you drive.

6. Visualizing missing information: this enables you torecognize and anticipate a threat or hazard even whenpart of it is hidden from view.

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

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

This assessment requires two people, the driver and a helper. Italso requires a stable, straight-back chair that does not roll, tilt, orswivel; a measured 10-foot path near the computer; and about anhour to complete. The results are completely private and availablefor your review after completing the program. I recommend it asan excellent fi rst step in determining your driving fi tness.


If an in-home assessment suggests a problem, the next stepwould be to consult with the older person's physician or anotherhealthcare 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 abilityamong older adults, the American Medical Association createdan assessment guideline for physicians called the Assessment ofDriving-Related Skills (ADReS). This is a set of brief tests, conductedin a doctor's offi ce, which measures the three key functionsfor safe driving (vision, cognition, and motor function). Some physiciansmay use other systems or they may have developed theirown strategies for assessing function. If your physician is not familiarwith the ADReS, it can be freely accessed via the internet fromthe professional resources section (Public Health: Geriatric Health)of the AMA Web site (www.ama-assn.org or via the National HighwayTransportation Safety Administration at www.nhtsa.dot.gov/people/injury/olddrive/OlderDriversBook). Here's a brief overviewof the ADReS evaluation and what you or a loved one can expect.


Aspects of vision that are important for safe driving can beassessed by most primary care physicians. Far visual acuity isassessed using the standard Snellen E Chart. With the charthung at the proper distance the patient reads the smallest lineof text possible. The visual acuity score is based on the lowestfull-row read. One's fi eld of view is measured by what is calledconfrontational testing. The examiner sits or stands 3 feet infront of the patient, at the patient's eye level. The patient isasked to close his or her right eye, while the examiner closeshis or her left eye. Each fi xes on the other's nose. The examinerthen holds up a random number of fi ngers in each of fourquadrants 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 aline between small circles on a page in a specifi ed order.Research indicates that poor performance on the test is associatedwith poor driving performance. Another simple evaluationof memory, visual perception, and executive skills is theClock Drawing Test. In this test the examiner gives the patienta piece of paper and a pencil and asks him/her to draw a clock,including the face and numbers, and to indicate the time asspecifi ed.


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


An assessment by a driving rehabilitation specialist or geriatricdriving clinic is the most comprehensive test of driving fi tness,but it's also the most time-consuming and expensive. An assessmentat a program like the DriveWise program at Beth IsraelDeaconess Medical Center in Boston, Massachusetts, takes twopatient visits to complete. Visit One, the actual multidisciplinaryassessment, takes four hours and involves a social worker, a neuropsychologist,a nurse, an occupational therapist, and a certifi eddriving rehabilitation specialist. First, an assessment conductedby a social worker determines driving needs and driving history,driving-related knowledge, license status, and a complete medicaland medication history. Then a neuropsychological evaluation isdone to assess cognitive status, followed by an evaluation with anoccupational therapist to examine refl exes, vision, and mentalstatus. Finally, an actual road test assessment is conducted by acertifi ed driving rehabilitation specialist. In Visit Two about twoweeks later, the fi ndings are reviewed with the driver and family.Driving assessment clinics are often based in academic medicalcenters (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 thepeace of mind afforded by such a comprehensive assessment isworth every penny.

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