What support and interventions are effective at reducing casualties associated with older drivers?
Mobility is important for sustained independence and well-being (Whelan, Langford, Oxley, Koppel & Charlton 2006; Box, et al., 2010) and, unsurprisingly, imposed driving cessation may also lead to negative psychological consequences. This is emphasised by findings of associations between driving cessation and an increase in depressive symptoms and satisfaction (Marottoli, 1997; Stutts et al., 2001). The ability to connect with friends and family, and to access services, especially in areas with little public transport, remains central to the health and well-being of older people. Moreover, the use the private car remains at the centre of mobility for this age group. For this reason, developing interventions that improve older driver comfort, confidence and safety is a key task going forward.
Below are a number of key areas believed to show the promise for older drivers.
New technology that can influence older driver safety takes the form of vehicle technology and design, but also considers possible changes to the driving environment.
Eby and Molnar also reviewed available technology to help improve older driver safety, though their focus was on vehicle design. They report that many older drivers face difficulties with simple tasks such as getting in and out of the vehicle, seating comfort, and using and adjusting vehicle mirrors (Eby & Molnar, 2012). They also discuss the use of Intelligent Transport Systems (ITS) (systems designed to provide drivers with information and assist with the driving task) to help drivers compensate for any functional impairments such as night vision and object distance.
One form of ITS that is particularly accessible and that has been evaluated in the literature is the in-vehicle navigation system (IVNS). These use Geographical information Systems (GIS) and Global positioning systems (GPS) to give feedback and support to drivers navigating the road systems. Recently, a study using focus groups was carried out to assess older drivers’ perception and use of IVNS with both current users and non-users of the technology. Their findings showed that IVNS provide older drivers with increased confidence, and potentially deters them from undertaking more risky behaviours. For example, some drivers who did not have experience with IVNS reported that they used strategies such as writing instructions in large letters on a paper and placing it on the passenger seat or their lap (Emmerson et al., 2013).
However ITS may increase distractions and driving workload for older road users, thus it is important that future ITS is designed to ensure safety is enhanced (Eby & Molnar 2012).
IVNS is only one of many technologies that can be used to enhance older driver safety. Other tools include park assistance, blind spot warning systems, and vehicle stability control. The latter helps to automatically bring the vehicle back in the intended direction of travel, particularly useful for driving on curves or through bad weather. Again, these are only a few examples of the available technologies to help assist older people with the driving task. These tools will not only increase safety by assisting with driving skills that may have deteriorated, but they also help to provide comfort and confidence that can help keep drivers driving safer for longer.
Changes to the driving environment
Boot and colleagues’ (2013) mini review mentions several possible changes to the driving environment that may improve safety for older drivers. Some examples include the use of offset turn lanes, internally lit street signs, and advanced street name signs (signs placed at a certain distance before the road – this allows drivers to start making decisions earlier) (Boot, Stothart & Charness, 2013). However, changes to the road design, and infrastructure are beyond the scope of this review and should be considered separately. The interested reader is redirected to Boot et al. (2013) and Box et al., 2010.
According to Boot et al. (2013), there is evidence to suggest that changes to the roadway and driver training strategies can bring the abilities of older drivers back into alignment with the demands of the driving task. This said, the evidence available seems to be somewhat mixed with regards to the effectiveness and transferability of driver training interventions.
A recent review of literature on available mobility interventions identified five randomised controlled trials for evaluating cognitive training. These varied in terms of total training time (from 4.5 to 24 hours total training time), length of training period (2-8 weeks of training), administration format (computerised and paper-and-pencil training exercises), and cognitive functions covered (e.g. speed of processing, memory, reasoning, attention and executive function) (Ross et al., 2012). The interventions included training speed of processing, memory, reasoning, and attention; speed of processing was the most common training used. The authors concluded that the results of the cognitive training demonstrated transfer of training to driving safety, using measures such as at-fault crashes and simulator driving. The authors conclude that as many of these were large, multisite clinical trials, cognitive training shows good promise for extending mobility for older populations.
Physical exercise programs have also been evaluated as potential interventions to improve driver’s control of the automobile and physical movements necessary for completing the driving task. This form of intervention seems to have received the most attention, and Ross et al.’s review alone identified 65 randomised control trial studies evaluating exercise-based interventions. The interventions were incredibly varied in terms of content and application, and included walking, dancing, yoga and tai chi (among others). However, most functional measures used to evaluate the interventions were physical fitness measures with only one study relating the intervention directly back to the driving task. This was the study by Marottoli and colleagues in 2007 (as cited in Ross et al., 2012) who evaluated a twelve week exercise program guided by a physical therapist with older drivers over the age of 70. The routine included a daily 15-minute session, seven days a week and targeted driving-related physical abilities such as trunk and axial rotation. A post intervention follow up at three months showed that the group receiving the specialised program had a significantly greater road test scores and made 37% fewer critical errors on an on-road test. The errors considered included inattention, turning or changing lanes without looking, and ignoring signs or signals; these were evaluated by a specially trained driving evaluator. However, Boot’s mini review warns that more evidence of the effectiveness of these interventions in reducing crash risk is needed.
Although cognitive training interventions have been evaluated to a lesser extent than exercise training programs, these have shown more promise as most studies have been with large sample sizes and have shown good transferability to driving. On the other hand, exercise programs are very varied and have rarely been linked back to on-road or simulator driving. Because of this it is difficult to establish what interventions work best as well as which may lead to the desired outcome: lowered crash risk.
In addition, some research shows that take-up of existing training interventions may be low. For example, a large study conducted by Stutts and colleagues in the United States showed that 26%, of current older drivers, and only 11% of former drivers reported they had attended a driving class or refresher course (Stutts et al., 2001). As many of these courses require a degree of self-motivation by the driver and varying degrees of time commitment, the low uptake may be a hindrance to this type of intervention. Low uptake of interventions may also affect the results of this type of study as people taking part in the research may not be an accurate representation of the population as a whole. However, as this research was over ten years ago, it is difficult to draw any conclusions of current uptake based on this survey. Therefore, more research is needed to better understand the current situation of training acceptance and uptake by older drivers.
No literature was identified that met the inclusion criteria for full-text follow up on this topic. This said, there are a number of community services available for older drivers, especially at a local council level where older drivers may be of particular concern. For example, councils such as Devon County Council and Suffolk County Council both have training courses available for older drivers. Suffolk host a driver workshop called 'Grand Driver' which focuses on three main areas: health and mobility, refreshing knowledge of the Highway Code and improving hazard perception skills for drivers over the age of 60.
Devon County Council also has a number of interventions available for older drivers including the 'Driving Safer for Longer' program, which is hosted in partnership with the Devon and Cornwall Constabulary. It is intended to help drivers stay safer for longer and also to help them make choices about their driving future.
The main issue with many of the interventions used at a local level is that there are few (if any) evaluation programs looking at the effectiveness of these with the older driver population. In the future, work should be done to understand which interventions are most accepted by drivers, but that also show the greatest promise in terms of reducing risk.
The same literature review by Ross et al. (2012) identified 10 studies evaluating the effectiveness of different educational interventions on self-report and on-road driving tests. The findings of all studies are somewhat mixed. Some interventions used in the United States and Canada (such as classroom-based driving retraining intervention by Bédard et al.,, 2004, as cited in Ross et al. 2012) had no impact on objectively measured driving performance; however, a similar classroom program combined with on-road driving education showed improvement in some (but not all) of the on-road driving measures (Bédard et al., 2008).
A number of other evaluations identified through the review did not directly target driving, but focused on more general mobility outcomes, such as walking difficulty (Mänty, Heinonen, Leinonen, Törmäkangas, Hirvensalo, Kallinen, Sakari, von Bonsdorff, Heikkinen & Rantanen, 2009).
The authors of the review are careful to note that the interventions found varied greatly in terms of content and length of the interventions, and the time frame in which they were evaluated. The interventions also varied in terms of the outcome measure, with those relating back to the driving task being the least successful. It is possible that educational interventions, when used appropriately to target general areas of functioning (such as general mobility) could have a very positive effect. However, driving is a complex task that requires the successful performance and integration of a number of tasks, therefore educational interventions may only be effective when combined with other forms of training such as on-road re-training.
Increased engagement with healthcare professionals has been considered as an important step toward increasing safety for older drivers. There is good evidence to support that older people trust healthcare professionals. A survey with over 4,000 drivers in the United States (Coughlin, Mohyde, D’Ambrosio & Gilbert, 2004) found that 31% of married older drivers, and 41% of those living alone would choose to talk to their GP about driving concerns. For married older drivers, this came second only to speaking to a spouse. GPs may therefore play an important part given the role they play in advising their patients.
However, GPs are limited in terms of the knowledge of the subject area and are faced with the ethical conundrum of recommending that a patient should cease to drive. The French government have taken steps toward improving GP knowledge so as to mobilise this valuable resource to improve older driver safety. In order to support GPs, the French ministry of Health edited a booklet in 2012 entitled ‘Driving According to one’s health, physicians what is your task?’ This booklet was distributed to all physicians in France, and includes clear and concise guidelines and frequently asked questions that can help guide physicians advising older drivers. Although this does not represent a definite solution to the problem, it can help GPs to take a more active role in their patients’ road safety.
There are some risks in GPs taking on the responsibility of older driver regulation. Not only could it undermine the doctor/ patient relationship, but as Berry mentions in a review, the ‘medicalisation’ of driving regulations may encourage older people to stop taking responsibility for their own driving (Berry, 2011). In addition, there is little evidence that stringent medical examinations for relicensing necessarily result in increased safety. Mitchell (2010) uses the example of Finland where medical examinations are required at 45, 60, 70 and every five years thereafter. Not only is licence holding for older age groups lower than other EU countries such as Sweden and the UK, but fatality rates per population are generally the same than countries with less stringent medical examinations. There is also evidence that this modal shift may increase risk for older people as they become pedestrians (Mitchell, 2010).
Self-regulation, in this context, is the practice of adjusting one’s own driving patterns to compensate for functional limitations due to changes in cognitive, sensory and motor capacities. It relies on drivers’ motivations to self-assess their driving ability, and to make the decision to self-regulate where they see fit. A number of studies have demonstrated that older drivers tend to be sensitive to the effects of ageing on driving performance, and that they learn to adjust their driving patterns to limit their exposure to difficult or threatening situations (Lang et al., 2013, for a discussion on the topic).
However, the nature of self-regulatory practices is not straight forward, and authors, such as Berry (2011), mention that the process of self-regulation does not seem to be working as effectively as it could be. It is, therefore, necessary to understand the process of self-regulation and how it is used by different groups of people.
A study by Molnar and colleagues examined some of the factors that may mediate self-regulation and posed the question: ‘Is driving avoidance always self-regulation?’ The authors identified that some of the motivators to limit driving are not always based on self-regulation (and therefore, on awareness of one’s own driving abilities). For example, they found that driving avoidance may be due to changes in lifestyle or preferences, though this was only for certain situations such as in-vehicle distractions (Molnar, Eby, Charlton, Langford, Koppel, Marshall & Mann-Son-Hing, 2013). Another study by Gwyther and Holland (2012) found that although self-regulation increases with age, anxious driving style and negative affective attitudes (defined as confidence in difficult driving situations) were independent predictors of self-regulation behaviour. This suggests that self-regulation behaviours are not unique to older drivers. Similarly, Kulikov (2011) found that state driver’s licence renewal requirements (in the United States) also made a significant difference in the driving mobility of older Americans. They also found that living alone, education and, interestingly, restricted licencing policies, were significantly related to prolonged driving. The latter is somewhat different to the case of the United Kingdom as, when compared with other EU countries, it has one of the highest rates of licence holding by people aged 65 and older, which, according to Mitchell (2008), is due to the relatively lax relicensing process and may have a positive effect on the wellbeing and safety of older drivers.
Other research shows that self-regulatory practices may not always be timely. Research by Stutts et al. (2001) used focus group data to show that there is a subset of the older driver population who tend to stop driving too early. These are mostly women who have family member available to drive them, or who have been deterred from driving because of crash involvement or discomfort. Given the negative consequences that have been linked to driving cessation, further research by the same authors used survey data to gain a better understanding of the premature reduction and cessation of driving with a sample of 2,510 adults aged 65 and over. This said, numbers for the ‘older old’ age group (particularly those 85+) were particularly low (n=118). Results showed that former drivers were more likely to be female, older, and less satisfied with their ability to go places. Women were also likely to cite comfort-related reasons for stopping driving, while men were more likely to quote health reasons.
Studies have also found relationships between cognitive ability and self-regulation. A recent study by Wong, Smith & Sullivan (2012) explored the relationship between older drivers’ cognitive ability and self-regulation with a sample of 70 Australian drivers aged 65 years and over. Drivers completed a questionnaire about their driving and a measure of cognitive function believed to rely on visual-spatial and executive function the (Clock Drawing Test (CDT)). Results showed that those who failed the CDT were significantly less likely to report self-regulation, and showed less interest in taking part in driving programs. They did, however, report driving significantly fewer hours.
The process of self-regulation is complex and requires better understanding, especially given that it is currently viewed as the most effective ‘intervention’ to increase older driver safety. However, this process is not well understood and more research is needed to further understand how and when older people use self-regulation as a tool for safety. In Stutts et al.’s study authors also highlighted the fact that nearly a third of all survey respondents who were former drivers felt that they stopped driving too early. Given the negative psychological consequences linked to driving cessation and the gender differences reported in studies (such as Stutts et al., 2001), it is important to ensure drivers do not stop driving too early in order to ensure prolonged safety and mobility for all.
As mentioned previously, self-regulation involves adjusting one’s own driving patterns to compensate for functional limitations. Although it is widely known that ageing increases the potential for decline in particular skills and abilities, it may not always be straight forward to identify what constitutes a ‘significant’ change. It may also be difficult to understand what specific skills and abilities may have an effect on driving performance. With this in mind, research has turned to the development of self-assessment tools to help older drivers to self-regulate, and to make important decisions about driving cessation.
Currently, both interactive and non-interactive self-assessment tools are available through universities, local councils (UK), and the internet. Although many of the tools available have been developed in the United States, one example of a UK-based tool is the adapted Devon Driving Decisions Work book. This is part of a wider initiative called ‘Driving safer for longer’ developed by Devon and Cornwall Constabulary, and is based on an American tool (The Driving Decisions Work Book, Eby et al, 2000, as cited in Lang et al., 2013) that was developed over the course of many years and an extensive research progam. It is a paper and pencil questionnaire that can be completed by the driver alone or with a family member. It includes questions about on-road behaviours and preferences, including questions on memory, speed of decision making, and reaction time. It also includes a subdomain for health. The results of the questionnaire provide drivers with feedback and information about their driving.
Another UK tool is the ‘Older driver risk index’ developed for Suffolk County Council, and that is part of the ‘Grand Driver’ Scheme mentioned previously. The Driver risk index is a web-based profiling tool that uses self-report items to assess four areas: situational risk, behavioural risk, coping risk, and socially desirable responding. The aim of the tool is to establish the attitudinal and behavioural risk of older drivers as compared to their peer group. This is provided by the council as part of the Grand Driver scheme and is part of the overall program aimed at maintaining safe mobility.
Although the development of self-assessment tools for older drivers has gained importance in recent years, more work is needed to validate the effectiveness of these tools. In addition, the main issue of self-assessment tools (and self-regulation as a whole) is the fact that it relies on older driver’s self-motivation and self-awareness of their own driving behaviours in order to uptake such interventions. This means that although self-assessment tools will attract a segment of the population, this will likely be the same segment that is likely to take up other types of training, or in fact, self-regulate independently of any tools or training. Nonetheless, these tools can help older drivers to make more timely decisions about when to stop driving, but can also facilitate the conversation with family members or a GP.
For more detailed information of other available self-assessment tools and a discussion on issues surrounding existing self-assessments, the interested reader is referred to the work by Lang et al. (2013), ‘Driving Choices for the older motorist: The role of self-assessment tools’.
Publicity, Campaigns, Policy and Enforcement
No literature was identified that met the inclusion criteria for full-text follow up on these topics.
- Date Added: 03 Apr 2012, 08:08 AM
- Last Update: 26 Jan 2017, 05:11 PM