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Using "Age" as a Fitness-to-Drive Criterion for Older Adults

To better understand the tangible and intangible ways in which the use of age criteria for fitness to drive evaluations affect the lives of older adults, we conducted two focus groups with seniors (5 in each focus group). These seniors all resided in Sidney, British Columbia and volunteered to take part in these focus groups by responding to an advertisement placed in the local seniors centre. In addition, we conducted interviews with 4 health care providers, 3 physicians and an optometrist who:

• routinely conduct clinical assessments of older adults, and

• are regularly required to provide opinions concerning the fitness of older adults to drive.

Through these interviews, different perspectives on fitness-to-drive evaluations were brought together concerning the present procedures in British Columbia and their impact on the lives of seniors and experts required to perform evaluations. The questions posed to the respondents focussed on current policy and included such topics as:

1. How do you view mandatory driving re-evaluations based on age?

2. How adequate do you think evaluations based on age are for identifying problems drivers? How comfortable do you think assessors are in making an assessment as to whether a person is sufficiently impaired so as to present a hazard on the road?

3. Are there other factors that influence driving other than age? Under what conditions would you recommend fitness-to-drive evaluation?

4. What are the benefits and drawbacks of fitness-to-drive evaluations?

5. How important an issue is driving to older adults? Why/why not?

6. How could the procedure be improved? What would you recommend to improve driving conditions for older adults?

Our main goal was to capture views of the present procedure in British Columbia. In this way we hope to have a better understanding of the benefits and drawbacks of these procedures.

These respondents surveyed generally covered the issues of interest. It must be acknowledged that our sampling of respondents was small and these individuals may not have raised all potential comments and concerns surrounding the present procedure. Moreover, these comments are specific to the procedures in British Columbia alone. We did not attempt a broader survey of the present procedures employed in other provinces.

I. HOW DO YOU VIEW MANDATORY DRIVING RE-EVALUATIONS BASED ON AGE?

In general, the need for some form of mandatory driving re-evaluation procedure was supported by both seniors and experts. However, a variety of opinions were expressed as to whether or not age was the criteria of choice. Although there seemed to be agreement that basing the lower limit for driving on age seems reasonable because of biological maturity, health care professionals differed as to whether or not age should be the basis of re-evaluation later in life:

“The lower limit is there because of biological factors which suggest that maturity, ability to maintain concentration, and to have the skills and maintain the skills while driving a motor vehicle would not be there in the majority of people below a certain age. ...The change in human abilities with age is documented. Both with regards to achieving maturity through adolescence and in the decline in the senior years, as one gets older...And I think that it is a discrimination, but discrimination is a reasonable thing -- I think discrimination's got a bad name because of inappropriate discrimination in terms of, for instance, race. And this concept of ageism and discrimination on the basis of age is not the same thing. There are recognized and quite well-accepted changes that occur biologically with age. Which can affect the ability to, for instance, operate dangerous equipment, including a motor vehicle. And I think it's very appropriate to make rules which protect society -- both the people operating the equipment and the people who may be influenced by the operating of a car. So I think it is discrimination, but it's appropriate discrimination.”

“I would think there's probably a more rational way to target people who could be evaluated, or should be evaluated...Biased against older adults -- there's certainly prejudice built into it that's somewhat ageist. And I think it's a fairly rough line to draw. It's not nearly as valid as the line we draw when people are young. If they're less than 16, we say no, because we know developmentally people up to the age of 15 or 16 are developing these skills. But we don't know that when people reach 80 they start losing these skills at any appreciable rate. So I can't see the fairness in that.”

Seniors, while strongly in favour of mandatory re-evaluation, consistently agreed that using age as a criteria for re-evaluation, if the intent is to identify problem drivers, seemed unfair and unwarranted.

“I don't think it [age] has anything to do with that, actually. I mean you've got drivers 20 years old, 30 years old, 40, 50, what have you. And they can have a lot easier chance of getting into accidents and causing trouble just by their actions on the road. You'll find that most people when they get over 65 are very careful drivers.”

Even those seniors and health care professionals in favour of age criteria varied as to the appropriate age at which evaluations should take place:

“I think the age of 80 is a very generous allowance, really. But I don't think -- and actually, they could start testing everybody over the age of 70. Because they don't do the car testing the way they used to many years ago, used to be every two years, you get a bit older, you'd be tested. But they can't -- simply can't do it...-- they could just send a notice out to people at the age of, say, perhaps 65, 70.”

“You could make them more frequent, so therefore the person -- you're doing it on a more frequent basis... Well, if you take tests more regularly, they aren't as much tests any more, are they? Just -- instead of starting at age 80 and making it every -- maybe it starts at age 65 or something like that.”

It was acknowledged, most notably by health care professionals, that age serves as a convenient proxy by which to screen for complex medical conditions, use of medications, cognitive impairment, or “multiple organ failure as a biological feature of life.” It also is universal in that everyone, regardless of whether or not they attend a physician regularly, must see a physician to have the fitness-to-drive evaluation form completed:

“Because I think that people who are 80 or something should have a physical. I mean quite often it's the only thing that drags them into the doctor to have a physical at all. So it's for their own well-being anyway”

II. HOW ADEQUATE DO YOU THINK EVALUATIONS BASED ON AGE ARE FOR IDENTIFYING PROBLEM DRIVERS? HOW COMFORTABLE DO YOU THINK ASSESSORS ARE IN MAKING AN ASSESSMENT AS TOWHETHER A PERSON IS SUFFICIENTLY IMPAIRED SO AS TO PRESENT A HAZARD ON THE ROAD?

The primary concern about the fitness-to-drive evaluations for both seniors and health care professionals is centred on the need for a standardized approach to completing the evaluation form. Although most seniors acknowledged that a person’s own family doctor, who has known them for a period of time (e.g., two years), should have the requisite knowledge to complete the form accurately, concern was expressed about variability between doctors in their approach to completing the evaluation form. It was noted by the health care professionals that many physicians are not aware that guidelines (federal and provincial) exist. Even when physicians are aware of the guidelines, it was noted that clinical judgment is required and so the rules may not be applied in a standardized or uniform way:

“You take a look at that individual and it is not necessarily a completely objective thing. You're also -- if you know who that individual is, and you know what they do ... -- I mean there are other factors that come into filling those forms out.”

Health care professionals indicated that certain aspects of the evaluations address fairly obvious problems (e.g., vision, mechanics, loss of consciousness) and that these things are quite readily and reliably noted by evaluators. There are established clear guidelines for the identification of these disorders (e.g., CMA) and health care professionals interviewed felt confident that, as long as the evaluators are familiar with the existing guidelines, these conditions will be easily and consistently identified. However, it was also noted by the health care professionals that there are other cognitive or behavioural factors such as insight and judgment that may not be so easy for evaluators to assess. To accurately identify problems with judgment and insight, a conversation with a collateral informant may be necessary. It was suggested by one health care professional that, in situations where cognitive impairment is suspected, a multi-disciplinary team approach including neuropsychological assessment may be required. All health care professionals indicated feeling very uncomfortable making judgments where guidelines are unclear or non-existent, and in particular, where cognitive impairment or hidden substance abuse are concerned:

“If they're physically fine but mentally there are some problems, or there's some hidden substance abuse problem, then I don't feel very comfortable at all with making that [decision about fitness-to-drive].”

One health care provider questioned the need for the present system of having physicians complete fitness-to-drive evaluations:

“I think that for the number of people being brought in for examinations, the amount of work is probably of very little benefit... and an awful lot of seniors running around. I bet there's a much more efficient way to do it.”

III. ARE THERE OTHER FACTORS THAT INFLUENCE DRIVING OTHER THAN AGE? UNDER WHAT CONDITIONS WOULD YOU RECOMMEND FITNESS-TO-DRIVE EVALUATION?

As noted earlier, most health care professionals acknowledged that age is being used as a means of screening for medical conditions such as multiple medical problems, medication use, cognitive impairment, vision problems the risks for all of which increase with age. Other factors that were identified included reaction times, ability to turn the head, concentration, impulsivity, and the likelihood of unpredictable events occurring (e.g., seizures, sleep attacks, heart attack). Particularly of note, these unpredictable events may affect anyone at any age. Both the seniors and the health care professionals noted that having licenses with specific restrictions (e.g., no night-time driving, driving only within a certain geographic area) can be very beneficial by allowing people to maintain access to their motor vehicle under these conditions. This flexible approach to licensing was viewed as appropriate:

“I mean I believe if you look in the back of the driver's licenses now, it talks about, "You're not allowed to drive more than x kilometers from your home," or something like that. I think there is a restriction for that ... going back and forth to (the grocery store, doctor’s office) --sometimes that's all that people use the cars for ... for individuals that are very active and well -- very mentally alert-- they should be allowed to go back forth -- you know, to the bank and back.”

IV. WHAT ARE THE BENEFITS AND DRAWBACKS OF FITNESS-TO-DRIVE EVALUATIONS?

Seniors and health care professionals agreed that fitness-to-drive evaluations were important and necessary for protection of the individual and society. Some of the drawbacks that have already been identified above included the concerns over fairness in how the forms are completed by evaluators, the need for better guidelines for assessors around the accurate identification of insight and judgment problems, and the fact that many physicians are not aware that the guidelines (i.e., federal and/or provincial) exist. Specifically, health care professionals noted that the following areas are not adequately articulated in the existing sets of guidelines: cognitive impairment, the role of medications affecting cognition, multiple diagnoses, and combinations of several problems or a minor nature:

“... you can judge it by a single event, and the single event you look at is seizure frequency -- it's not that difficult to draw up regulations. I think with mild cognitive impairment it becomes more difficult. And with some other areas of physical function, for instance vision, there are quite clear rules about complete visual field defects of complete loss of vision. But if you take a typical older person, there might be milder degrees of visual deterioration, combined with subtle impairments in concentration, combined with slower reaction times. All in someone who is not cognitively impaired but is nevertheless processing at a somewhat slower speed just because of their age. So they don't meet criteria for cognitive impairment, but in fact processing speed is slower, and they have other multiple physical factors which may slow their reaction times. The complete picture could in fact constitute a hazard for driving ... And the guidelines may be much more difficult to draw up given that it's not an episodic disorder where you can specify seizure-free incidents, time, or control of heart symptoms and so on. You're dealing with more subtle variables. So if there was a greater degree of uniformity -- and I think if there was something which was legislated and administered in an arm's length way, where we could say, "We're not doing this out of any -- it's not me as a doctor who's saying you're not allowed to drive. Basically it's constitution -- it's mandatory, it's mandated by law. That this type of testing is appropriate, and it appears that you may not reach the criteria, or that you do require further testing." And I think it needs to be determined, first of all, what the appropriate guidelines are.”

Of concern to all health care professionals was the effect the fitness-to-drive evaluations can have on the practitioner-patient relationship. If the a problem is reported on the fitness-to-drive evaluation form, the source of the information is stated on the follow-up letter to the older adult. Even though the practitioner was acting on the best interest of the older adult, the older adult may become very upset and no longer see their physician. Although most practitioners accept this and try to communicate their position effectively to the older adult, it was suggested that either this information be kept confidential or that these evaluations be conducted by a third party.

“And the downside of it might be that people are angry with you for pointing out the obvious ... And possibly that assessment could be by someone other than the family doctor. Whereas you don't really want to have people's doctor-patient relationship suffer over an area of conflict.”

Of concern to the seniors was the cost of having the fitness-to-drive evaluation form completed. Many seniors were unclear as to why the completion of this form should be viewed differently from other aspects of their health care for which no charge is levied. Since they were seeing their own family physician, who is fully aware of their medical status, some seniors viewed this as an unnecessary doubling of costs. However, of particular concern was the variation in the price of completing the form among physicians. Apparently the cost varies from $50.00 to $100.00 in the local area. There was some concern that some seniors may not be able to afford these costs.

“But it seems to vary with doctors. I hear the remarks. Some people say that it cost them 40, some 55, some 70. Some doctors throw it in every year with their checkup.”

V. HOW IMPORTANT AN ISSUE IS DRIVING TO OLDER ADULTS?

The seniors and the health care professionals indicated that being able to drive is very important to most older adults as this allows them to maintain their independence and mobility. Not being able to drive has significant consequences for the older adult as they may not be able to get to public transportation. Moreover, the loss of the license tends to be equated with a loss of ability to live independently and care for oneself. The loss of a license may require a move (i.e., to a new location) or may result in withdrawal from services (e.g., no longer attend physician). Both seniors and health care professionals indicated that people may also withdraw socially if they do not have the means to get around. However, it was also noted by seniors that many older adults choose to give up their cars and are pleased with the result. A number of the respondents, both seniors and health care professionals, indicated that there are alternatives to driving if the ultimate goal is mobility and that perhaps it is the attitude toward driving that needs to change. As two health care professionals note:

“I mean it really cramps them, their style, for this -- especially if you've got two elderly -- one isn't driving anymore, and that person is the driver for both of them. And suddenly they can't do these things ... You know, people say, "Well, there's the bus." Well, that's all fine and dandy, but if the bus means you've got to walk two blocks up a hill, you might not be able to do that. And then you've got to have friends come and drive you, or take a taxi. Well, maybe you can't afford a taxi.”

“It means a lot to seniors right now. But I would think that perhaps the younger generation could be led to be less invested in their driving. Especially if it's somehow seen to be environmentally cool not to be a driver all your life. If taking cabs became OK. I mean many seniors believe that cabs are never a possibility because it's too expensive, when they insure cars and fill them full of gas and keep them sitting in paid parking garages and only use them once a month. But our society's economically and culturally addicted to cars, and I think it's to the detriment of our cities and our planet. And hopefully we can come up with some ways around that to some extent other than just electric cars.”

It was also noted by a health care professional that some older adults who do not drive wish to maintain their driver’s license for identification purposes. Requiring a fitness-to-drive evaluation for these persons would not appear warranted.

VI. HOW COULD THE PROCEDURE BE IMPROVED? WHAT WOULD YOU RECOMMEND TO IMPROVE DRIVING CONDITIONS FOR OLDER ADULTS?

The respondents indicated that there are a variety of other methods for addressing fitness-to-drive that could be used in conjunction with or as alternatives to the present procedure. These responses generally fell into 4 categories: education, road engineering, reporting mechanisms, and access to alternative modes of transportation.

The need for education concerning fitness-to-drive issues arose both in the context of seniors and physicians. Both the seniors and health care professionals noted that a system that allows the person being re-examined an opportunity to demonstrate their fitness-to-drive would be an improvement over the current system. It was acknowledged that on-road driving assessment for all persons at or over a certain age appear impractical but that a system that allows seniors to obtain reasonably priced driver education would be useful. A number of the older adult respondents indicated that they have taken such courses and benefited from them. It was suggested that course content be both theoretical and practical with the opportunity for on-road experience. Some suggested that offering these courses through Seniors Centres would improve accessibility. Others noted that driving schools and some other organizations (i.e., 55 Alive) presently offer such courses, although the prices and quality varies. It was felt that this education could be made mandatory or could be non-mandatory and result in savings or a rebate on automobile insurance rates. As two seniors noted:

“I think perhaps if they made it mandatory, a defensive driving test, for people at a certain age. Because I took it when I was in my thirties, and I was amazed at how little I knew. And it really made me very alert to a lot of things. Because you get -- as you get older, you get busier, and you don't really -- probably not as careful about measuring distance and things like this as you should be. But I think the defensive driving test -- my husband got me doing that, because certain members of the forces -- he was in the Navy -- and he had to do it, and he said, "You'll find it very, very helpful." And I did. It made me very much aware that I was lacking in a lot of things which I should have been aware of.”

“But I think the mandatory defensive driving -- they could just send a notice out to people at the age of, say, perhaps 65, 70. After this that perhaps you should -- to hold a license you should be required to take a defensive driving course, or else read the book -- they have a very good book, the Motor Vehicle have -- I got that the other day. Telling you all the things -- a lot of things that us older drivers who learned to drive, probably from a member of the family, many, many years ago -- don't learn. Whereas if you go to a driving school now, as we like our grandchildren to do, it's a different course altogether.”

A health care professional made similar observations:

“So I think that a sort of non-mandatory thing where a patient can submit themselves -- ... I think patients and people generally have a fear of arbitrary authority taking their license away just like that. And a process which doesn't in fact involve them face-to-face with the licensing authority, but has them going through a process of assessment which is not -- which they see as perhaps not resulting in instantaneous loss of license, but giving them perhaps the ability to improve their driving skills, or being -- I think they want fairness. I think what people want essentially is to feel that they are going to be dealt with in a fair, equitable way in which there will be some redress, or their voice will be heard. If they say, "Well, but I can do this better," or, "I want to try it again," or, "Maybe get off these pills and see if I can pass -- if I can concentrate better." I think they would be much more comfortable with that. And I think the fear of people is that once you've lost your license, that's it.”

Respondents noted that a non-mandatory self-assessment process may alert people of factors that may affect driving (e.g., medical conditions, vision problems) and provide suggested actions people could take. Many older adults are already preparing for the driving evaluations and providing everyone with the same information and opportunity may be another way to facilitate individual involvement in the re-evaluation process. Two health care professionals noted:

“Well, why not send people a survey, and say, "Is there any reason you can't shoulder check, or use your mirrors? Is there any reason you" -- and it would be fairly easy for people to do some sort of visual screens...the only way that I know in the office if a person has had a blackout or a seizure or loss of consciousness, is that people tell me. We could survey them about that, and just let them know that the law says if you knowingly have something like this, then you should not be driving until your condition has been stable for six months and the doctor says you're fine. So I think those kinds of reminders would help all the reasonable people. And that kind of survey would help with everyone reasonable no matter what age.”

“...these people know that they're getting close to the time where they're going to be called in to get their driver's license checked by the family physician. And it's kind of like studying up for a test. They want to come in to make sure their vision meets the requirement first...So I think the feeling of some flexibility in the system.”

Health care professionals noted that physicians, and other health care providers, could do more to provide information to their patients about driving issues:

“So people have reasonable choices to make which will allow them to become independent of the car. It's only when it happens suddenly. I think people who are planning ahead can easily learn how to manage without a vehicle, and it's not such a big blow. So in a sense, maybe public education around the issue of the need to consider the fact that you may not be able to drive when you get older would be an important point. And a lot of people do consider that anyway...Well, the thing about public education is that doctors have a role in public health in the sense of dealing one-and-one with their patients. We need to advise on things like nutrition, good health issues. And with increasingly older patients, issues of maintaining independence often do come up in discussion. So absolutely, doctors should be saying, "Look, you know, you must realize that in the next ten years or so you may find it increasingly difficult to live in your single-family dwelling which is out in the country and which requires you to have a driver's license." So for physicians, you're very well placed to raise the issue of review of the need to consider the possibility they won't be able to drive. And I think yeah, doctors are in a good position to discuss that with people.”

“Mak[e] driving safety a discussion point in any kind of health problem where the health problem might affect driving.”

Health care professionals and seniors noted that ensuring that road conditions facilitate safe driving is something that will be of benefit to all drivers, not just seniors:

“I think I'd like to say that we probably should be working to make all the roads as safe as possible”

“Make their signs a little bit more clearly! ... I think they have very poor signs and directions. I may wear glasses and I can see the signs, but I still think they're too small, or -- and some of the big signs are too confusing, as far as I'm concerned...They don't know where they're going. They're afraid and they'll slow down and they're looking, trying to find the sign, and everything like this. This does -- the main thing, the most important thing, is to keep the traffic moving. Then you'll have less accidents.”

Respondents also noted that mechanisms allowing for the report of unsafe drivers by health care professionals or others may adequately capture persons who are a hazard on the road, regardless of the age of the driver. It was noted by health care professionals that a variety of procedures could be used to identify persons for further evaluation:

“But if there are concerns because of reports of others, or accidents, or medical visits -- using some data from hospital, if there's a discharge diagnosis from the hospital of anything that needs to be concerned about ... perhaps those are the people we should be targeting... But I'd also like to have some sort of -- if there are concerns, some sort of report from either a spouse or a relative or someone else saying that they -- if there's any question or concern, asking for them to support that person. And if they don't support that person, then maybe we should be evaluating further... families do have an influence. And people think twice about things if their family members don't want to drive with them anymore. And if that's not the case, then we should be looking at it. Most people don't know that they can call the Motor Vehicle Branch and say, "I have concerns about this person's driving." I think people should know that... it should be for anybody. I think anybody should be able to express concerns. And I think that they should be willing to swear and sign something saying that they're doing this with absence of malice, and no biases, and only out of care for that person, and have some sort of way of demonstrating that, I suppose. Or concern for public safety. And as long as people do make that report with an absence of malice, then I think it should be OK. And if people are found later to have -- done it in a malicious way, then I think there should be some kind of punishment. I think that would discourage people from misusing the system.”

Respondents also noted that there is a need to improve the types and access to alternative modes of transportation. If easily accessible, affordable, convenient transportation was available, more seniors may voluntarily reduce their need for a motor vehicle. Available alternatives included taxis, buses, scooters, and volunteers drivers. It is important to understand the factors that influence the use of alternative modes of transportation beyond cost, accessibility, and convenience when developing new modes of transport. For example, it is often noted that taxis are too expensive an alternative to maintaining a private automobile. Yet, often the cost is, in fact, less, but other attitudinal factors appear to influence choices. There were special issues identified concerning the use of alternative transportation after dark by seniors:

“Oh, it's [night-time travel] a big problem, yes. That's where if you have a car, you really don't have that much of a worry. But you have to take it careful anyway. But if you have to move around on foot or something of that nature, then you have to be really careful, and you have to take it as it comes.”

“Years ago there was a smaller bus that went around XXX, and some of the different outlying areas -- because there's a lot of people, older people, that live out in these areas... But I think if they had some type of small bus that would go at certain times, people would know -- I mean if it goes at one o'clock, you make your appointment for two o'clock or something....I think the service that we were talking about, which was in existence here for a while, was along the lines -- instead of a bus running around empty all the time, if it was needed, they'd phone and say it was needed. But that's -- it's probably less expensive than running an empty bus around.”

Health care professionals, too, raised the issue of alternative modes of transportation:

“The main thing I wanted to say is that alternative methods of transportation have to be encouraged. Especially in seniors' communities and other communities where the population is very dense and cars are more -- cause more traffic and more pollution and more problems than they're worth. Many people who don't drive very much still want to keep their car and their license and their insurance, even though it financially doesn't make sense, and other transportations could give people just as much independence and for less cost. And freedom... I would think that you should be able to design our cities for people to get around quickly and efficiently, without so many cars on the road. Buses, streetcars, cabs. Alternative methods of transportation such as that should be somehow made more popular and more accessible. This odd preoccupation we have with needing to drive to be free and independent, that idea needs to go.”

VII. SUMMARY

It was clear from our interactions with the seniors and health care professionals that there was general agreement that driving in an important issue for older adults and there was general appreciation of the need for driver re-evaluation. However, less clear was whether age was the criteria of choice. Seniors clearly noted that they felt age had very little to do with identifying problem drivers. Others felt that the age at which re-evaluation should be pursued should be lowered. Most respondents, seniors and health care professionals, acknowledged that age is used as a means for identifying persons at high risk for medical conditions. Some health care professionals felt this was warranted; others did not. Specifically, both seniors and health care professionals noted that the medical evaluations of fitness-to-drive lack reliability, especially since some physicians seem unaware of presently available guidelines. Specific areas where the existing guidelines lack clarity were identified by the health care professionals: cognitive impairment, role of medications affecting cognition, multiple diagnoses. Seniors expressed concern over the variability in the cost of these assessments. Health care professionals expressed concern about the effect that fitness-to-drive evaluations can have on patient-practitioner relationships.

Various suggestions were offered as to how the present procedures may be improved. For example, a more elder-friendly approach to on-road driving assessment perhaps could be provided through third parties such as driving schools. In addition, it was suggested that non-mandatory self-appraisals could be used as adjuncts to the present procedures, and that physicians be encouraged to make driving safety a discussion point for any kind of health problem that might affect driving regardless of age. Finally, the need for accessible, affordable, convenient alternative forms of transportation was raised to meet the needs of older persons who no longer drive. However, it was noted that a more general shift in attitudes toward driving and the use of alternative modes of transportation may need to occur before such transportation becomes generally available and utilized.