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I.B. DEVELOP MODEL PROGRAM COMPONENTS TO REGULATE AND
COUNSEL HIGH-RISK OLDER DRIVERS AND TRANSPORTATION SYSTEM USERS
I.B.1. DMV/Licensing Activities
With the sharp increase in the number and percentage of older drivers in the
population that will occur in the years ahead, and the decline in a wide range
of functional capabilities that is normally associated with aging, there will
be an inevitable impact on highway safety unless the most at-risk individuals
can be identified through screening procedures that are fair, accurate, and
which can be administered cost-effectively by State/Provincial licensing agencies.
The development and field testing of a Program which can meet these goals, while
educating and counseling affected drivers about options to preserve (or even
extend) their mobility are all key to success in this area.
A crucial first step is to evolve a framework to guide and coordinate the activities
of the various external sources that may refer drivers into a screening Program,
while seeking to standardize the reporting procedures and formalize lines of
communication back and forth between these referral sources and a Motor Vehicle
Agency. From the very outset of an individual's Program involvement, it must
be assumed that community and private sector organizations will play a major
role in the identification of at-risk drivers--and that motor vehicle
agencies will report back to external sources the status of referred drivers
within legal bounds of privacy and confidentiality. It is recognized that external
referral sources and referral mechanisms will need to be identified and described
in detail prior to implementation of the Model Program.
Of course, at-risk drivers may also be identified through activities undertaken
by an Agency itself. Applicants for renewal (and, optionally, original applicants),
could be"pre-screened" through direct interactions with counter personnel, where
candidates for functional screening are selected using standard and objective
criteria. Screening might also be triggered by crash or violation experience;
by age; or by a statistical sampling procedure (reflecting, for example, the
relationship between age and crash rates). Self-selected populations, such as
those applying for handicapped status, also could be required to undergo screening.
Selection of candidates for testing will vary from one jurisdiction to another.
But the Model Program will emphasize the need for drivers, once targeted for
functional screening, to be assessed in terms of a common set of "first-tier"
performance criteria.
The first-tier screening procedures focus on gross impairments (and, optionally,
vision screening and/or road sign and knowledge tests). These tests are designed
to catch those persons with the most serious physical or mental limitations
using procedures that can be administered in a brief time (under five minutes),
by current staff (with special training), in existing facilities, and without
special equipment. Such persons would typically experience loss of licensure
or restriction of term and/or privilege, allowing for due process. At the same
time, the most capable--given a clean driving record--would be passed
for license renewal without any further action.
Another outcome of the first-tier screening activities could be an administrative
determination for additional testing. This might occur, for example, where an
individual's standardized scores are marginal (i.e., a gross functional deficit
is not demonstrated conclusively), but his/her driving record contains indicators
of prior negligence. It is also possible that some individuals, depending upon
their source of referral into the Program, could proceed directly to this "second
tier" of assessment. Second-tier testing will likely address medical conditions,
and/or attentional, perceptual, or cognitive functions, using tests that often
require more sophisticated, costly, and lengthy procedures to assess reliably.
While an Agency may wish to undertake such testing "in-house," the Model Program
will certainly allow for physicians or other health care professionals or (certified)
private sector entities to carry out these activities, given uniform reporting
requirements.
Under the Model Program, after the requirement(s) for functional testing are
completed for a given individual, any among a full range of licensing actions
may follow (including no action). Specific actions relating to specific test
outcomes or cutoff scores will be suggested but not mandated within the Model
Program. States' practices with regard to options for restricting driving privileges
will vary, as will drivers' rights to appeal restriction or removal of privilege,
to demand retesting when diminished functional capability is indicated, or to
demand a road test. In all cases, however, the Model Program will call for an
Agency to provide individualized feedback on test performance and its consequences
(i.e., prior to a licensing action). Education and counseling activities are
also critical: Individuals should be provided with information identifying alternative
transportation options in their communities; and, those who retain driving privileges
should receive materials describing strategies and tactics to help compensate
for future loss of functionality (e.g., flexibility and strength-building exercises,
walking, proper nutrition), together with techniques for self-testing to increase
awareness of one's own declining abilities.
Pilot studies conducted in Maryland between Spring 1998 - Fall 1999 will evaluate
components of the DMV model, with a focus on driver screening and assessment.
The objectives of driver testing activities carried out in Maryland are to perform
limited validations of Model Program components in a DMV setting, using a retrospective
case-control study methodology which tests how well functional measures can
discriminate between matched older driver groups who are and are
not (a) crash-involved; (b) medically referred to the MVA for evaluation;
and (c) who have and have not accumulated 3 or more points
on their driving records. Thus, data collection and analyses resulting in the
preliminary validation of screening instruments in terms of crash involvement,
(multiple) violation involvement, and the (medical) referral status of older
drivers are study goals. These data will support an assessment of the administrative
feasibility of all included functional testing/screening techniques included
in the pilot study and may assist with assignments of individual drivers to
receive tailored road tests for selected conditions (e.g., visual, cognitive
and/or physical problems).
I.B. DEVELOP MODEL PROGRAM COMPONENTS TO REGULATE AND
COUNSEL HIGH-RISK OLDER DRIVERS AND TRANSPORTATION SYSTEM USERS
I.B.2. Integrated Health, Social Service, and Community-Based
Agency Activities
The most comprehensive solution to improved driver screening and
evaluation is likely to incorporate a community-based approach where driving
assessments and case management components are performed by entities outside
of the DMV. Current examples of this approach are the "Getting in Gear" (GIG)
program in Florida; Older Driver Evaluation Program of The Ohio State University
Medical Center Office of Geriatrics and Gerontology (Franklin County); Michigan
Area Agency on Aging "You Decide: Senior Driving Awareness Program" (Ann Arbor,
Birmingham, and Romeo); Mature Driver Retraining Workshops (Oakland County,
MI); the Older Driver Safety Project (DeGraff Memorial Hospital and Rochester
Rehabilitation Center, New York), Howard County, Maryland's "Getting Around--Seniors
Safely on the Go" Program; and The Senior Health Center at St. Mary's Hospital
(Richmond, VA). The following discussion highlights components of these programs.
Community-based programs offer an opportunity to provide early detection of
driving problems and a range of solutions--through referrals to remediation,
retraining, and counseling about changes in driving habits and alternative transportation
options--in convenient and non-threatening settings. With the availability of
affordable and effective tools, applied consistently across settings, interventions
in the community can address a range of older driver needs that fall outside
of traditional procedures for license renewal. As diagrammed on the following
page, the overview of an integrated approach to driver screening and evaluation
assigns prominent and complementary roles to the DMV and to service providers
in the community.
This approach relies heavily on coordination, cooperation, and communication
between various agencies within a community, and while the basic mechanics will
be similar across communities, the specific entities will likely vary with each
program implementation. Community-based programs, including voluntary programs
to assist aging drivers assess their skills and remain safe on the road include
the following components: (1) assessment of competency to drive; (2) driver
education and training; and (3) case management/agency referral.
External Referral Mechanisms: External (outside of the DMV) referral
mechanisms include: self referral; referral by family, friends, and other caregivers;
physicians, hospital discharge planners, Geriatric Evaluation Services (GES);
occupational and physical therapists; individuals working in Area Agency on
Aging facilities (e.g., senior centers); insurance agents; and law enforcement.
The Older Driver Evaluation Program in Ohio has a formal program with four
municipal courts in the area, which allow the Judge or Mayor to give the older
adult a choice to agree to undergo the evaluation either as an alternative to
formal charges for a motor vehicle violation, as a means of identifying deficits
that might threaten future successful driving and independence, or as a means
of determining current function and potentially lessening license suspension
time frame. However, in the GIG program in Florida, participation in the program
is currently voluntary, and there are no consequences for not participating.
Regarding police referral, experience in Florida has indicated that although
deputies supported the program and referred a total of 71 drivers during a test
period, most of the drivers who were contacted by Program staff during a follow-up
telephone call denied that they had diminished capabilities and needed the Program's
service. Over 65 percent of those contacted stated they should not have been
pulled over (e.g., "no one stops for that stop sign"). Eighty-five percent of
those who were contacted declined to participate, once they learned that there
were no consequences. Seven percent of those contacted did participate, and
an additional 4 percent gave up their licenses on their own after being pulled
over. The Program Director offered that this component "needs an incentive,"
to get law enforcement-referred drivers to participate. Such an incentive would
include implementing a requirement for drivers stopped by law enforcement to
participate in the GIG Program in lieu of ticketing, or to reduce the fine.
But without this kind of incentive, drivers won't use the program.
[ Integrated Model Driver Screening
and Evaluation Program Overview ]
For senior assessments at St. Mary's Hospital, patients must be referred to
the center by their primary physician. A caregiver or family member with the
patient's history must be present at every appointment. The comprehensive senior
assessment is helpful for the following kinds of individuals: those with a decline
in functional ability; those who may need a change in living situation; those
who show increasing frailness; those who show a change in behavior or increased
forgetfulness; those who have unsteady balance or have a history of falls; those
who have a problem with incontinence; those who use multiple medications; and
those with multiple active medical problems. The focus is on identifying remedial
problems that, when addressed, can maximize independent functioning, and thereby
improve a person's overall quality of life. Often, physicians refer clients
for an assessment to avoid the unpleasant consequences of telling a patient
that he or she should no longer be driving. Families often want an objective
decision to back up their beliefs that a client should not be driving.
The three Area Agencies on Aging sites participating in the "You Decide: Senior
Driving Awareness Program" in Michigan coordinate with state and local agencies,
and public transportation authorities to identify older drivers who either (1)
should no longer be driving; (2) want/need to determine if driving is still
safe; or (3) want/need to plan for a future when driving may no longer be possible.
These persons are targeted for participation in the Program.
Referral into the DeGraff program are made by primary care physicians, family
members, individual older drivers, the Alzheimer's Association, and Allstate
Insurance Company officials. In addition, the following community partners will
refer older persons into the program: Offices for Aging, health professionals,
AARP, the Department of Motor Vehicles, the American Automobile Association,
NYS Office of Vocational Services for Individuals with Disabilities, and human
service organizations.
Driver Assessment Component: Present assessment tools employed by various
programs follow.
The GIG program includes the Mini-Mental State Examination (MMSE), the Automated
Psychophysical Test (APT), the Useful Field of View (UFOV) test using the Visual
Attention Analyzer, and an on-road driving test. Assessments performed by professionals
in the Ohio Older Driver Evaluation Program include: a self-report questionnaire
to obtain information regarding health status and behaviors, adaptive aids,
driving habits, living arrangements, caregiving responsibilities, and much more;
a pharmacological review; a hearing screening; MMSE; Trail-Making Parts A and
B; vision screening (Optec 2000 Vision Screener); range of motion, balance,
strength, and endurance; reaction time and threat recognition subtests of the
Doron L225 Driving Simulator; and an on-the-road assessment, first in the parking
lot and then in traffic. The Michigan Mature Driver Retraining Workshops (conducted
by a AAA-certified instructor) include a 4-hour session using AAA's Safe Driving
for Mature Operators course, supplemented with psychophysical tests to allow
an individual to evaluate his/her own abilities (participation is voluntary
and results are confidential). The tests include simple RT; visual acuity and
depth perception; and visual attention (Visual Attention Analyzer/UFOV). An
on-road driving evaluation is also given by a retired law enforcement officer
who is AAA certified, on a course laid out by University of Michigan Traffic
Engineering Department. The instructor indicates problems in driving behavior
and offers suggestions for improvement. The on-road appraisal results are also
confidential.
At the Senior Health Center at St. Mary's Hospital, driving history and fitness
to drive are assessed as part of the health assessment. The client's previous
driving record is reviewed, the family is asked if they have observed unsafe
driving behavior, and questions are asked of the client and family about whether
the patient gets lost while driving. A physician performs a review of the client's
medical record, and other team members administer a battery of cognitive and
functional tests. The cognitive tests include: the MMSE, a clock draw test,
and the set test (which requires clients to name as many items in four categories
as he or she can think of). A geriatric depression screen is also administered.
Functional tests include a review of activities of daily living, and tests of
mobility, gait and coordination. Clients may be referred to a neuropsychologist
for more in-depth testing, including reaction time. The assessment outcomes
are categorized as follows: (1) clearly safe to drive; (2) clearly unsafe to
drive; and (3) possibly safe with intervention/needs more testing.
DeGraff Memorial Hospital and Rochester Rehabilitation Center are developing,
implementing, and evaluating a replicable driver assessment, remediation, and
referral program for older adults. The evaluation and assessment component includes
visual acuity testing (day and night); reaction time testing; cognitive testing;
and hearing tests, in addition to an assessment of rules of the road knowledge
and an on-road driving assessment.
Driver Education and Training Component: Experienced (i.e., non-novice)
drivers participating in the GIG program take the NSC Defensive Driving Course
("Coaching the Mature Driver"). This 6-hour course deals with the effects that
aging has on driving ability. Drivers then receive a three-year auto insurance
discount. Interestingly, according to the GIG program director, the people who
choose to take the National Safety Council's defensive driving course are younger
and more mobile than the people who want the driving assessment. Of the 200-300
people she taught over the past year, all have known someone else who
should stop driving, but none think they have a problem with driving. The Program
director noted that none of the Mature Driver class participants came to GIG
for assessments or training. Preliminary findings of several research studies
currently underway indicate that perceptual skills training to increase the
size of the useful field of view (using the Visual Attention Analyzer) may reduce
the crash risk of older drivers, and make it a tool for remediation of certain
types of deficits [see Notebook Section IC3(a)ii]. The Getting in Gear
Program has recently implemented UFOV testing and training.
The Mature Driver Retraining Workshops in Michigan include a 4-hour classroom
review using AAA Workshop Materials. The workshop is conducted by certified
instructors (AAA certified), who are retired enforcement officers (and therefore
are age-peers of the participants).
The goals of the "You Decide: Senior Driving Awareness Program," conducted
by the Michigan Area Agency on Aging through funds provided by the Michigan
DOT Service Development and New Technology Funding Assistance Program, are to
assist older persons and their families with driving safely for as long as possible,
and to assist older adults with locating appropriate resources, alternatives,
and support when safe driving is no longer possible. Educating older persons
and providing input into the development of new or alternative/public transportation
is also a goal of the Program. The "You Decide" model is based on the program
"Driving Decisions for Seniors," developed by Ms. Ethel Villeneuve, in Eugene,
Oregon (see Heckmann and Duke, 1997). Older persons will be trained to become
volunteer peer-counselors to educate, support, guide, and assist older drivers
in making appropriate mobility decisions. (Currently, project coordinators facilitate
the groups, however, proper volunteer training is crucial to sustaining the
project after the pilot period has ended. Project coordinators will recruit
and train up to 10 volunteers to lead the program after the 2-year pilot program
has expired). Senior Driving Awareness Program participants meet monthly at
local senior centers for a two-part meeting. The first part offers information
on a variety of topics including: how to improve or assess driving skills; when
to consider restricting driving; how to cope with the emotional aspects of driving
restriction or cessation; what public and alternative transportation options
are available; how to participate in transportation planning efforts and public
forums; and what to consider when planning for future mobility needs. Meeting
topics to date have also included video presentation of AAA's "Older and Wiser
Driver;" a discussion of the effects of medication and driving with a pharmacist,
where attendees bring medications to the meeting for a one-on-one discussion
with the pharmacist; and presentations by occupational therapists from the driving
rehabilitation programs at several area hospitals. The second portion of the
meeting is a support group where older persons and/or family members discuss
issues of relevance to the older driver, such as lack of alternative transportation
and geographic limitations, dealing with anxiety and feelings of separation
associated with no longer driving, and problems with assisting family members
who have dementia and other disabling conditions and continue to drive. Group
trips are also arranged to help older persons who have never used or are uncomfortable
using public or alternative transportation. Whenever possible, group trips are
coordinated with travel training programs which are sponsored by local public
transportation providers.
The Area Agency on Aging in Michigan publicizes the meetings through press
releases, public service announcements, posters, flyers, and senior newsletters,
distributed through local senior centers, libraries, YMCAs, and senior apartment
buildings. The program has also been featured in at least one local newspaper.
An evaluation report was produced by Special Program Evaluators and Consultants,
Inc. (SPEC Associates) for the period January-March, 1998. A total of 111 individuals
attended one or more sessions. Based on six meetings of the "You Decide: Senior
Driving Awareness Program," the average number of participants per meeting has
been 15; 72 percent are female and 28 percent are male. The average age of the
participants is 75. Forty-eight percent of the participants are still driving
with no restrictions and 37 percent are self-restricting their driving in some
way. Sixteen percent reported having had a crash in the past two years. Focus
group interviews were held with the participants; they dislike the name of the
program because of the term "older driver." (Note: the program was begun under
the name of "You Decide: Older Driver Program.") The participants agreed on
a new name in April of 1998; the name of the Program has been changed to "You
Decide: Senior Driving Awareness Program." The evaluation report states that
the "Senior Driving Awareness Program helps participants to retain driving privileges
for as long as safely possible by attracting a high-risk group of participants
and providing for them a forum for discussing driving safety-related issues.
The Program helps seniors cope with the emotional distress and life changes
that accompany driving cessation by helping them to see that they are not alone
in their experiences, and by teaching them how to cope with the substantial
changes resulting from cessation of driving." A total of 433 individuals have
attended meetings during the period of January 1998 to December 1998.
Case Management/Social Agency Referrals: If a driver decides to reduce
or stop driving, or does poorly on the computer and road tests, professional
case managers working in the GIG program help link the individual with available
social programs such as alternative/public transportation, shopping, meals on
wheels, adult day care, housekeeping, etc. Or, the case manager may refer a
client to a physician for a physical exam or pharmaceutical review. The case
worker works closely with the client's family regarding alternative transportation
and dismantling/selling the client's car, if necessary.
In the Ohio Older Driver Evaluation Program, training may be prescribed or
doctor visits recommended. A transportation resource guide has been developed
to lead people to alternative transportation, if they must restrict or eliminate
driving. The program works closely with the family, as the older driver issue
is a family issue. The program can also help with alternative housing choices
(to make alternative transportation/mobility easier) and other spin-offs of
the older driver issue (e.g., nutrition). Program administrators have found
that stopping driving can have a negative impact on health, and become involved
in conversations with older adults and their families which illustrate these
issues on a regular basis. Evaluation outcomes for the 400 drivers evaluated
to date are as follows: 56 percent of the clients were found to be capable to
drive safely at the time of the evaluation, or were capable with vehicle modifications;
and 44 percent were determined to be incapable, which included those who are
unsafe now, but may be safe after rehabilitation, surgery (cataracts), etc.
For Senior Health Center (St. Mary's Hospital) clients who are deemed clearly
safe to drive, a recommendation is made to the client's family to ride with
the driver frequently to keep track of the client's performance, and to notice
cognitive changes over time. If a family member becomes uncomfortable riding
with a client, that is a danger signal that the person's competency may need
to be reassessed. For those who are deemed clearly unfit to drive, a "no driving
prescription" is written and the client is reported to the DMV; the DMV will
revoke a license. For those who need intervention, a referral is made to additional
disciplines, such as ophthalmologists if the problem involves visual capability
(e.g., for cataract removal) or to a physical therapist if the problem involves
mobility/flexibility/strength. There are two private pay driver evaluation programs
in Richmond, VA that provide additional testing and restorative therapy. For
drivers who need more testing, referrals also are made to the DMV for knowledge
testing, on-road testing, or both (at no charge to the client). The Health Center
does not perform driving evaluations. The Center counsels families of clients
who are judged not fit to drive, about what to expect from the client (anger,
depression, etc.). Tips are given regarding how to keep a cognitively impaired
client from driving, who doesn't remember that he or she is not supposed to
drive. Alternative transportation options are also explored, including public
transportation, connections with volunteers, paid private drivers, as well as
a consideration of moving to an assisted living community that provides transportation.
One of the products that will be produced by the "Senior Driving Awareness
Program" will be an information and referral database to include a variety of
mobility resources for older drivers including: current defensive or driver
improvement courses; physician assistance and medical retraining/evaluation
programs; secretary of state offices; counseling resources; public and alternative
transportation resources; and peer-support programs including the "Senior Driving
Awareness Program." This will fill a void--there is no local or regional source
that older adults and families can turn to for comprehensive information and
assistance with mobility decision-making and planning. Area Agency on Aging
staff have reported making referrals for participants to defensive driving/educational
programs, medical programs, local transit providers, and housing.
Possible interventions included in the DeGraff program are: referral to special
vehicle modifiers; referral to driver specialist for on-road remediation; referral
to medical personnel; referral to driver retraining programs (AAA or AARP);
support group/counseling for driver (and family) who is advised to cease driving;
and counseling on options/alternatives to driving.
The GIG Program manager indicated that several issues should be considered
in future programs. First, some drivers who give up or lose their driving privileges
may be physically isolated (no spouse, friends, grown children) and become emotionally
isolated. They stop socializing, going to church, and doing proper (healthy)
grocery shopping. They are at risk of clinical depression and can become suicidal.
The GIG program manager recommends that a depression screen be part of any program,
and be completed within 3 months following the decision/requirement to cease
driving, so counseling can take place, if necessary. For those who choose to
reduce driving, GIG recommends a re-test after 1 year, and during that year
they suggest that the driver learn about and experience alternative forms of
transportation. A recent study that highlights the importance of staying socially
connected in one's community deserves mention. Researchers at Iowa State University
in Ames, Iowa, and the University of Iowa College of Medicine in Iowa City concluded
that extreme loneliness was a significant predictor of admission to a nursing
home among rural older men and women. Study senior author Dr. Robert Wallace
of the University of Iowa says, "interventions to prevent loneliness should
be explored in order to keep older people independent." He and his colleagues
believe that many of elderly living in rural areas need better access to transportation
so that they can more easily stay in contact with relatives and friends. Community
groups need to be encouraged as a means of bringing still-independent individuals
together. Regular involvement in group activities seems to help ward off a dependence
on nursing home care. For example, the investigators discovered that elderly
churchgoers experienced much lower rates of nursing home admissions compared
with those who did not regularly attend services.
Next, it was brought to the GIG program director's attention that a young/middle-aged
female may not be the best choice for counseling older men to restrict or eliminate
driving. Older men are proud and independent and see the car and driving as
part of themselves. In homes where there is a wife, there is often domestic
abuse; oftentimes, the wife is silent about encouraging the husband to reduce
or stop driving. The director suggests having older men mentor older men, possibly
through the employment of retired police officers who would go to a driver's
home to help him make decisions about stopping/reducing driving, what to do
about a car (e.g., how to sell it), and going with the older person to show
him how to use alternative transportation.
On the other hand, older women who have never driven but find themselves faced
with no transportation after the death of a spouse, may start or resume driving,
with little skill. Older women may benefit from referral to a driver education
program, as well as information about alternative transportation in the area.
Additionally, assertiveness training may be recommended, because it was noted
that many women will not ask for help from providers of transportation (stepping
up on a bus) and will just not use the alternative transportation option.
Diversity of Practices Regarding Interactions with DMVs: Currently in
Florida, only with the client's consent can GIG staff provide feedback regarding
poor performance to the Department of Driver Licensing (DDL), and to the family,
the physician, and other care providers, for that matter. Otherwise, test results
are confidential, and GIG believes referral to the DDL without permission is
a breech of confidence that would be a detriment to the success of the program.
However, if a client decides to voluntarily surrender his or her license after
counseling by GIG staff regarding computer and road testing performance, a voluntary
surrender form, developed by the DDL can be signed, and a GIG case manager can
forward the form to the DDL. The DDL will update the driver history and send
the driver a letter of appreciation. If a driver voluntarily surrenders his
or her license directly to the DDL, the DDL will contact GIG, if there seems
to be a need for counseling and social services link up (regardless of age).
Although not currently in place in Florida, if a driver fails a DDL mandated
re-examination (e.g., can not pass the road test after 5 tries), he or she will
be given the choice of immediately having the license suspended or having a
45-day suspension with the opportunity to participate in the GIG program. The
driver will need to successfully complete the DDL re-examination to keep his
or her license. DDL and GIG procedures act independently of one another, such
that a road test given by GIG does not count as a test given/passed/failed by
DDL. If the driver does not contact GIG and re-take the DDL re-examination or
does not voluntarily surrender the license, the Florida 5-day process will continue
(the re-exam must occur in 5 days, or the license will be immediately suspended).
One point the program director at GIG made was that some proportion of drivers
whose licenses are suspended continue to drive. GIG wants to analyze some of
the DL records this year. Also, if a person with dementia has his or her license
suspended, who follows up to make sure the individual isn't driving? Who helps
the person with selling the car?
The results of the assessment conducted by Older Driver Evaluation Program
staff (Ohio) are provided in written consult form to the older adult's physician,
with a copy sent to the older adult to facilitate communication and compliance
with recommendations. Of particular interest, is that a consultation letter
is not sent to the Bureau of Motor Vehicles. The evaluation is a health care
referral program, and is handled within the health care boundaries between program
staff, the older adult, and his or her physician. It is the physician's responsibility
(moral obligation more so than a legal obligation) to ensure that an unsafe
driver doesn't drive, and the evaluators work closely with the referring physicians
to identify liability and other legal issues related to the driving decisions
of their patients.
Participation in the Michigan Mature Driver Retraining Workshops is voluntary.
No psychophysical test scores are maintained, and the results of the on-road
evaluation are confidential. The Workshop results have no bearing on driver
licensing.
Getting Around--Seniors Safely on the Go. Another, noteworthy
attempt to implement and evaluate an integrated, community-based model for driver
screening, counseling and referral activities is being carried out as part of
the Maryland Pilot Study, in Howard County, MD, through the Area Agency on Aging
and its affiliated Senior Centers in the county. An overview of key elements in
this project is presented in the diagram on the following page.
The Howard County, MD project is funded initially to run from March through
December, 1999, beginning with two and expanding to four Senior Centers. Its
stated goals are to: (1) Keep older drivers safely on the road as long as possible;
(2) Provide effective intervention for unsafe older drivers; and (3)
Ensure that older adults who no longer drive are provided with appropriate
and adequate alternative transportation in order to remain connected with their
communities.
In its 9-month pilot phase, the Howard County effort will help explain how
well functional abilities for safe driving--as measured by a quick, simple,
and low-cost screening tool (GRIMPS)--relates to seniors' driving experience.
Analysis of the data for a projected sample of 650 seniors may contribute to
a preliminary validation of the screening tool. By performing the screening
in Senior Centers, it may also be determined if the national Area Agency Network
can be utilized to engage seniors in maintaining safe mobility--by driving as
long as they can safely do so and then choosing the best transportation alternatives
to sustain a high quality of life--through accurate screening, counseling, and
referral services. Follow-up information for all seniors taking the screening
will be collected for up to five years by telephone and/or mail surveys. This
includes changes in health, driving habits, use of transportation alternatives,
and driving incidents and crashes.
Project activities are carried out by older volunteers trained as "peer screeners,"
Occupational Therapists (OTs), and staff of the Senior Centers themselves. Senior
volunteers are trained to administer GRIMPS, but provide feedback to older drivers
only to the extent of sorting performance into two categories: "below average"
versus "average or above," based on "cut points" for each test procedure provided
through NHTSA's "Model Driver Screening and Evaluation Program" contract. Further
feedback, interpretations of screening results, referrals, etc., is provided
by an OT who has completed in-service training in driver evaluation by a Certified
Driver Rehabilitation Specialist (CDRS). Screening and counseling is done on
an appointment basis only.
[ Pilot Study Elements Conducted
Through the Area Agency on Aging ]
The OT reviews and discusses the screening results with the driver. This health
professional provides feedback to the driver in one or more of the following
areas depending on whether the focus is skill maintenance and/or long-range
mobility planning for those who score average or above average on all GRIMPS
measures. For drivers with below average scores, the OT's recommendations may
be in the direction of follow-up assessments, remediation/treatment activities,
and/or changes in driving habits. These include:
Recommendation to see an eye-care specialist, either through the older person's
primary care physician, or an eye-care specialist covered under the driver's
medical insurance;
Recommendation for a physical exam or pharmacological review by the driver's
primary care physician;
Recommendation for examination by a neuropsychologist/psychologist (by referral
through the primary care physician) if dementia or other cognitive impairment
is suspected or evident;
Recommendation for consultation with an Occupational Therapist or Physical
Therapist for remediation;
Referral to a senior center, community wellness center, or other exercise
program for health maintenance activities;
Referral to a certified driving rehabilitation specialist (CDRS) if the driver
has recently suffered a stroke, head trauma, appears unfit to drive, or could
benefit from adapted driving equipment;
Referral to a driving school is the person is fit to drive but lacks confidence;
or
Referral to a mature driver retraining class (such as AARP's 55-Alive) if
general information is needed such as visual, cognitive, and physical changes
with age; effects of medication and fatigue; review of signs, signals, pavement
markings, driving in adverse weather; trip planning, etc.
After the older driver has been screened, but before he or she is seen by the
OT, written material is provided. This material can be perused by the driver
while waiting for counseling, and may be referred to during the counseling session.
The older driver is given material on alternative transportation in Howard County,
senior resources, and material related to safe driving and aging. For access
to public transportation, the driver may be referred by the OT (which can be
reinforced by the Senior Center staff) to the Senior Information and Assistance
staff who can certify older adults over the phone and will discuss other types
of community-based transportation depending on the individual needs of the older
person.
At the end of the screening and counseling session, participants are given
written information describing reporting procedures and review practices of
the Maryland Medical Advisory Board (MAB). While the Howard County Office on
Aging will not directly report any program participants to the Motor Vehicle
Administration, it is appropriate to reinforce knowledge of existing laws and
procedures regarding medical competence to drive.
The Howard County Office on Aging promotes the screening and counseling program
through:
Publicizing in the Howard County Office on Aging Senior Connection
newspaper;
Local cable coverage through regular senior shows and special taping of screening
and counseling activities with willing older drivers;
Direct promotion through all Howard County Senior Centers;
Direct mailing to approximately 10,000 seniors on Office on Aging mailing
list;
Interviews of volunteers and/or participating older drivers with local and
regional newspapers;
Press releases to newspapers in Baltimore-Washington area;
Promotion to local churches, senior groups, and other appropriate organizations;
Purchase of advertising in local newspapers;
Promotion to groups consisting of adult children;
Posting information on the Howard County Office on Aging web site;
Promotion of project through other community publications such as Howard
County General Hospitals "Wellness Matters" mailed to all Howard County households;
and
Publicizing through Howard County government internal newsletters (such as
The Daily Grind for Howard County employees, and the Police Department's
paper).
In addition, word-of-mouth promotion is very effective in the senior community.
The use of senior volunteers in the screening is considered part of the promotion
process, with an aim of conveying the feeling that this activity is "safe" and
part of the valuable actions which seniors can take to make themselves and the
community safe for driving. Program promotion also includes medical professionals
chosen because of the nature of their speciality or if they have a practice
consisting of large numbers of older patients. Physicians are educated by the
Maryland Medical Advisory Board on functional abilities needed for safe driving,
the nature of remediation for older drivers to promote safe driving, and alternative
transportation resources in the community for patients choosing to self-restrict
or cease driving. The Howard County Police Department has expressed interest
in the project, and will design appropriate linkages with the Office on Aging
to promote and support the activities. To complement these activities, the Howard
County Office on Aging will make available materials providing guidance to law
enforcement officers in identifying older drivers at high risk.
I.B. DEVELOP MODEL PROGRAM COMPONENTS TO REGULATE AND
COUNSEL HIGH-RISK OLDER DRIVERS AND TRANSPORTATION SYSTEM USERS
I.B.3. Information and Educational Support for Safe
Mobility Choices by Public Agencies, Private Professionals/Organizations, and
Concerned Individuals
Summary:
In a recent study investigating high-risk older driver state reporting requirements
and practices, as well as information outreach programs, Aizenberg and Anapolle
(1996) examined over 75 documents and other materials. They found that less
than 15 percent of the materials collected for the review provided counseling
tips for assisting older drivers with problems or for assessing driver competency
(e.g., self-assessment questions, warning signs). About one-third of the publications
discussed licensing issues; and only a very few addressed reporting unsafe drivers
to authorities. In addition, less than one-half of the publications mentioned
the possibility of driving cessation and about one-third specifically advised
or made reference to using alternative transportation. The reviewers concluded
that most of the materials dealt with the issue of older driver safety on a
very general level. Few publications dealt with specific problem groups or with
interventions that may be especially effective or justified with different subpopulations.
Decina, Staplin, and Lococo (1997) identified several dozen safety publications
in their information search, which are currently available to the public from
state licensing agencies and other organizations (predominantly the American
Association of Retired Persons [AARP], American Automobile Association [AAA],
and AAA Foundation for Traffic Safety) to help older drivers and their concerned
family and friends. The material collected ranged from booklets and pamphlets,
to less common items such as flyers, reference cards, newsletters, and even
some videos. Most of the publications targeted older drivers themselves. However,
a small percentage of materials targeted caregivers, including family members.
These publications covered a wide range of topics, including: older driver safety;
vehicle design and adaption measures; vehicle maintenance; environmental/road
design and adaptions; driver improvement and rehabilitation; behavior change;
occupant protection; aging and health; specific medical problems (i.e., vision,
dementia); professional referral sources; licensing issues and procedures; transportation
options; driving cessation; assessment tips; and counseling tips. Aging and
health issues were common topics mentioned in the publications. These issues
covered information on demographic trends, morbidity and health characteristics
of the older population, and cognitive and physical changes that accompany the
aging process. Other common topics were references to professional resources
(i.e., physicians, optometrists); driver improvement and rehabilitation; and
behavioral changes and safe driving practices to reduce collision risk.
The American Association of Motor Vehicle Administrators (AAMVA) Public Affairs
and Consumer Education (PACE) Committee compiled a catalog of written and audio
visual materials pertaining to older drivers, in its member jurisdictions (US
States and Canadian provinces). The most widely available pamphlets are in the
self-help category, directed at older drivers. AAMVA states that few pamphlets
are available that provide advice to older drivers' families, friends, and caregivers.
(The Malfetti and Winter report is helpful in this area). AAMVA also identified
gaps in the topics of medical community responsibility, and alternative transportation.
The success of Model Program activities will rely on effective informational and
educational (I & E) materials, using a variety of appropriate media, which:
Facilitate self-regulation by sensitizing older drivers to the types of functional
declines they may experience, and their consequences for safe driving.
Provide advice and identifying resources to aid friends and family in problem
identification and support for driving reduction/cessation.
List and describe alternative transportation options specific to a community/county.
Inform physicians of the driving risks associated with identified functional
deficits, and describe feasible and standardized techniques for functional screening.
Describe behavioral cues that police officers can use to identify at-risk
older drivers, and procedures for referring suspect motorists for screening
(in lieu of citation or other punitive actions).
Provide easy-to-use tools for health care and social services field personnel
to identify gross impairments, guidelines for referrals for follow-on tests
and/or remedial programs, and advice on issues of confidentiality and reporting
to licensing authorities.
The Maryland pilot study will include the Public Information and Education
(PI&E) goals of promoting: (1) a broad social awareness that driving while
(functionally) impaired is a serious public health issue; and (2) a broad social
awareness that loss of mobility is a serious health and quality of life issue
for older people. After a review of the available materials (listed above),
a working group within the Maryland Research Consortium (MRC) will: develop
Public Relations (PR) materials which illustrate how safe mobility lowers costs
to society while improving quality of life for seniors; develop PR materials
which illustrate how maintaining safe mobility is central to maintaining physical
and mental health in old age; identify a spokesperson(s) to deliver the message;
identify available PI&E resources and determine additional needs to attain
the goal; and create the campaign content, implementation strategy, and evaluation
plan.
An educational brochure created for distribution to seniors who participate
in the screening activities conducted at several Senior Centers and Motor Vehicle
Administration offices in Maryland during the pilot study is presented ot the
end of this section. It will be a 2-sided, 3-fold brochure, and will be enlarged
to measure 11 inches by 17 inches, to increase its legibility.
References:
AAMVA (1997)
Staplin and Lococo (1997)
Aizenberg and Anapolle (1996)
Decina, Staplin, and Lococo (1997)
SELF AWARENESS GUIDES
USAA. (1990). Adaptive Driving: Safe At Any Age.
Brenton, Myron (1986). The Older Person's Guide to Safe Driving.
Public Affairs Committee, Inc,
PennDOT. Drive Smart and Drive Longer: Tips for the Older Driver.
PA Dept. of Aging. Getting Older...And Going Places: Benefits for Older
Drivers and Older Riders
USAA. (1992).Helpful Tips to Reduce Your Risks While Driving.
Maryland Motor Vehicle Administration. Maryland's Guide for Drivers Over
55.
South Carolina Dept. of Highways and Public Transportation, SC Commission
on Aging. Mature Driving: Some Serious Thoughts for Older Drivers.
AAA Foundation for Traffic Safety. (1997). Older and Wiser Driver.
AARP. (1992). Older Driver Skill Assessment and Resource Guide.
Platt, Fletcher N. (1996). Going on 80: Tune up your Driving Skills.
AAA. (1992). Straight Talk for Older Drivers: Good Vision...Vital to
Good Driving.
AAA. (1993). Straight Talk for Older Drivers: Maintaining your Vehicle.
AAA. (1992). Straight Talk for Older Drivers: Meeting the Challenge.
AAA. (1992). Straight Talk for Older Drivers: Rx for Safe Driving.
Nevada Office of Traffic Safety. Tips to Help Older Drivers Ease on Down
the Road: Alcohol and Medications.
Nevada Office of Traffic Safety. Tips to Help Older Drivers Ease
on Down the Road: Safety Belts.
Nevada Office of Traffic Safety. Tips to Help Older Drivers Ease
on Down the Road: Vision.
GEARED TO PHYSICIANS
Texas Medical Association/Texas DOT. (1991). The Physician, the Older
Patient, and Driving Safety: A Physician's Guide.
GEARED TO LAW ENFORCEMENT
Malfetti, J.L. and Winter, D. J. (1987). Safe and Unsafe Performance
of Older Drivers: A Descriptive Study.
McKnight, A.J. and Urquijo, J. I. (1993), "Signs of Deficiency Among Elderly
Drivers."
Transportation Research Record, 1405.
Zimmerer, L. Florida Highway Safety Patrol Questionnaire
GEARED TO GENERAL PUBLIC/FAMILY MEMBERS
Malfetti, J.L., and Winter, D.J. (1991). Concerned About an Older Driver?
A Guide for Families and Friends; AAA Foundation for Traffic Safety
PennDOT. Talking with Older Drivers: A Guide for Family and Friends;
PA Dept. of Aging, PA Dept. of Transportation.
CALDMV. Tips you Can Give to a Mature Driver
[ How is Your Driving Health?
]
[ How is Your Driving Health (part
2) ]
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