Scrutiny of older drivers may cut deaths but loss of independence can be painful

I recently found this great article in the Washington Post, a well regarded US newspaper.  It is an interesting read, and reminds us of the high level of dependence that we all place on driving.  It appears that this is an issue that transcends the Pacific Ocean all the way over to Australia !

By Sandra G. Boodman

Special to The Washington Post
Tuesday, August 10, 2010

My father was furious. Then 83, he lived independently in a retirement community and prided himself on being an excellent driver who, early in his career as a scientist, had been involved in pioneering auto safety research. He had always loved the freedom of driving and could claim a nearly spotless record: a minor accident or two and a similar number of tickets, none recent, in more than 65 years. So why was his trusted doctor ordering him to undergo a driving evaluation?

Alarmed by his increasingly risky behavior behind the wheel, the result of end-stage congestive heart failure and accompanying dementia, and stymied by his refusal to take taxis or the private minibus that provided door-to-door service around his Boston suburb, my sister and I decided we had to act. She held onto the car keys that he had given her for safekeeping during a brief hospitalization and, without telling him, called his doctor, who broached the subject during one of my father’s increasingly frequent appointments. Then we both refused to give him back his keys unless he passed the two-part test that I scheduled for him.

We were surprised when he aced the first part, which assessed cognitive function and mobility. By the time the driving exam rolled around several weeks later, in November 2006, the matter was moot. He had fallen and was in a nursing home where he died peacefully a few weeks later, never having learned that his children had dropped a dime about his driving.

My family’s dilemma — whether and how to intervene when a potentially dangerous elderly driver, often a parent, refuses to hang up the keys — “is happening all across the United States in families up and down the streets every day,” said Elinor Ginzler, a senior vice president of AARP. “It’s a huge issue.”

“Impairment, not age”

Ginzler and other geriatrics experts predict that the issue will explode in the next decade as the leading edge of the 78 million-member baby boom generation hits its 70s. In 2008, according to the Insurance Institute for Highway Safety, 78 percent of the 28 million Americans older than 70 had licenses, up from 73 percent in 1997, an upward trend that is expected to continue.

Because more Americans are living longer with progressive, disabling diseases that make driving iffy or downright dangerous — heart problems, stroke, Parkinson’s, dementia and diabetes, to name a few — families are increasingly wrestling with questions that defy easy answers. Although many seniors stop driving voluntarily or sharply limit their driving, others refuse. Some fear being marooned in their suburban homes, while others, like my father, cling tenaciously to the independence a car represents, unaware of how hazardous their driving has become. A survey by the MIT AgeLab and the Hartford insurance company found that age enhances confidence in driving ability. Drivers 75 and older were twice as likely to say they planned to drive into their 90s as did those 65 to 74.

Such confidence can belie reality. A 2007 report by the Government Accountability Office found that drivers 75 and older were more likely than drivers in all other age groups, including adolescents, to be involved in a fatal crash.

“In the old days, or even 20 years ago, people just did not live long enough for this to be a problem,” said Elin Schold-Davis, head of the American Occupational Therapy Association’s Older Driver Initiative, who notes that some older drivers are taking potent medications that fog concentration. “People are living with a level of impairment that is unprecedented. And these days driving is more complicated. There’s more congestion, more complicated signs and traffic patterns,” while cars no longer demand the physical strength required before power steering and power brakes.

Drivers with dementia are of particular concern. One study estimated that 4 percent of drivers older than 75 have dementia, and many drive until the disease is advanced. In April the American Academy of Neurology issued new guidelines stating that some people with mild dementia may be able to continue to drive. The recommendation is based on research that found that 76 percent could pass a road test.

Spurred by highly publicized fatalities caused by elderly drivers, a growing number of states are tightening restrictions, requiring vision exams, in-person license renewals or a doctor’s approval to retain a license. But according to the National Highway Traffic Safety Administration, there is no single test or screening tool that will reliably weed out unsafe older drivers.

Often it falls to family members, who are most familiar with the driver’s condition, to take action. But the emotions such decisions unleash can be anguishing, igniting conflict among siblings and creating resentment in parents who feel their meddlesome children are bossing them around or, worse yet, ratting them out. Because such discussions invariably occur at a time when loss — of a spouse, close friends, health, independence — dominates, giving up driving can be a terrible blow, particularly for men.

“Driving is an issue of control,” Ginzler said. “It’s a mistake to say, ‘This isn’t a big deal.’ It’s a very big deal.”

Even those who decide to stop driving on their own may mourn the loss. “Many’s the time I wish I hadn’t given it up,” said Emmett Miller, 89, of Arlington, who suffers from sight-robbing macular degeneration. Miller said he traded his Virginia license for a DMV-issued ID card two years ago after an incident in a supermarket parking lot when his car “suddenly shot forward like a bullet” but caused no damage. “I thought to myself, ‘I’ve had it.’ “

How old is too old?

The most infamous crash of an elderly driver involved 86-year-old George Weller, who in July 2003 plowed his 1992 Buick LeSabre through a crowded farmers market in Santa Monica, Calif., killing 10 people and injuring 63. Weller, who was convicted of 10 counts of vehicular manslaughter and gross negligence, apparently confused the brake and the gas pedal. Two weeks earlier, he had hit a gardener’s truck; previously, he had backed over a retaining wall and repeatedly struck a car in a parking lot.

Experts emphasize that Weller’s age was not the problem; some people can still drive safely at 100, while others are too impaired at 60.

“The bottom line is that it is really about function, not age or even diagnosis,” said Carl Soderstrom, a former trauma surgeon who heads the Medical Review Board of the Maryland Motor Vehicle Administration. The board, the nation’s oldest and one of the most respected, evaluates the fitness of about 8,000 drivers annually, many of them older than 65 and some of whom have been flagged by police, families or specialized driving instructors who conduct evaluations. (Maryland, Virginia and the District grant confidentiality to doctors and relatives who report problem drivers, according to the American Medical Association.)

There is some indication that state laws requiring stronger oversight of license renewals may be having some effect. In June, the Insurance Institute reported that the rate of fatal crashes among drivers older than 70 declined by 37 percent from 1997 to 2008, a sharper decrease than among drivers 35 to 54, whose fatal crash rate dropped 23 percent. Officials say the finding was unexpected and are planning more research. One theory is that the decline also reflects better self-policing by seniors, the improved crashworthiness of cars and reduced driving because of the faltering economy.

Although aging causes declines in vision, flexibility, response time and memory, many older drivers can and do compensate by taking refresher courses or using adaptive equipment such as pedal extensions. “We do things on a case-by-case basis,” Maryland’s Soderstrom said. “Our job is to keep the roads safe, not to take people’s licenses away.” Sometimes the board recommends a restricted license that allows driving within a three- to five-mile radius of a person’s home. “If you live right off Connecticut Avenue, you’re not going to be a candidate for this,” he said, because of the volume of traffic.

One mistake families make, AARP’s Ginzler said, is to tell an elderly relative to stop driving without “figuring out how they’re going to get where they need to go. You can’t say, ‘Oh, you can just take [public transportation] from now on’ ” if the person has never taken the bus.

Specificity is important, Ginzler noted. “You need to know the warning signs and have observed them, and to be as concrete as possible. That may mean saying, ‘Dad, I noticed you really didn’t come to a complete stop at that intersection.’ A big mistake is to say, ‘I know better than you.’ “

Washington internist Alan Pocinki said he raises the matter with patients who he suspects may be having problems or whose relatives contact him. “There are definitely times you have to be the bad guy,” he said. “They’re going to take it better from me than from their [children].”

Families should also pick the right person to deliver the message, typically the one with the most influence. “It might be the firstborn son who lives in California and sees Dad three times a year,” Ginzler said. Often siblings disagree about what should be done, sometimes for financial reasons or because they fear they will be forced to shoulder a disproportionate share of the burden.

“One of my sisters was a holdout,” said a 43-year-old Washington area auto club employee who took the lead in confronting his elderly parents after several minor accidents. She “probably fought it more than my father did. But the rest of us decided, ‘We’re doing it,’ and she stepped up.” The siblings take turns driving their parents, who live in their own home. “They can’t walk to anything and are very dependent on us,” he said. “It’s definitely been more work for us kids.”

Many physicians are unaware that they can refer a patient for an evaluation with a driving rehabilitation specialist, Soderstrom said. In Maryland, the two-part evaluation usually costs the driver about $200 per segment. The first part consists of a 90-minute assessment of vision, cognitive ability and physical mobility, said Carol Wheatley, a driving specialist employed by Baltimore’s Good Samaritan Hospital. Those who pass proceed to a road test.

Not infrequently, drivers who are referred for evaluation by their doctors or the police are weeded out along the way. Some are unable to make or keep an appointment, Wheatley said, while others decide to stop driving on their own rather than risk failing the test.

Wheatley has witnessed the fallout firsthand. Her father-in-law, who suffered from cancer and dementia, had no problems driving when his dementia was in its early stages. After he got lost driving home from a familiar bowling alley, his Virginia doctor wrote him a prescription that said: “No driving.” The family took his car so it was not a constant reminder, and initially things went smoothly — until he insisted on getting his keys back.

“He went through a period where he was very angry, and my mother-in-law had to endure that for a month until he forgot about it,” Wheatley said. “It really made me appreciate the day-to-day difficulties of families dealing with this.”

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