January 1997
Preface
In December 1995, Secretary of Transportation Federico Peņa asked for
a long-range overview and a preliminary, proactive Department-wide strategy to
accommodate the growing cohort of older adults that will be providers and
consumers of transportation in the twenty-first century. This overview was to
encompass the perspective of older adults in all transportation modes, operating
commercially as well as privately.
The Operating Administrations of the Department have for years been
actively working to support the safety and mobility needs of older adults. Their
programs and the extensive information collected by them provided a broad base
upon which to conduct this overview.
This report is based on reviews of the literature and ongoing
Departmental programs, and on input from five expert panels. The panels covered
Demographic Scenarios of Aging in the U.S., the Human Factors of Aging,
Alternatives for Personal Transportation, Medical Considerations in Aging,
and Management Practices and the Older Transportation Worker. We would
like to thank the members for making the time to join the expert panels and we
are especially grateful for the time and extra efforts of those panel
participants who served as host or discussion leader for them. The panel
participants are listed in Appendix
D-I of this report.
The overview was guided primarily by a Departmental Steering
Committee on which all modes were represented. The conclusions that emerged out
of the deliberations of the committee are reflected in the following material.
Of particular emphasis was the planning strategy of assuring safe mobility for
older adults. In this work, the Department has identified a set of possible
responses to the impending demographic shift, as baby boomers begin to swell the
ranks of the elderly in the next century.
This document begins with the demographic setting by which future
transportation problems must be viewed. It includes a detailed description of
the aging process and the medical issues which should be of concern for older
adults in all modes. It then reviews the issue of safety, including crash
involvement of older operators, and the risk management systems that have
evolved in each commercial mode. The next section moves into the area of
lifelong mobility, and examines what can be done to keep older adults safely
mobile, including the provision of non-driver alternatives, countermeasures for
the fragility of older adults, and what can be done with new technology to add
to the years over which older adults can continue to operate independently and
safely. There are unsafe drivers in all age categories, and the report details
the programs to identify and evaluate the problems particular to older drivers,
and what can be done to help them. The report also discusses such issues as
mobility and the quality of life, and personal security.
In each area, the issues are briefly summarized, and a number of
remedial proposals are offered for consideration. These initiatives were
developed from the proceedings of several groups, including the five Expert
Panels, the Steering Committee, and the previous work of the Department. Most of
the proposals build on ongoing Departmental and other Federal, state and private
sector activities.
We wish to thank all those who made contributions to this report.
This work was the product of the joint efforts of many people: the expert
panelists and the Steering Committee as just noted, but also the staff of the
Safety Division in the Office of the Assistant Secretary for Transportation
Policy, and the Volpe Center. The names of all participants appear in Appendix D
of this report.
Departmental Steering Committee
(in alphabetical order):
David Albala, M.D. White House Fellow
Bert Arrillage Federal Transit Administration
Jesse Blatt National Highway Traffic Safety Administration
Teresa Doggett Federal Highway Administration
John Eberhard National Highway Traffic Safety Administration
Chris Krusa Federal Maritime Administration
Alex Landsburg Federal Maritime Administration
Harold Lunenfeld Federal Highway Administration
Truman Mast Federal Highway Administration
Bob Nutter Office of the Secretary of Transportation
Tom Raslear Federal Rail Administration
David Schroeder Federal Aviation Administration
Donald Sussman Volpe National Transportation Systems Center
Donald Trilling, Chair Office of the Secretary of Transportation
Stewart Walker United States Coast Guard
Charlene Wilder Federal Transit Administration
Table of Contents PREFACE EXECUTIVE SUMMARY
Section & Page
1. Our Maturing Society 1.1 Older Adult Population 1.1.2 Older Adults as an Economic Force 1.1.3 Retirement Patterns 1.1.4 Maturing Baby Boomers 1.2 Older Operators by Mode 1.3 Older Adults' Interface with the Transportation System 1.4 The Aging Process 1.4.1 Aging vs. Disease 1.4.2 The Heterogeneity of the Aging Process 1.4.3 The Effect of Aging on Functioning 1.4.4 Fragility 1.5 Medical Considerations vs. Relative Risks 1.5.1 Medical Conditions 1.5.2 The Role of the Medical Community 1.5.3 In Summary 2. Safety in Transportation 2.1 Adaptation and Self Regulation 2.1.1 Private Motorist 2.1.2 Commercial Operators 2.2 Crash Involvement 2.2.1 Private Motorist 2.2.2 Truck and Bus Drivers 2.2.3 Aircraft Pilots 2.2.4 Maritime Crew 2.2.5 Recreational Boating 2.2.6 Rail Crew 2.2.7 Pedestrians 2.3 Medical Requirements for Licensure 2.3.1 Federal Aviation Administration (FAA) 2.3.2 Federal Highway Administration (FHWA) 2.3.3 National Highway Traffic Safety Administration (NHTSA) 2.3.4 United States Coast Guard (USCG) 2.3.5 Saint Lawrence Seaway Development Corporation (SLSDC) 2.3.6 Federal Railroad Administration (FRA) 2.3.7 Federal Transit Administration (FTA) 2.4 Overview of Current Risk Management Strategies for Commercial
Transportation 2.4.1 Aviation 2.4.2 Highway 2.4.3 Marine 2.4.4 Rail 2.5 International Perspectives 3. Safe Mobility, For Life 3.1 Background 3.2 Non-Driving Mobility Alternatives 3.2.1 Planning for Lifelong Mobility 3.2.2 Non-Driving Mobility Alternatives 3.2.3 Initiatives for Consideration 3.3 Improving Our Identification and Evaluation Systems 3.3.1 Improving Our Systems for Identifying Problem Operators 3.3.2 Developing Better Assessment Tools 3.3.3 Role of the Health Care Community 3.3.4 Identification/Evaluation of Commercial Operators 3.3.5 Present DOT Supporting Programs 3.3.6 Initiatives for Consideration 3.4 Policy Research 3.4.1 Linkage Of Mobility to Health Care, and Social Services,
Costs 3.4.2 Influence of Mobility Alternatives on Driving Cessation 3.4.3 Security Concerns of Older Adults 3.4.4 Initiatives for Consideration 3.5 Countermeasures for the Fragility of Elders 3.5.1 Fragility Problem Defined 3.5.2 Present DOT Supporting Programs 3.5.3 Initiatives for Consideration 3.6 Technological Programs 3.6.1 Highway Design 3.6.2 Vehicle Design and Ergonomics 3.6.3 Simulator Development 3.6.4 Fitness for Duty Testing 3.6.5 Research on Operator Capability Requirements 3.6.6 Present DOT Supporting Programs 3.6.7 Initiatives for Consideration 3.7 Improve Data Bases to Evaluate the Success of the Program 3.7.1 Data Base on Elderly Characteristics and Scenarios for
Aging 3.7.2 Fiscal Base to Evaluate Program Effectiveness 3.7.3. Present DOT Supporting Programs 3.7.4 Initiatives for Consideration 4. In Conclusion 5. Additional References
List of Figures
1. Population Projections for U.S. Residents 2
2. Crash Involvement Rate per 1000 Licensed Drivers 24
3. Driver Fatality Rate, 1994 (per 100 million VMT) 25
4. Age/Fragility Relationship Fatalities per 1000 Crashes 26
5. Road Accident Deaths by Age Group and Country (International Comparisons of Transport Statistics 1993) 35
6. Fatality Rates for Older Drivers and Passengers by Country (1991 Statistics of Road Traffic Accidents in Europe) 36
List of Tables
1. Resident Population Projections by Age 1995-2050 3
2. Age of Selected Commercial Transportation Occupations 6
3. Forecast Increase in Commercial Operators by Mode 5
4. Jurisdictions Requiring In-Person Renewal and Conditions U.S. States as of 1994 12
5. International Licensing
Requirements 15
1.1 OLDER ADULT POPULATION
The number of older adults(2)
in the population has increased eleven-fold during this century as compared to
only a three-fold increase for those under 65 years of age. The U. S. Census
indicates that older adults numbered 33.5 million, or 12.8 percent of the
population in 1995. This age group will total 36.2 million by the year 2005 and
53.2 million, or 16.5 percent of the population, by 2020. By 2030, 1 in 5
Americans will be an older adult.(3)
This past growth, and the forecast of a continuing increase, is due
to reductions in mortality rates; the improved chances of survival at the very
end of the age spectrum (the 'longevity boom'); decreases in the birth rate
lowering the influx of younger people; and the size of the "baby boom" (those
who were born between 1946 and 1964).(4)
Figure 1 and Table 1 show the
actual and projected growth of the U.S. population by age categories.
We are all aware that Americans are living longer. Many can expect an
extended period of health and activity beyond age 80. Life expectancy has
increased 28 years since 1900 (5).
Because the span of the remaining expected life for older adults is increasing,
the U. S. Census now subdivides that sub-population into three segments: (1) the
'young old' (65 to 74 years); (2) the 'aged' (75 to 84 years); and (3) the
'oldest old' (85 years and over). (6)Currently,
the population aged 85 and over is the fastest growing of the older population
segments. It will continue to grow for the rest of this century.(7)
This growth in the population of older adults represents a profound
demographic shift that will impact all aspects of our society. It represents as
well a unique challenge to the community of transportation officials. The
actions we can take now to get the system ready will have an important effect on
the lives of future older Americans.
1.1.2 Older Adults as an Economic Force
Social Security and Medicare transfer payments alone average almost $12,200 per person for those over 65. This is expected to increase to $23,600 (1993 dollars) by 2030. In terms of assets, as a group, adult householders 65 and older have a median net worth of $88,192, as compared to householders under 35 whose net worth is $36,623. Even excluding home equity, those over 65 average a net worth more than eight times those under 35.
In 1992, only 12.9 percent of older adults lived at or below the
poverty level ($6,729 for a single-person household and $8,437 for an elderly
couple) as compared to 14.7 percent of the population under age 65.(8)
However, older adults in the United States are diverse in their financial
status. For this segment of the population, the U.S. Census reports significant
differences in income related to characteristics such as age, sex, race,
ethnicity, marital status, living arrangements, educational attainment, former
occupational status, and work history. (9)
At the lower end of the income spectrum, 26 percent of older adults relied on
Social Security benefits for more than 90 percent of their income. And Social
Security was the sole income source for 14 percent of the older adults.(10)
1.1.3 Retirement Patterns
Some transportation problems for older adults are directly associated with their patterns of retirement:
Location - Data show that more than 90 percent of Americans retire in place (in the same community and often at the same address they lived at before retirement). That means that many older adults retire in the suburbs, exurbs, and rural areas where transportation is strongly dependent on the automobile.
Living Status - Thirty percent of the older adult population
live in single-person homes. Forty percent of those are women living alone.
1.1.4 Maturing Baby Boomers
The first of the Baby Boomers, those born in 1946, reached age 50 in
1996. They will reach age 65 in 2011 and start to enter the older adult
category. They may be more accustomed to automobile mobility than are current
older adults. Unlike current older adults, most women will have a drivers
license as future generations approach universal licensing.
1.2. OLDER OPERATORS BY MODE
Over one-half of people eligible now take Social Security at age 62. However, gradual increases in the eligible age for full Social Security will start in 2003. People born after 1960 will not be eligible for full Social Security benefits until age 67. Thus, we can expect that there will be more older adults in the commercial workforces for air, trucking, rail, marine, and other modes.
The present population of older operators is shown in Table 2 (see next
page). Along with the maturing of the modal workforces, in
some industries there are increasing economic pressures to extend work life and
to postpone retirement. Today, there are incentives for retaining older truck
operators as decreased entry and quick turnover of younger drivers makes the
existing driver pool smaller. The growing need for operators in some commercial
transportation industries is seen in Table 3, which shows the projected
percentage increase in workers from 1994 to 2005.
1.3 OLDER ADULTS' INTERFACE WITH THE TRANSPORTATION SYSTEM
Americans prize mobility and older adults in their golden years are no exception. A substantial amount of work is underway within DOT to support the safe mobility needs of older adults. (NHTSA) has had an older driver program since 1988. FHWA embarked on a major program in 1989 for improving highway travel for an aging population.(11) Federal Transit Administration (FTA) grant programs for older adults and persons with disabilities, for rural transportation, and for paratransit, all provide benefits to older adults. Additional details on these programs are found below and in Appendix A.
Nevertheless, there are still many elements in the current transportation system that present major barriers to some older adults. These elements include aspects of highway design, like freeway entrances, intersection configuration, long cross walk distances relative to older pedestrian walking speeds, placement of signs relative to decision points, and the size of letters on signs.
Many older adults have difficulty in using some vehicles. Kneeling and low floor buses are helpful, but most vans are very difficult for the older adults to get on and off. Cramped airplane, bus, or train lavatories, narrow aisles, and overhead racks or bins may be difficult to use for older travelers. Few employees have sensitivity training for dealing with older adults or training on how to help evacuate older adults in an emergency.
Bus, rail, and aviation terminals present special problems for many older adults. Problems include signs that are difficult to read or interpret, long walks from one area to another especially in large airports, lack of places to sit or rest, and difficulty in boarding commuter planes.
Older adults are less resistant to trauma caused by transportation crashes. Osteoporosis is prevalent, particularly among older women. Safety belts that protect younger persons may injure older adults. Similar problems related to fragility may exist with airbags. Slipping and falling accidents in terminals, transit stations and on urban buses represent a significant risk of injury.
Many older adults continue to hold or would like to hold post-retirement jobs in order to supplement their incomes, and add to their community involvement. Transportation can become a barrier to the taking on of such jobs, either because of the lack of non-driver alternatives, or because of its relatively high cost compared to the low pay such jobs usually entail.
The U.S. life style is based on full mobility, and for most, this means we have a primary dependence on operating or riding in private automobiles. As a result, we need to make major adjustments when we can no longer drive. Regulation and custom have defined the point at which young people are sufficiently mature to operate the various transportation modes. This is accomplished by means of an age threshold plus licensing and certification procedures. As transportation technologies have developed, the definitions of maturity and skill required for beginning operation have been refined. However, as the number of operators in the older segment of the population expands, questions have arisen whether these older workers retain the requisite abilities to operate the transportation systems safely.
Restrictions in the ability to operate personal vehicles due to
age-related reductions in capacities can isolate individuals from full
participation in society. Technological change may represent both a significant
hope and challenge for older adults. Technology brings with it a promise of
benefits in the ability to overcome limitations of older operators. However, the
technology may come at the price of increased cognitive workload. In some areas,
aging operators, because of seniority, are likely to be the most challenged by
this new workload in some industries. To complete the circle, technology itself
can be used to mediate the cognitive workload. The goal must be to develop
human-friendly technology, and particularly elder-friendly technology.
1.4 THE AGING PROCESS
Generally, aging results in the decrease of physical and mental
capabilities as the result of various forms of "normal" deterioration. With
aging there is also an increased frequency and severity of disease. While some
diseases and deteriorations may present themselves suddenly, generally there is
a slow build-up of deficits.
This aging process varies widely from person to person. In general, older adults do not perform as well as younger adults on almost all available measures of physiological functioning. However, in many cases, these deficiencies are small and the range of measured responses often overlap, with some older adults functioning better than their younger counterparts. Therefore, these average measures for any chronological age can not predict individual performance. At best, only generalities can be made regarding the physiology and functioning of older adults in comparison to younger adults.
Differences among individuals widen as age increases, which makes
analysis and policy making on aging difficult. Even if aging changes were
precisely identified, the impact on transportation would not always be clear.
Humans compensate for deficits by finding alternative ways to perform desired
activities.
The following principles define aging:
- Aging is universal and inevitable but not necessarily predictable;
- Aging-related changes are characteristically detrimental in nature, cumulative and irreversible over time, but often lack sharply defined points of transition;
- As the human animal ages, homeostasis becomes more difficult to maintain as resistance to environmental stress declines;
- Changes begin at different chronological ages, progress at varying rates, and do not affect each body system in the same way or follow an identical course; and
- There are wide individual and socio-cultural variations to the
aging process.
1.4.1 Aging vs. Disease
The normal process of aging is associated with increased incidence and severity of diseases. For some, several diseases may present at once. Although disease can often be treated and its effects halted or even reversed, the body of the older person rarely returns to full pre-disease efficiency.
The universal consequence of the aging process on the human body is a decrease in the efficiency and ability of the body to maintain functional levels within normal limits while under stress, and the slowed rate of return to normal levels once systems are stressed. Conduction velocity of nerves, cardiac output, renal function and respiratory function are all less capable of withstanding stress in older adults.
Aging, therefore, becomes the succession of events that accumulate
and increase the probability and onset of functional failure. As the prevalence
of chronic disease increases with age, it becomes more difficult to
differentiate between functional loss due to the effects of disease versus that
concomitant with the normal aging process.
1.4.2 The Heterogeneity of the Aging Process
The aging process involves complex interactions of genetic and environmental influences. There is a lack of uniformity of age-related changes between individuals and within the same individual. The onset, rate and degree of changes vary depending on the organ, system, or function in question.
It is important to consider the compensatory responses that can
counteract losses due to aging, and the potential for rehabilitation to make up
for functional losses. However, the heterogeneity among individuals increases
with age, both in terms of decrements themselves and the compensatory ability to
offset decrements. While a single impairment might be compensated for with
relative ease, multiple impairments are more difficult to overcome. This extreme
heterogeneity of functional status strongly supports the view that older adults
must be evaluated on an individual basis, especially as health and fitness
status, and social, economic and environmental conditions continue to impact how
Americans age.
1.4.3 The Effect of Aging on Functioning
Sensory functions such as vision and hearing diminish with age. Cognitive functioning, including attention, memory, and learning ability, is also negatively impacted by the aging process. While crystallized intelligence (the ability to learn from experiences) and verbal skills are usually maintained into old age, fluid intelligence (the ability to think and reason abstractly) and nonverbal skills show measurable losses.
Although psychomotor functions such as reaction time slow with age, older operators often compensate by substituting experience, accuracy and consistency for speed of response. Physical strength often decreases dramatically after age 60 while work capacity decreases significantly after age 70, although again there are wide individual differences. The normal aging process also has a decremental affect on body conformation and composition, tissue and organ systems and cardiovascular and respiratory systems. For a detailed discussion of physiological changes due to the normal process of aging refer to Appendix B of this report.
Since the prevalence of many medical conditions increases with age,
those that may impair the cognitive, sensory or psychomotor skills necessary to
operate a vehicle safely need to be identified. Impairing conditions are of
concern because they affect functional capacities. Older individuals tend to
have more chronic musculo-skeletal disorders and, as a whole, are less flexible
than younger drivers. This affects the ability of older drivers to turn their
heads when turning and merging. There are also restrictions in "useful field of
view" or UFOV, which involves the processing of visual information and is most
critical in complex or novel situations. Dementia, as characterized by
diminished cognitive abilities in judgment and memory, is of particular concern.
Other medical conditions may be of concern either because they may cause an
individual to lose consciousness while operating a vehicle or prevent adequate
bodily control of a vehicle. Those medical conditions and disease processes that
may have an adverse effect on an individual's ability to operate a vehicle
safely are discussed in detail in Appendix
B.
1.4.4 Fragility
Older drivers tend to be over represented in fatal and serious injury crashes where they, themselves, are the victims. One explanation is their increased fragility. The results of the normal aging process and the presence of certain disease processes combine both to decrease the older individual's ability to withstand trauma, and to increase the likelihood of post-traumatic complications that can result in death, extension of disability or a prolonged recuperative period.
Approximately one-third of the health care costs expended on injury
are spent on the elderly although they represent only 12 percent of the U.S.
population. Higher post-traumatic hospital and nursing home costs for older
adults are due not to a higher level of initial severity but to the increase in
subsequent complications and increased recovery times. One study found that 72
percent of older victims who survived serious trauma and were discharged from
the hospital remained in a nursing home one year later (DeMaria, 1993)13.
Optimistically, other studies have shown that the majority of older trauma
victims eventually return to the quality of life they had prior to the injury
(DeMaria, 1993). The leading predictor for mortality following traumatic injury
is advanced age. The same traumatic injury that kills 10 percent of the 65- to
79-age cohort will result in the death of nearly 50 percent of the cohort aged
80 and above. The primary reason for the higher mortality rate has been
attributed to the increase in post-traumatic cardiac, pulmonary and septic
complications suffered by trauma victims over age 80.(12)
1.5 MEDICAL CONSIDERATIONS VS. RELATIVE RISK
1.5.1 Medical Conditions
Further study is needed to determine the relative risk of medical conditions for increased likelihood of impaired vehicle operation. Research in this area is currently under way in the Department of Transportation. This type of analysis should help identify the relative risk of the presence of medical conditions as well as the severity level or stage of those conditions. Previous studies have been hampered by methodological problems that have made their results suspect or inconclusive.
The usefulness of a relative risk scale is two-fold. A relative risk scale could serve as a guideline to assist the medical and allied health professions to identify those patients who need further evaluation, monitoring and rehabilitation to continue to drive safely, and to identify those patients who should be counseled to limit or desist from driving altogether. The relative risk scale could also serve as a tool for establishing the appropriate regulatory determination of licensure eligibility. Currently states vary widely in terms of private automobile re-licensure requirements for the elderly. Table 4 lists requirements for license renewal for the U.S. and Canada. Table 5 lists similar information for other countries.
For a relative risk scale to be useful in application to older operators, the deficits of normal aging and the co-occurrence of disease conditions would have to be included. For example, the relative risk of a younger diabetic may be drastically lower than an older diabetic who also suffers from heart disease and arthritis. Severity or stage of condition is also crucial in determining fitness to drive. Some studies have concluded that mild cognitive impairment does not increase the risk of operating a vehicle safely while moderate to severe cognitive impairment precludes the safe operation of a vehicle altogether. Additionally, while an individual's ability to cope with one limitation may be sufficient for safe vehicle operation, additional deficits interfere with that ability to cope.
Once identification and assessment tools such as a relative risk
scale are developed, the determination of what to do with those people who are
deemed "high risk" remains. Acceptable versus unacceptable risk levels have to
be determined before a relative risk scale can be applied in establishing
consistent regulatory guidelines. The relative risk of medical conditions and
disease processes can be utilized effectively by the medical and allied health
professions in the interim. They can provide guidelines for
identification and counseling. It is believed that a mild risk deemed acceptable
for a driver of a private automobile on limited local trips could be wholly
unacceptable for a commercial operator responsible for the lives and safety of
many others.
1.5.2 The Role of the Medical Community
The medical community and particularly physicians could play a
heightened role in the identification of older drivers at high risk for motor
vehicle crashes. Physicians have the clinical training and diagnostic skills to
identify and advise patients who may be at-risk. They also have frequent
exposure to the older population at-risk. The social workers' role usually is to
determine the need for continued driving once limitations have been identified
and to locate alternatives for the impaired individual. The occupational
therapist plays an invaluable role in determining whether an individual, whose
capacity for driving has been compromised, can through training and
rehabilitation return to driving. Assessment and training programs run by
occupational therapists expert in impaired drivers vary widely, and physicians
are aware of them mostly by word-of-mouth. Existing medical and non-medical
referral systems fall short in accommodating the needs of the impaired older
driver.
1.5.2.1 Concerns Inherent in the Evaluation Process - A prime responsibility of the physician treating an elderly, community-dwelling patient is to enable that patient to maintain his or her independence. Access to transportation is crucial to meeting the social, medical, economic and other basic needs of the elderly. More often than not, transportation is provided by the private automobile. Without access to their own car, many elderly would become isolated and unable to meet their most basic needs.
The medical community also has ethical and legal obligations for maintaining public safety. If their elderly patient is at high risk for a motor vehicle crash, then that person poses a threat to him/herself and to the public. The conflicting obligations present an ethical dilemma to physicians and allied health professionals.
- When does a patient's age-related or disease-related deficits constitute a need to recommend that their patient cease driving?
- When is the degree of risk sufficiently high to warrant the tradeoff of independence that an automobile provides?
- What risks does the physician face in terms of liability for not intervening or reporting a patient who continues to drive against medical advice?
- To what extent might a patient seriously in need of medical help avoid consulting a physician for fear of losing driving privileges?
Retchin and Anapolle (1993)(13) recommend that physicians use a driving history assessment as part of their social evaluation of geriatric patients and be prepared to counsel patients regarding their driving ability. Physicians should also be well versed regarding evaluation requirements in their state, the availability of assessment and training programs and statutes regarding their obligation to report patients who may be a threat to themselves or public safety. Underwood (1992) (14) provides assessment recommendations for physicians to utilize with older patients who drive, as well as clinical recommendations for the prevention of motor vehicle crashes.
Physicians have a fiduciary responsibility toward their patients that dictates the confidentiality of the physician-patient relationship. This relationship allows for the patient to disclose information that will assist in accurate diagnosis and treatment without fearing repercussions. Physicians also have a legal responsibility toward protecting the public interest or the private interest of their patient which supersedes confidentiality. This duty to warn regarding public hazards is the basis for statutes that require physicians to report patients who are a threat to third-parties, particularly in cases of psychiatric illness and communicable disease. In terms of driving, physicians have been held liable for failure to warn patients about the danger of driving with certain illnesses or while taking certain medications. Physicians can also be held negligent for failure to properly diagnose an impaired patient.
Reporting impaired patients to the authorities is required in cases of a "foreseeable" threat. Therefore, appropriate evaluation, diagnosis and documentation of functioning deficits, or lack thereof, are critical in protecting the physician from the legal ramifications of caring for the elderly driver. Reporting requirements vary from state to state. Some states allow anonymous reporting while others require the reporting of specific diagnoses.
Physicians and allied health professionals will face this issue with greater frequency as their patient population base ages. Driving history and other assessment tools are available to help identify those patients who may present a threat to themselves or others. The relative risk scale discussed above that provides guidelines regarding the risk of driving with certain medical conditions would assist the medical community in advising older patients and their families about driving capability and privileges. Physicians have the clinical training and diagnostic skills to identify and advise patients who may be at-risk. They also have frequent exposure to the older population at-risk. Koepsell, et al (1994)(15) reported that nearly 97 percent of the older drivers they studied who were injured in motor vehicle crashes had visited a physician at least once in the year prior to their injury. Inclusion of driving history in the social evaluation of patients and functional assessment tools in routine clinical care could result in preventive intervention to almost all older drivers at-risk.
The physician's role in the evaluation and treatment of the elderly
operator should be regarded as a pivotal challenge in the complicated management
of the health of the elderly population.
1.5.2.2 The Role of the Occupational Therapist in Screening and Evaluation of the Older Driver -Occupational therapists (OTs) are trained to assess and treat those who are impaired by birth defect, injury, disease or the aging process. They help people with disabilities adapt so that the disabled are better able to carry out life's tasks. Occupational therapy can and does play an active role in the evaluation of elderly individuals' driving abilities. Through the application of evaluation methods, OTs strive to first determine an individual's capacity for driving and then to identify those factors which through training and rehabilitation could improve an individual's driving ability.
The need for a formal driving assessment may be indicated by an individuals perceived decrement in ability or at the suggestion or requirement of family members, physicians or regulatory agencies. A new and permanent change in condition such as stroke, brain injury or hip replacement should also indicate the need for a formal assessment before the individual resumes driving (Cifu, 1993)(16).
Evaluation methods and training programs vary, as does the availability of OTs trained for driving assessment and rehabilitation. The evaluation usually consists of a pre-driving assessment including psychometric tests and an on-the road (or off-the-road course) driving tests. Some programs utilize simulators along with, or in place of a road test, but many OTs question the ability of driving simulators to capture the true driving experience especially with the elderly (Hunt, 1993)(17). The cost and availability of simulators can also be prohibitive.
The pre-driving assessment usually consists of an interview, review of medical and driving history, license eligibility and evaluations of sensory, cognitive and motor ability. The purpose of the interview is to determine why the older driver requires evaluation and whether the individual recognizes their limitations. In order to implement a compensatory plan to improve driving ability the older driver must first acknowledge the limitations that exist. The medical and driving history and license eligibility is reviewed to determine if there are specific limitations which indicate the need for special modifications or adaptive equipment or preclude driving altogether. The motor, sensory and cognitive evaluations determine not only the capabilities and limitations of an older driver but also the ability and likelihood for rehabilitation. These off-the-road tests are performed prior to a road test to determine if the older individual is safe to drive at all and to determine if training and compensatory adjustments need to be made prior to the road test. If, for instance, range of motion or vision is so impaired as to render the individual unsafe to drive, the evaluation turns to identifying if an exercise program or medical intervention would be effective in ameliorating the deficit. If the pre-driving tests determine that an individual lacks the judgment to drive safely, cognitive testing should be undertaken to determine the extent and cause of cognitive impairment and the possibility for rehabilitation. Outcomes would be used to provide recommendations regarding the administration of a road test.
The road test may be performed by the OT alone, by a driving instructor alone, or by both. The OT would advise the instructor of any problems and a test or course would be designed to test those abilities in question as well as other crucial driving tasks. The individual is usually tested in their own car. The course may be one familiar to the older individual or a course chosen to test specific tasks and abilities. The final determination of ability to drive is made by the OT and the driving instructor together. The OT then designs a training program to address those factors which the assessment has identified as rehabilitative deficits.
These assessment and procedure tools can identify those elderly
drivers who could benefit from training and a tailor-made training program can
be designed to meet the individuals particular needs. The final assessment may
also lead to recommendations of voluntary restriction of driving, such as
daytime only or limiting to a familiar location. A basic driver's assessment and
training program costs between $350 and $1,000 (Cifu, 1993)17.
More extensive rehabilitation and adaptive devices add to the total costs.
1.5.3 In Summary
Aging is associated with an increased incidence and severity of diseases. They collectively increase the probability and onset of functional failure and disease. The prevalence of many medical conditions increases with age. Those conditions that impair the cognitive, sensory, or psychomotor skills required to operate a vehicle or other transportation system safely should be identified and evaluated for the risks represented. Among the conditions that increase with age and impact mental and physical functions are: dementias, cardiovascular conditions, cerebrovascular conditions, diabetes mellitus, epilepsy, ocular system disease, chronic obstructive pulmonary disease, arthritis, medications, and polypharmacy.
The level of mental and physical performance appears to remain higher and to last longer for today's elderly compared with earlier generations. Many of today's older adults have benefited from increased education, and adoption of healthier life styles including: increased exercise, abstinence from tobacco products, moderation in the use of alcohol, and dietary changes. These changes appear to have delayed the negative consequences of aging.
Improved medical procedures and diagnostic techniques also play an important role in supporting the extension of full functionality into older age. Examples of these improvements include better cardiovascular procedures and medicines, better oncology treatments, advanced technologies and other interventions to enhance sensory functions, and improved techniques that directly affect mobility such as hip replacements. However, the extended period of well-being resulting from improved life style and medical technology is not without limits and can sometimes be followed by a rapid decline.
The continued anticipated growth in the number and proportion of older U.S. citizens who are vehicle operators during the next several decades will increase the significance of the impact of medical, ethical, and health policy issues on safe mobility. This impact will be a function of the number of individuals capable and willing to operate vehicles, the availability of alternative forms of transportation, and how vital services are made available.
Medical services become increasingly important to an aging population. Assuming that the same economic forces continue to affect the U.S. health care system, there will be no decline in the growth of outpatient procedures. With the continued development of sophisticated medical technologies, we can also anticipate increases in the number and types of treatments that require frequent scheduled administration. This will make the continuation of mobility for older adults even more important. As an example, reliance on frequently scheduled blood dialyses for individuals with kidney disease has made mobility a survival issue. Such economic and technological factors will make the need for continued mobility critical for our elderly population.
Although data aggregated across the population as a whole show a smooth decline in mental conditions and physical capabilities, individuals often experience episodic incidents of mental and physical decline. People age differently and differences among individuals' capabilities increase with age. If an age were to be selected for the average onset of some functional impairment among the population, 75 years old might be such a threshold. However, the use of chronological age as a substitute for measures of functional capacity raises a host of problems.
At this time, it is unclear what the specific relationships are among different types of medical conditions and the safe operation of vehicles and other transportation systems. Objectively assessing these relationships is a very complex process because many people with such conditions develop strategies to compensate for individual functional deteriorations. They try to avoid those conditions where the deterioration is most problematic. Many older drivers curtail their night driving in response to visual losses.
Until we have widely accepted objective tests to measure functions
critical to safe and effective operations, age will remain the only universal,
objective, and quantitative index available for use in law and regulation.
Notwithstanding the absence of objective criteria and tests, judgment of ability
or competence made solely on the basis of age is often seen as a form of
discrimination. One long term goal should be establishment of mental and
physical criteria that are independent of age. Ideally we should be able to
relate these functional criteria to an individual's ability to operate his or
her vehicle safely and effectively.
2.1 ADAPTATION AND SELF REGULATION
As noted in the previous section, there is a slow accretion of
deficits at rates that vary widely among people. This extensive variation in
performance capabilities and differing abilities to adapt to the limitations
these deficits present, indicates why we must eventually move to more
age-neutral, performance-based screening and evaluation systems.
2.1.1 Private Motorist
Generally most people self-regulate when operating their private vehicles. For older motorists, maturity and experience typically help compensate for declining skills. In general, older adults reduce their driving as their skills decrease. As a result, contrary to widely held stereotypes, the crash rate per older licensed driver is low, as illustrated in Figure 2. For some, the sudden onset of a serious disabling condition makes driving impossible. Most, however, withdraw from driving gradually and responsibly. They make strategic decisions to drive less frequently, over shorter distances, avoid driving at night, in rush hours, in bad weather, in unfamiliar places, or on crowded or high speed highways. A small number of people whose judgment has deteriorated may not recognize their incapacities and not give up driving. The irresponsible actions and widely publicized crashes of this small subset may give an incorrect impression of the driving behavior of the entire older adult population.
The effects of such mental pathology on driving safety can be troublesome. Senile dementia, particularly Alzheimer's disease, is worth special consideration because those so afflicted may not self regulate as much as those unafflicted. Or if they do self regulate, they may not do so effectively. Operators may lack the awareness that their skills are eroding and may not seek or accept the advice of others. They actively deny there are any age related declines. Such individuals (men, more so than women) usually will not seek or accept the advice of others. Obviously, intervention is needed in such cases.
The perception of an older driver safety problem may also come about when the crash rate per mile driven is examined. The fatality rate per 100 million vehicle miles traveled stays reasonably level for drivers up to age 75, and then increases, climbing steeply for persons over 80 (see Figure 3). The much higher fatality rate for those over 80 is partly attributable to their greater fragility (see Figure 4), and the vastly reduced recuperative capacity of older adults, compared to younger persons.
By 2020 there will be an additional 20 million more older adults in the population and presumably on the road in at least the same proportion as they are today. For the group aged 75 and above, a linear projection of today's population-based fatality rates indicates that fatalities could increase by 45 percent or more. In addition, current trends toward a higher proportion of licensed drivers in the older population, and a more disbursed retired population (implying higher VMT per driver) could increase the number of fatalities for those aged 75 and above even higher, unless the safety community can lower their crash rate or increase their crash protection.
By age 85, women outnumber men by 5 to 2 in the population. By age 85, 80 percent of formerly licensed older women have stopped driving. Men are less likely to curtail driving with 60 percent above 85 indicating they drive.(18) One reason that fewer males than females cease driving is that males are more likely to overestimate their driving capabilities and skills. This tendency to overestimate driving skills may not be the only reason men are less likely to cease driving earlier. Driving continuation may also result from perceived responsibilities as transportation providers.
There is one study that indicates that older motorists are
over-represented in crashes involving heavy trucks.(19)
This analysis provides little explanation as to why there is a higher proportion
of crashes involving trucks and cars being driven by older adults than cars
being driven by the population at large, or why these crashes result in a higher
number of fatalities. The fragility of older adults is one obvious factor
regarding the latter. The extent to which differences in speed between trucks
and cars driven by older adults along the highway could be another factor, and
this warrants further investigation.
2.1.2 Commercial Operators
Maturity and experience can also compensate for loss of some driving
skills and capabilities of older operators of commercial motor vehicles.
However, commercial drivers do not have the freedom private motorists have to
make similar adjustments in when and where they drive. Job requirements,
particularly schedule adherence, make it difficult to do so.
Some older commercial operators, because of seniority, can select shorter and
safer runs. It is also possible, however that some may select higher paid but
more arduous runs to maximize salary and pension payouts.
Older operators of trucks, buses, general aviation airplanes or ships do not appear to present a significant safety problem at this time. Typically, they maintain their performance levels by using their experience, automation of some activities, streamlining of tasks, and accommodation. The vast majority of older commercial operators retire responsibly, before medical conditions or capacities become an issue. As seen in Table 2, only a few transportation industries have operating employees above the age of 65 in significant numbers. Two exceptions are bus operators, 8.2 percent, and taxi/limousine drivers, 10.8 percent. No significant increase in crash rates has been attributed to older operators in these groups.
Shortages in the number of new qualified truck drivers may motivate motor carriers to keep their existing qualified drivers. Improvements in truck technology support the continuation of driving. Notable improvements include lowered cab vibration, noise, temperature extremes, and fumes. But because of these physical improvements, drivers can potentially (if not legally) drive longer hours and at faster speeds. Increases in the work day can interfere with circadian rhythm with resulting sleep loss and fatigue-related disruptions. Sleep and fatigue related problems are known to increase with age. These environmental conditions may fall more heavily on older drivers.
Some maritime operators are active into very old age. The maritime
environment is often physically stressful and mentally demanding. Individuals
working on small commercial and fishing vessels often face the most arduous
conditions. The types of safety risks that older operators face under these
conditions are not completely clear.
2.2.1 Private Motorist
On a per-licensed driver basis, older drivers have a low crash rate compared to other age groups. In absolute numbers, older drivers have fewer crashes of all types. It is only on a per-mile driven basis that older drivers have relatively high rates of crash involvement. Undoubtedly, their self-restricted number of miles driven on average contributes to this. In fact, some quite elderly drivers may retain their licenses but drive few, if any, miles.
The reasons for the high crash rates per-mile among older drivers need to be explored. Involvement in property-damage-only crashes among older drivers predominate. However, fatal crashes increase steadily after the age of 75. It is unlikely that this increase is fully accounted for by loss of driving skill, or the inability to compensate for capability losses. Increasing physical fragility probably plays an important role in the increased fatality rate. We need to better understand the types of crashes older drivers are involved in to identify countermeasures.
Crash rates for older drivers are not evenly distributed across the
various types of crashes. The sharpest increases with age involve intersection
and crossing-path situations, where older drivers must make complex maneuvers
and interact with opposing traffic. These include turning accidents (both
right-and left-turn) particularly in urban areas, and lane-change accidents on
2-lane rural freeways. Older drivers are also over-involved in accidents at stop
signs where the driver has stopped at the sign and then proceeded to pull out in
front of another vehicle. (20)
This may be due to the fact that older drivers have more difficulty perceiving
and judging the dynamics of traffic movement and performing cognitive tasks with
time constraints. Even if programs aimed at maintaining safe mobility succeed in
lowering crash rates in the future, older drivers will be involved in more
crashes on an absolute basis. This is simply the result of a growth in the
elderly population. Population changes, particularly the aging of the 'baby
boomers' and their extended longevity, will increase the number and proportion
of older drivers, as seen in Figure 1 and Table 1.
2.2.2 Truck and Bus Drivers
There is no evidence that older commercial operators of trucks and
buses are disproportionately represented in crashes. However, FHWA
investigations found that when older operators were involved in crashes,
cognitive factors were more likely to have played a role. Cognitive factors
cited as significant in crashes were errors of omission (failing to take some
action), and inattention.(21)
Some commercial operators may have a problem of failing to commit undivided,
concentrated attention to the driving task. One estimate(22)
is that 60 percent of crashes involving older drivers occur because of cognitive
factors. Another(23)
is that 25 to 50 percent of crashes are the result of driver inattention.
Inattention is also a likely culprit in many rear-end collisions, since drivers
have better sensitivity to movement toward them as opposed to away from them.
This indicates a reduced role of perceptual abilities (24).
The literature on aging, and on older driver decision making, selective
attention, and attention sharing, indicates that capacity limitations exist in
older adults. Age-related performance differences are even more substantial
under demanding circumstances.
2.2.3 Aircraft Pilots
In aviation, there is some evidence that Class II and Class III
(defined in
2.3.1) pilots have more fatalities at older ages. In the age category 65-69
they had higher crash rates than pilots aged 60-64. However, pilots between the
ages of 63 and 69 generally have lower crash rates than pilots in their
30's.
2.2.4 Maritime Crew
As with rail operators, no significant increase in marine casualty
rates have been attributed to older maritime crews. But in this industry changes
in the availability of qualified workers, economic conditions, or patterns of
retirement, can influence the sheer numbers of older workers. To the extent that
these changes occur it will be important that monitoring for safety take
place.
2.2.5 Recreational Boating
There is no evidence of increases in boating mishaps with age. But,
as with other transportation activities, the age of individuals engaged in
recreational boating will increase. The safety implications must be monitored.
2.2.6 Rail Crew
There is no evidence that older rail crews presently exhibit any
special safety problems. Most rail workers come under a formal retirement system
which results in few, if any, operating staff remaining at work after 65. No
significant increases in rail crash rates have been attributed to older
operators. However, changes in economic conditions, and in particular changing
patterns of retirement, might affect the absolute number of older rail workers.
2.2.7 Pedestrians
Pedestrians aged 70 and higher represented almost 9 percent of the
population, but accounted for 19 percent of all pedestrian fatalities in 1994.
The death rate for this group was higher than for any other age group -- 4.36
per 100,000 (vs. 2.1 per the overall population). The safety of older
pedestrians presents a significant challenge to the Department. (However, pedal
cyclist fatalities for persons over age 70 were not anywhere near as
significant, with death rates of 1.50 to 1.81 per million of
population.)
2.3 MEDICAL REQUIREMENTS FOR LICENSURE
The medical requirements for licensure vary greatly among the different modes of transportation. There is still comparatively little scientific and epidemiological data to document the role of medical impairment (not including substance abuse) as a contributing factor to crash rates. (For these and other reasons, medical standards have evolved over the years based almost entirely on empirical evidence and clinical experience rather than on rigid scientific methods of experimentation, analysis, and evaluation.) Despite these drawbacks to quantifying the role of medical impairments, licensing agencies must establish regulations governing safe operation of all transportation modalities. In recent years, a renewed interest in medical impairment has surfaced because of the attention now given to commercial operators.
Operator evaluation should be based on functional capability to operate a specific vehicle under certain circumstances and not on simply the diagnosed condition or disorder itself. In this context, chronological age is not a good indicator of functional capability, but chronological age may be one component of a screening process based on functional capabilities. Summarized below are the medical requirements by each transportation modality. (All commercial operators are also subject to statutory drug and alcohol testing.)
2.3.1 Federal Aviation Administration (FAA)
- First Class Medical Certificate. This is the highest class of medical certificate and is needed for operations that require an airline transport pilot certificate (this includes all pilots who command the plane in operations conducted under air carrier rules). This certificate is valid for six months. A complete physical exam is needed and an electrocardiogram (EKG) is needed on the first exam after age 35. At age 40, an EKG is needed on an annual basis. Both vision and hearing testing are done for this certificate.
- Second Class Medical Certificate. This medical certificate is needed for a commercial pilot certificate (all commercial pilot duties other than those that require an airline transport pilot certificate). This certificate is valid for one year. A complete physical exam is needed. There is no EKG requirement. Both vision and hearing testing are done for this certificate.
- Third Class Medical Certificate. This medical certificate is needed for all general aviators. The certificate is valid for 36 months for those under the age of 40. Over that age, the certificate is valid for 2 years. A complete physical exam with hearing and vision testing are needed.
Air Traffic Controllers are required to undergo periodic medical
examinations.
2.3.2 Federal Highway Administration (FHWA)
The requirement for a commercial driver's license (CDL) for truck
drivers (greater than 26,000 pounds) and bus drivers (carrying 16 or more
passengers) is a self certification that they have met the Federal physical
qualifications for interstate operations every two years. If the driver remains
intrastate, the Federal requirements do not apply. There can be no impairment
with power grasping or limb defect. Drivers can not have diabetes mellitus that
require the use of insulin nor can they have any history of seizures. Vision,
hearing, drug, and alcohol testing are also required.
2.3.3 National Highway Traffic Safety Administration (NHTSA)
NHTSA has no requirements for private drivers. Licensing procedures
are administered by state governments. Significant variability exists from state
to state. Applications for new, renewal, and transfer licensure require personal
identification information; questions are asked about the presence of certain
medical conditions or signs and symptoms that may be indicative of certain
conditions. The most common driving restriction is for vision
problems.
2.3.4 United States Coast Guard (USCG)
Certification is required for most merchant mariners. A complete
physical examination is required every five years for officers and qualified
seamen. All mariners must be able to climb steep or vertical ladders, and enter
or exit enclosed compartments through hatches or doors with sills up to two
feet. Vision, hearing, drug, and alcohol testing are also required. Licensing
requirements also vary with size and type of vessel. There are currently no
medical testing requirements for recreational boaters.
2.3.5 Saint Lawrence Seaway Development Corporation (SLSDC)
The corporation has no industry medical requirements. For hazardous
materials operators, the SLSDC uses FHWA requirements.
2.3.6 Federal Railroad Administration (FRA)
The medical requirement for certification includes testing for vision
and hearing acuity. For distant viewing, visual acuity shall be at least 20/40
(Snellen) in each eye with or without corrective lenses; distant binocular
acuity of 20/40 (Snellen) in both eyes with or without corrective lenses.
Hearing loss in the better ear can be no greater than 40 decibels at 500 Hz,
l000 Hz and 2000 Hz with or without the use of a hearing aid.
2.3.7 Federal Transit Administration (FTA)
The medical requirement includes only statutory drug and alcohol
testing performed by the transit operator. All those who operate vehicles
carrying 16 or more passengers must have CDLs -- this is the vast majority of
transit providers.
2.4 OVERVIEW OF CURRENT RISK MANAGEMENT STRATEGIES FOR COMMERCIAL TRANSPORTATION
Governments and industry have established monitoring and evaluation systems to manage risk and assure operators are capable of performing at or above certain minimum standards. These minimums are usually limited to capabilities that are easily measured. An example of this is the widespread use of conventional static vision testing for driving licensure as opposed to dynamic vision testing which is more difficult and costlier to perform.
Evaluation systems vary widely by mode, medical requirements,
enforcing authorities, proficiency testing, and by monitoring through
authorities. The most comprehensive risk evaluation system is found in aviation;
in contrast, recreational boating is the least regulated, least studied mode.
Systems for certain transportation modalities are described below.
2.4.1 Aviation
The aeromedical certification system is the most highly developed and sophisticated program of its type in transportation. Aviation medical examiners are medical doctors. They are required to take periodic aeromedical related training provided under the auspices of the FAA. Further, these examiners are often aviators themselves, which gives them a special understanding of the relationship between medical conditions and flying.
Pilots are required to demonstrate a certain level of proficiency to acquire an airman certificate. They must continue to meet performance requirements, as well as the medical requirements listed above, in order to retain the right to fly using their airman certificate. Airmen may not act as pilots in operations conducted under air carrier rules after reaching 60 years of age. There is no age restriction for general aviation pilots or other commercial pilots as long as they maintain their medical certification and licensure. About 5.3 percent of commercial pilots and 7.7 percent of general aviation pilots are over 65.
The Federal Aviation Administration has in effect a rule barring pilots over 60 from piloting aircraft operated under air carrier rules. This has been a source of considerable debate over many years, in part for the reasons cited above. After much public comment, the FAA recently decided to keep this rule in effect, to maintain confidence that existing levels of safety will be preserved. Although there are undoubtedly many pilots over 60 perfectly capable of flying those aircraft in safety, it is not yet possible to pinpoint with certainty those few who could not. For commercial operations, where there may be many lives at stake, the Department must adhere to a very high standard for safety.
Air traffic controllers must undergo periodic medical examinations.
They have age-based mandatory retirement. After 1997, an air traffic controller
must be separated from employment before reaching age 56 (although waivers can
be granted for special skills).
2.4.2 Highway
In the surface transportation industries there are differences in levels of rigor of proficiency and medical assessment. Commercial truck and bus operators must maintain a current Commercial Driver's License (CDL). If the driver operates in interstate commerce, the Federal Motor Carrier Safety Regulations require a medical examination as noted above every 2 years. There is no minimum age requirement for obtaining a CDL other than the state driving age, but interstate drivers must be at least 21. Defacto minimum and maximum age requirements, where they exist, are a function of individual company and or union policies. Major trucking, and major urban transit systems often have quite rigorous procedures for monitoring their operational personnel. About 2.3 percent of truck drivers are over 65.
School bus operators are required to have a CDL and thus need medical
examinations every 1 or 2 years, depending on the state. Most operators of
transit vehicles are required to have a CDL. Taxi operators, contract bus
operators, and independent owner operators often have only the most rudimentary
company monitoring programs. Further, the level of surveillance of these groups,
provided by state and municipal government, varies widely. About 8.2 percent of
bus drivers are over 65 and 10.8 percent of taxi operators are age 65 and
older.
2.4.3 Marine
In maritime industries, licensed ships officers do not have an upper
age limit and are required to renew their licenses every five years and radar
recertification for deck officers. Depending on the vessel and work function,
they must undergo basic medical examinations. However, periodic retesting varies
and is employer-driven. Approximately 3 percent of ship captains and mates are
over age 65.
2.4.4 Rail
In the railroad industry, the retirement age is largely determined by the Railroad Retirement Act. The number of railroad engineers, conductors and yardmasters over 65 is less than 1 percent.
In summary, our screening and evaluation systems for commercial operators appear to be serving the population well with regard to age factors. There are still potential improvements that might be made. In the highway realm these improvements are being identified and evaluated. FHWA has a series of studies underway to reassess current medical requirements.
Also, a relative risk scale is currently being developed by the
American Association of Automobile Medicine (AAMVA) and NHTSA that could support
a set of national criteria for determining licensure. This scale would provide a
list of medical conditions that may impair operators of personal and commercial
highway vehicles. It would also propose a method for assessing such conditions
in relation to safe vehicular operation.
2.5 INTERNATIONAL PERSPECTIVES
It is illustrative to examine the risk associated with motor vehicle
operation and licensing practices and age across countries. The risk of traffic
fatalities is higher for older adults. The overall road traffic accident
fatality rates show that older adults (operators, passengers and pedestrian) are
at higher risk in virtually all countries examined. This is illustrated in Figure 5. This figure also shows that the United States ranks 6th in
traffic fatality rate for older adults of the 21 nations examined in terms of
relative risk of traffic fatality. As shown in Figure 6, within the older adult population, those aged 75 and older have
a higher risk of fatality than those 65-74 in all of the 22 countries examined .
Older adults have a substantially greater risk of becoming pedestrian fatalities
than the population at large for the 18 countries examined, as illustrated in Figure 7.
The most common way to license motor vehicle operators is to grant
what is essentially a lifetime license with periodic renewal requirements. There
is an emerging international trend to review motor vehicle licensing practices
in relation to increased age of the operator as may be seen in Table 5. A number of jurisdictions either terminate licenses or require a
special license renewal triggered around age 70 accompanied by some level of
medical review (i.e., Denmark, Finland, Ireland, Italy, Luxembourg, Netherlands,
New Zealand, Portugal). If the results of the age-triggered procedure permit
vehicle operation, the older operator is issued some variant of a "term" license
which is valid for a defined time period. Several countries which currently
issue life time licenses are discussing some form of an age-based review process
or introducing restricted licenses as part of their motor vehicle licensing
procedures. Germany is debating the former and New Zealand the latter. Other
countries have recently added additional types of medical review for older
operators (United Kingdom, Sweden for 'heavy' vehicles).
3.1 BACKGROUND
One of the primary forces contributing to the vitality of our Nation is its high degree of personal mobility. As Americans we expect to travel when and where we please. And we expect to travel how we please, whether it is in our own car, or even our own boat or plane, or by using a transportation service we independently select from an array of choices. The United States now has more cars than licensed drivers as well as 11.4 million watercraft, and 170,000 airplanes. All these conveyances are for personal mobility (for transportation and/or recreation) in one form or another.
With the exception of people with very low incomes, the primary constraint on full mobility in our personal lives comes with the onset of physical or mental problems of sufficient severity to compromise the safe operation of a vehicle. For the vast majority of people this occurs through the processes of aging outlined above. Personal mobility is so taken for granted that for many its restriction becomes the true point at which the quality of life begins to deteriorate. Independent choice of time and destination then narrows. In areas where public transportation services are unavailable or unsatisfactory, many must ask for transportation from family or friends to get to such necessary destinations as grocery stores, clinics, places of worship, and social engagements. The isolation thus resulting has not been formally linked to effects on health and well-being, although the current thinking is that social interaction plays an extremely important part in older people's overall well being. This linkage is becoming the subject of a national dialog, and will be discussed below.
This emphasis on mobility presents several public policy contrasts:
- It is in the national interest to keep people operating their personal vehicles (cars, boats, planes) as late in age as possible for quality of life reasons -- yet we do not want that operation to unnecessarily endanger the individual or the public.
- It is also in the national interest to maintain the productivity and value-added of those who operate vehicles commercially, as long as it is safe -- yet we must recognize the higher public risks presented by those operating commercial vehicles.
- Most individuals, who detect their faculties for safe operation deteriorating, withdraw in responsible ways and require no action from authorities -- yet some continue to drive when they should not. A system is needed to protect against such drivers.
- The public believes that the licensing systems run by the individual states screen out unsafe operators of private motor vehicles -- yet states are reluctant to place special conditions on drivers on the basis of age for fear of political consequences or violations of civil liberties. Individuals who voluntarily seek information to determine if their reduced capabilities will result in unsafe operation can find little objective guidance or information on options open to them.
- A number of agencies of the federal government have common interests regarding mobility as evidenced through programs that deal with both aging and transportation-- yet these programs have never been formally coordinated. A similar situation exists within DOT and the same is also true for many states.
These three considerations: safety, individual personal mobility, and facilitating the eventual transition to mobility alternatives define a strategic planning goal for the nation's transportation system for older adults: Safe Mobility, For Life. To achieve this goal a number of proposals are described below. These proposals would support the attainment of other DOT missions as well. The goal can best be achieved not through large, new infusions of federal funding but with better coordination of funds already available at the community level, along with increased education of the public. Safe Mobility, For Life is characterized by the following precepts:
- Keep people operating vehicles as late in life as possible, as long as they can do so safely, particularly in areas with limited transportation alternatives.
- Promote technologies that support those individuals with age-related deficits so they can continue to operate safely longer.
- Improve the public and private screening and evaluation systems which provide the means to determine when older adults can no longer operate safely.
- Bring new emphasis to the provision of non-driving alternatives for the transportation needs of older adults.
- Educate the public on what they can do to maintain operational
safety, and to prepare for older age without driving.
3.2 NON-DRIVING MOBILITY ALTERNATIVES
3.2.1 Planning for Lifelong Mobility
Mobility for the elderly should be integrated into planning at all
levels: individual; community; and state. This extends to the statewide and
urban transportation planning processes carried out by state and local agencies,
including metropolitan planning organizations (MPOs).
3.2.1.1 The Individual Level - There is a need to educate the
public that they need to plan for their own mobility in later life, including
the site of their retirement, just as they plan their estate and retirement
program. Such plans should consider a likely shift from independent individual
transportation to transportation alternatives which make use of friends,
relatives, and public providers.
3.2.1.2 The Local Level - Local agencies, including the MPOs should identify a goal for overarching community mobility and recognition of the need to provide comprehensive transportation services for older adults. Transportation plans should be evaluated on the extent to which they enhance elderly-sensitive transportation in community design (e.g. walking or biking to nearby stores or transit stops).
3.2.1.3 The State Level - The DOT and HHS, and a number of
other Federal agencies fund comprehensive programs that provide transportation
services to older adults. With the exception of the work of the DOT/HHS
Coordinating Council on Human Services Transportation, very little of the
delivery of this funding is jointly planned and coordinated at the state level.
Considerable improvements in the efficiency with which these funds are used
would be possible were the agencies to better coordinate their planning for the
transportation of older adults. The recent movement toward the appointment of
coordinators and task forces at the state level, however, has enabled a number
of states to coordinate and maximize the joint use of these funds.
3.2.2 Non-Driving Mobility Alternatives
Many forms of transportation service for the elderly exist, but they are frequently fragmented, uncoordinated, and not universally available.
3.2.2.1 Public Mass Transit - Although only about three percent of trips by those over 65 are by transit, it often represents the only mode available to many older Americans. Thirty-two million older adults increasingly rely on transit as their driving ability decreases with age. Transit offers a practical way for these people to maintain mobility, by providing low cost access to community and social services, economic activities, and medical care. The concept of public transportation for older adults needs to be revisited, with added emphasis on service, security, and accessibility, to overcome the view of transit as an inferior transportation alternative. Another emerging problem is that in some areas, the Americans With Disabilities Act paratransit requirements have resulted in elimination of the demand responsive services for older adults which used to be provided.
Although more than 1,100 rural transit operators exist, their ability is limited in providing service to their low-density areas, in providing demand responsive service, and in providing the level of perceived security required by older users. Reduced transit funding for rural operators could force older adults into isolation or out of their homes into publicly funded care which is far more expensive than door to door bus trips to the market or to the doctor's office. A proposed solution to the reluctance by older adults to pay out-of-pocket taxi costs would be a subscription system which could lower costs and "mainstream" taxis as a supplemental part of the rural transportation system.
3.2.2.2 Community Based Systems - Thousands of communities operate systems with support of FTA and HHS funding. Nearly 3,700 transportation providers operate vehicles obtained through FTA's Section 5310 program for the elderly and persons with disabilities. This assistance totaled $59 million in fiscal year 1995. Because the program provides capital assistance only, providers obtain funds to operate their vehicles from a variety of other sources. For agencies principally serving the elderly, about 43 percent of operating assistance comes from state and local governments. Human service agencies provide another 36 percent. In particular, elder transportation services get 20 percent ($64 million in fiscal year 1994) of their operating funds from Older Americans Act programs.(25) The Medicaid program provides 16 percent of total operating funds for all Section 5310 providers.
The Section 5311 program provides capital and operating funds for transit services in rural areas with populations less than 50,000. The FTA distributes the funds to state DOTs, which in turn allocate them to local providers. About $133 million in assistance was given to rural providers in fiscal year 1995. Section 5311 funds over 1100 providers -- 25 percent of them operate only 1 or 2 vehicles, and less than one out of three operate more than 10. While older adults represent only 18 percent of the rural population, they represent 36 percent of Section 5311 riders.
3.2.2.3 Informal Systems (Family and Neighbors) - Informal support currently provides the bulk of the local transportation service for older adults. Many places of worship, senior centers, hired drivers, and volunteer organizations provide transportation services, but most frail elderly (not in institutions) are transported in family automobiles. The next aging cohort may be more transportation disadvantaged because it may lack the help now provided by adult children. It may be unrealistic to continue to rely on family and neighbors as mobility providers in the future. Spouses and daughters have been the traditional care givers. In the future, spouses and daughters able (and willing) to take on transportation and care duties may be in short supply due to smaller family sizes, higher divorce rate, and greater proportion of women in the workforce. One countervailing trend is the emerging willingness of employers to accommodate the caretaker role of their employees.
3.2.2.4 Other Mobility Assets - The young-old often
provide transportation services for older segments of the elderly population.
For some, this may provide part-time, low wage jobs to supplement their
retirement incomes, or they may work voluntarily, but as pointed out in Section
1.3, the need for transportation may in turn become a barrier to getting to
these jobs.
3.2.3 Initiatives for Consideration
A number of initiatives can be considered to meet the substantial
spectrum of concerns for older adults. These initiatives were developed in part
from the proceedings of several groups, including the five Expert Panels
mentioned previously, the Steering Committee for the ITMS project, and the
previous work of the TRB's Panel on Aging.
3.2.3.1 Better Coordination at the Federal Level -
-Upgrade DOT/HHS Coordinating Council of Human Services Transportation. Nine Federal agencies fund transportation as part of 90+ programs, many of which include the elderly. Most of the funding is at HHS, which works with the Department of Transportation through the joint DOT/HHS Coordinating Council on Human Services Transportation. The Council has few dedicated resources of its own, with the professional members sharing their Council duties along with many others. The Council is expanding its current joint efforts to the promotion and coordination of transportation resources of other relevant Federal agencies that sponsor transportation (e.g., Departments of Veterans Affairs, Labor, and Housing and Urban Development).
- Sponsor International Cooperative Program. Since the entire industrial world is aging with many countries doing so at a faster rate than the United States, safe mobility for older adults is a world-wide concern and there may be better solutions developed through international cooperative programs. A world-wide conference, similar to the 1988 Transportation Research Board's "Transportation for an Aging Society" would help to identify and evaluate international solutions. That study occurred before the numerous activities on the issues were undertaken by the U.S. DOT, other government agencies and the private sector. An international study on transportation for an aging society is required that would both update the 1988 TRB report and greatly extend it by incorporating the international perspective.
- Public Awareness Programs. Work with Administration on Aging (AoA) to develop educational programs on mobility. Redefine retirement planning to include mobility planning, promoting an awareness of the importance of the provision of safe mobility at the community level. Work with the AAMVA Public Affairs and Consumer Education group to make older adults and the general public more aware of the issues and solutions for safe mobility. Review what public and private sector networks exist by which to get materials on safe mobility to older adults.
- Web Site. Develop a home page on the world wide web for transportation issues, and link to Senior Net, AARP, etc. Include latest developments in technology, medical issues, best practices in the communities for mobility, grants for new pilot projects, etc.
3.2.3.2 Better Coordination and Promulgation of Best Practices at the State and Local Level - Transportation programs for older adults are for the most part Federal-agency specific and use of funds is narrowly proscribed. A number of states (e.g., FL, NC) have established active coordinating authorities (e.g., councils, task forces) by which to take advantage of different funding programs with varying results. In general, there is a need to find better ways to coordinate services and combine funds from different agencies, which would be encouraged with more interest being displayed at the Federal level (e.g., more support for coordinated planning, indication of more willingness to allow waivers and exceptions if it leads to more cost effective service and higher utilization rates).
- MPO Best Practices. Identify best practices among MPOs for incorporation of mobility alternatives and coordination for the elderly within their communities. Promote the concept of mobility managers and mobility counselors as an adjunct to state coordinating agencies. At the local level, MPOs should have representatives from the elder community on their advisory committees and review the MPO's Transportation Plans and Programs. There are hosts of sources for non-driving mobility alternatives that would be considered in a comprehensive community plan. There are formal systems, such as those sponsored by DOT, HHS, and other agencies, and informal systems, as provided by family and neighbors, religious organizations, senior centers, and volunteer organizations. There is a need to provide training and technical assistance for state and local planners on older mobility issues.
- Stimulate Replication of the Most Effective Systems. Evaluate existing providers of mobility services around the country for their strengths, weaknesses, and gaps in service. Evaluate which models perform best (e.g., Portland, ME; Columbia, MO; Wichita, KS; Eugene, OR) and issue reports on best practices.
- Increase Technical Assistance. Increase FTA and FHWA technical assistance, to make transportation organizations and their customers more aware of how to improve mobility alternatives for older adults in a cost effective manner. Consideration should be given to research and pilot programs. In providing assistance, FTA should include advice on how to maximize the use of funds.
- ISTEA. In the ISTEA reauthorization process, create provisions to assure local and state planning for the mobility of older adults, allowing the transportation system to change in response to the growth in the older cohort. This planning should involve coalitions of those interested in aging issues. Also included should be provisions to expand eligibility for partnering of mobility networks and systems.
- Promote More Collective Use by Community Providers. Review DOT, HHS, and other regulations that inhibit participation by and full transfer of funds to the community providers (particularly HHS funding programs which are never fully subscribed). Based on this review, the Cabinet Secretaries could indicate areas where they would be willing to grant waivers and exceptions, to provide more cost effective transportation services and higher utilization rates.
3.2.3.3 Promote Coordination With Industry - Establish a
review team to consider what new forms of collaboration are possible with other
stakeholders (e.g., insurance companies, advocacy groups, university centers,
employers) to enhance non-driving mobility alternatives. Review prospects for
establishing an industry advisory group, or alternatively, initiate a separate
subcommittee under the existing Federal Advisory Committee to evaluate key
issues regarding elderly mobility alternatives that need to be addressed. The
committee members should consist for example of members from the President's
Committee on Employment of Persons with Disabilities, AARP, and other prominent
groups.
3.3 IMPROVING OUR IDENTIFICATION AND EVALUATION SYSTEMS
The highest form of personal mobility is achieved when people are getting around on their own. Thus, as a matter of policy, when transit is not an option, we want to keep people driving autonomously as long as they can do so safely. As noted in Section 2.1.1, contrary to stereotypes, the evidence shows that in the aggregate, older motorists are not necessarily dangerous. Many withdraw from driving when they fear their deficits are impairing their performance. Unfortunately, there are few places they can go to get guidance as to what their relative competence is, and how to maintain it at a safe level.
A policy of keeping private motorists driving their cars as late in
life as possible, however, establishes two corollary requirements: 1) finding
improved ways to identify and regulate drivers who may be or are becoming a
problem; and 2) developing ways of evaluating who has the capacity to drive
safely, and if possible rehabilitating them so they can continue to drive (even
under constrained conditions).
3.3.1 Improving Our Systems for Identifying Problem Operators
With the number of older operators growing, there is a need to develop more economical, reliable, and uniform screening techniques that can be applied to as many people as possible. Those screening techniques should identify those who may be, or are becoming problem drivers. Once identified there should be a procedure to refer problem drivers or potential problem drivers to the appropriate professional or agency.
3.3.1.1 Public Sector Identification Systems - Today most problem drivers are identified somewhat haphazardly and belatedly by their crash experience; traffic citations; reporting by a physician, police officer and/or family member; and their license renewal applications. There is little uniformity across states. There is also a need to shift from current adversarial approaches to more supportive and dignified approaches. As an example, Oregon has developed a system for identifying problem drivers in which older adult drivers can meet with a counselor who helps them to determine the extent of their driving capabilities. There is also a need to initiate programs that will teach people in the medical and social services field to look out for impairments which will lead to unsafe driving, and recalcitrant problem drivers.
3.3.1.2 Private Sector Identification Systems - Peer reporting and that of outside observers provides some checks on age-related performance among commercial operators. However, such reporting cannot be relied upon as a significant factor. A number of companies put 800 numbers on the back of their trucks (How's My Driving) to encourage motorists to report bad, as well as good, driving practices.
3.3.1.3 Family/Social Systems - Often it is a family member
who identifies problem drivers and generally helps the individual to recognize
his/her deficits. Sometimes family intervention is unsuccessful. There is a need
to establish guidelines for families on how to aid an older adult in making the
right choices. This need is particularly important for drivers who are
cognitively impaired.
NHTSA is developing ways to assist family members and social agencies in recognizing impaired drivers. Families are best positioned to identify problem members, but not necessarily to act. Psychologists contend that only families can control cognitively impaired drivers. However, they need education and a socially responsive support system. Specifically, the programs will inform older adults, their spouses, their children, or others in the health and social support system to recognize critical deficits related to driving; and, if deficits do exist, where they can go to seek help.
3.3.1.4 Identifications at the Individual Level - Some
individuals, facing the reality of the onset of serious disabling conditions,
withdraw from driving immediately. Others withdraw from driving gradually and
responsibly by constantly making strategic decisions. These strategic decisions
involve selecting the times and places to minimize the effects of their
deficits. As noted above, in some cases, individuals should withdraw and don't,
while in others drivers retire perhaps before they have to. Hence, there is a
need to improve on programs to facilitate self-assessment, and to develop
remedial tools older drivers can use to evaluate their own abilities for safe
vehicle operations. There is also a need for programs by which older motorists
can maintain or regain their proficiency in their operating skills, or to
provide for the transition to alternative transportation.
3.3.2 Developing Better Assessment Tools
The above identification techniques should quickly and economically identify potential problem operators for whom more extensive evaluation is needed. The conditions being evaluated may not be clearly black and white; rather, they exist along a continuum from the direct observation of physical problems, which prohibit safe vehicle operation in clear and obvious ways, to the measurement of perceptual and cognitive problems which are linked through inference to a high likelihood of crash involvement, and which require specialized testing procedures.
3.3.2.1 Public Sector Evaluation Systems - There is some variation among states in procedures for evaluating the proficiency of older operators. Other than static visual acuity testing, objective criteria are scarce. State DMVs actually remove relatively few people from driving (less than 10 percent of older drivers lose their licenses), and among states DMVs vary in their failure rates (as stated during the Management Expert Panel). NHTSA has research underway to develop new road and other tests focusing on disabilities prevalent among older adults. Most states and provinces are considering or actually privatizing license examination requirements. This trend in readjusting the licensing process could provide the opportunity to upgrade driver re-examination requirements, providing costs can be made reasonable.
3.3.2.2 Private Sector Evaluation Systems - Some private
companies have innovative programs of their own. The American Occupational
Therapy Association and the Association of Driving Educators for the Disabled
are leading the way in improving the evaluation and rehabilitation of
functionally disabled drivers. Companies with a large number of commercial
operators are naturally more likely to have more extensive medical programs.
However, there are no standard practices among even the largest companies.
Simulators, developed in the private sector, may have the potential to be an aid
in evaluation.
3.3.3 Role of the Health Care Community
At present, there is concern about how to optimally involve the full spectrum of health care professionals in dealing with the identification and treatment of medically impaired motorists. The role of medical conditions and functional disabilities in the safe operation of vehicles is not fully understood among researchers or within the professions. Also, the costs involved in assessing and treating these conditions are extensive. For example outpatient costs for an assessment by an occupational therapist can vary greatly in the U.S., from $200 to more than $1,000. The magnitude of these differences suggests that professionals are taking widely different approaches to assessment and retraining. The disparity indicates the need to make the process more efficient, tailoring assessments to the identified conditions (e.g., stroke), or cataloging best practices and assessment tools, and possibly certifying those who perform the service.
As part of the assessments, health care and driving licensing professionals must agree on what levels of operation are safe, if any. They must also decide whether the operator can be made more safe through training and/or rehabilitation, or at what level of proficiency cessation must be prescribed. Many states allow no discretion in the licensing review process with respect to certain diseases.
Initiatives in this area should be tied to the concept that mobility will be maximized when health care professionals work in concert: physicians, optometrists, physician's assistants, psychologists, nurses, nurse practitioners, and occupational and physical therapists. It has been expressed that the primary need of physicians is guidance on what medical conditions are of concern, and a better understanding of what can be done. NHTSA is working on the first issue through its Medical and Functional Standards Driving Project. With respect to the latter, it plans to develop systems for educating physicians and health care professionals regarding standards of care, what resources are available, and how to activate them. These plans are discussed further below.
3.3.3.1 Reporting Deficiencies - The health care community is
not clear or in agreement as to its responsibility to inform the state of those
operators who are incapable or unwilling to adhere to safe operating practices
(see Section 1.5.2.1).
For these purposes, a reporting system that protects those reporting needs to be
developed and implemented. The presence of such a requirement in Pennsylvania
has led to 45,000 reports annually (according to Expert Panel). One initiative
in this area would be to develop a model reporting system.
3.3.4 Identification/Evaluation of Commercial Operators
As discussed previously in Section 2.3, the operation of commercial vehicles of all modes require medical evaluations, prior to licensure, and continuing evaluations for maintenance of those licenses. Generally, aviation examinations and those examinations required by the OMCS Regulations are more definitive and physician intensive. However, practices are not uniform, and physicians can be unaware of the full spectrum of specialists to whom they can refer their applicants when there is uncertainty about performance potential.
3.3.5 Present DOT Supporting Programs
NHTSA has under development more dignified and economical techniques
for screening, some of which draw on the family and the community to identify
those who should be evaluated. This includes developing new tests that focus on
disabilities prevalent among older adults. It also has a research program
underway designed to help the states determine who should and who should not be
driving. Its focus is much more proactive than the traditional model and is
designed to identify those who are at the threshold of being unsafe drivers or
who have functional limitations that reduce their driving abilities. Under this
program, screening and diagnostic assessment tests and other tools are being
designed to determine who can compensate for those disabilities, who needs to be
told to stop driving and, with the aid of other organizations, who needs help in
transitioning to other alternatives. Built into the development is an extensive
series of field tests to help ensure that older adults are not being
discriminated against by the proposed measures.
3.3.6 Initiatives for Consideration
3.3.6.1 Medical Practice Parameters and Guidelines - Prepare a standard set of guidelines whereby physicians can consult with an authoritative source regarding diagnostic steps and definitive action to take. If a data base were to be established of medical practice parameters and guidelines (in the form of what is medically known as pathways), it could be used by physicians and all health care professionals. Development of these pathways would provide a practical way to diagnose and determine how severe a given medical condition or functional disability is, and its implications for driving or using other transportation facilities. The pathways would have to be developed by selected medical specialists (e.g., geriatricians, ophthalmologists) and involve the appropriate professional groups (e.g., AAMVA, Association for the Advancement of Automotive Medicine, and the American Medical Association). Some states allow no discretion regarding certain diseases; others leave the discretion to the physician. To reflect the considerable variations among the states, the guidelines would have to be state specific.
There is thus a need to organize a multi-disciplinary team to develop a set of guidelines for the use of physicians and health care professionals as an authoritative source when conducting evaluations required for commercial licensure, as well as personal licenses in instances where medical examinations are required. In addition to improving the diagnosis, this guidance would establish a standard of care, which in turn would provide a cost control tool, and a legal defense for what the health care professional determined. It would also provide an educational way to explain to patients why the action prescribed is required. The decision-making algorithms could also reflect the risk assessments described above. Where computer aided information is unavailable, guidebooks localized for the state(s) where the health care professional is practicing would be necessary.
3.3.6.2 Referral Data - There is a spectrum of health care providers to whom physicians could refer their cases. These practitioners have the potential through training or rehabilitation to work with the applicant or reapplicant to remedy the conditions for which they were rejected, or declared marginal for continued licensure renewal (e.g., physical therapy to improve range of motion for truck drivers). A data base which lists health care practitioners specializing in retraining or rehabilitating operators, as well as their locations, would provide referral information as the natural next step in the treatment process. (The TRB Older Driver Resource Directory which is in the process of being updated could serve as such a data base.)
3.3.6.3 Education of the Medical Community - Develop training modules covering medical conditions and deficits experienced by aging operators, and the performance problems they pose. The full scope of medical specialization regarding older drivers and/or mobility alternatives is not widely studied among primary health care practitioners. To increase awareness, training modules covering medical conditions and treatments and their implications for the driving performance of aging operators should be developed and distributed to health care practitioners, and be included in continuing education curricula.
3.3.6.4 Self Help Tools - Give renewed emphasis to development of family as well as self assessment and remedial tools (e.g., AARP, AAA, and National Safety Council pamphlets). Using such tools, older adults, their family members, and social agency contacts can evaluate the driver's abilities to continue to operate vehicles safely, maintain their proficiency in operating skills, or transition to alternative transportation.
3.3.6.5 Rehabilitation Best Practices - Identify, develop,
evaluate, and disseminate "best practices" for rehabilitation of drivers as
identified and evaluated above. These rehabilitation practices would be
established as common elements in forward-looking rehabilitation programs. These
would include driver training and vehicle modification programs for older adults
as well.
3.4 POLICY RESEARCH
There are a number of issues regarding mobility for the elderly for which information is only fragmentary, and additional research is needed to support public policy decisions. For example, enhancing mobility alternatives represents a policy response to three issues of concern to the elderly: their quality of life; their continued safety and security; and their health care costs. This justification cannot be unequivocally made, however, without much more research.
NHTSA and HHS have an ongoing project on Mobility Consequences of
No Longer Driving, but more research may be needed to demonstrate how to
overcome inappropriate consequences. FTA has funded a number of research efforts
aimed at enhancing transit security. While these programs do not focus on the
older user they do take a systems approach with regard to cost, staffing, and
overall system function. These programs seek to enhance security through
improved procedures and the use of new technologies. However, they are usually
restricted to the portion of the trip provided by the transit system.
3.4.1 Linkage Of Mobility to Health Care, and Social Services, Costs
It has been suggested that mobility for older adults, i.e., their
ability to get around, make social contacts, etc. may be related to their state
of well-being and thus their health care cost. While the adverse health effects
of social isolation have been documented,(26)
we cannot yet document the linkage of increased health care costs to reduced
mobility. To do this we must perform epidemiological studies of the impacts of
reductions of mobility on interrelated factors such as health-related
expenditures, longevity, and quality of life.
3.4.2 Influence of Mobility Alternatives on Driving Cessation
The provision of mobility alternatives can have two functions: enable
individuals who have ceased driving or have never driven to maintain their
mobility; and to allow those who are no longer comfortable as drivers to reduce
this activity. Research to determine the extent to which the availability of
mobility alternatives will effect an individual's willingness to reduce or
curtail driving will allow us to gain an important insight into the efficacy of
alternative mobility programs. The impact of modern communities, mail and
delivery services should be taken into account. It is entirely possible that
some of those too cognitively or physically impaired to drive may also be unable
to use many alternative forms of transportation, particularly transit. Some may
require travel training. These individuals may require a traveling companion to
assist them in meeting their mobility needs.
3.4.3 Security Concerns of Older Adults
In spite of the fact that taxpayers invest billions of dollars per year keeping transit, para-transit, and other mobility alternatives in place, many elderly avoid them because they see themselves as potential targets for harassment, intimidation and criminal acts. These perceptions are often fed by rumor and or lurid news accounts of isolated incidents. The result is reduced mobility and a loss of access to vital activity centers for many seniors. Although significant work has been done to improve and maintain the security of some transit systems, little work has been done to examine elder security issues across all modes, including airports, ferry and multi modal terminals. Security concerns can also restrict older adults from walking and using their private vehicles at certain times of the day and at certain locations.
There is a need to determine the actual and perceived security of all
transportation modes and their surrounding environment for all phases of the
trip. For example, in the case of transit buses, the bus itself may be secure
enough, but the exposure between home and the transit stop, or at the stop
itself must be considered. From the patron's point of view, if there is
insufficient security, the risk associated with the trip may be too great
although some modes are ostensibly more secure than others. Based on such an
approach, it should be possible to develop guidelines, procedures and
technologies for better protection of older adults. It may also be possible to
develop methods for fairly and accurately quantifying the risk of the trip in
terms of security to respond to the fears generated by rumor and sensational
news reports.
3.4.4 Initiatives for Consideration
3.4.4.1 Conduct a Study of the Impacts of Reductions of Mobility - Research the present national dialogue on the importance of social contact and independence to the state of well-being of older adults, and thus their health care cost. Determine through epidemiological studies the extent to which linkage exists between health care costs, quality of life and mobility, as described in Section 3.4.1. These studies will involve the impacts of reductions of mobility on factors such as health-related expenditures, longevity, and quality of life. Also, consider the impacts on the community of the loss of the contributions and social interactions of older adults.
3.4.4.2 Study the Influence of Mobility Alternatives on Driving Cessation - Evaluate the premise that the availability of satisfactory mobility alternatives actually affects the willingness of people to withdraw from driving, as described in Section 3.4.2. This analysis would be a follow on to the preliminary work ongoing with NHTSA and HHS.
3.4.4.3 Security in Transportation - Section 3.4.3 describes the need to ensure that the transportation system remains secure for elders, and therefore for all. A two part investigation is needed. The first part will build upon transit-related research assessing the scope of the problem. How do elders perceive transportation security as it relates to their safety and fear of victimization? How does their fear of crime relate to their willingness to leave the security of their own home, using private or public transportation services? Does the presence of the homeless in some terminals in any way affect the use of public transit? What alternatives are available to improve the perceived and objective sense of security to encourage their use of personal vehicles or mobility alternatives?
Although technology offers many countermeasures and detection tools (e.g., Mayday alert systems), full system security requires more than hardware. The second part of the investigation will move beyond identifying solely hardware-oriented solutions and apply an integrated systems approach to the transportation/elder security issue. The results of this work will provide an inventory of the utility and appropriate uses of environmental design, security policies, procedures, transportation personnel training, and the relationship of transportation facilities to their surrounding environment to increasing the elder-friendliness and accessibility of public and private transportation services.
Two areas which should receive special emphasis are:
--Elder-Friendly Terminals - Evaluate what cost effective ways are available for increasing the user friendliness of bus, rail, and aviation terminals, the passage of the older adults into and out of the transportation systems, their protection in crashes, and their evacuation following a crash.
--Elder-Friendly Pedestrian Facilities - Evaluate ways of
increasing the safety and security of pedestrian facilities to encourage the
more frequent use of those facilities.
3.5 COUNTERMEASURES FOR THE FRAGILITY OF ELDERS
3.5.1 Fragility Problem Defined
As noted above, the rate of automobile fatalities associated with the elderly increases disproportionately after the age of 75. Osteoporosis and increased fragility and loss of bone and muscular strength make the elderly more vulnerable (e.g., even standard safety belts can crack ribs leading to organ punctures; similar problems can exist with airbags). With the growth of the elderly population expected over the next 25 years, in the absence of additional action by the Department to reduce their crash rate, the level of elder fatalities will become of ever greater societal concern.
The life saving benefits of air bags may be greatly diminished for adults over age 70. In purely frontal crashes, data indicate that airbags could be reducing the drivers' fatality risk by 30 percent or more for drivers up to 55 years old, but only 11 percent for drivers age 70 and older. The relative benefits may diminish further in partially frontal crashes. The data do not indicate the precise causes for this reduction in protection (See NHTSA Technical Report (27)).
A substantial research and development program is needed to develop
countermeasures to compensate for the fragility of elders. This program would
involve biodynamic modeling and possibly even testing using crash dummies to
gain a better understanding of the problem. Potential mitigation technologies
would be considered, including improved vehicle design and smart (force
limiting) belts or (smart) variable aggressivity air bags. This program would
conduct research to establish age related fragility parameters and from these
develop guidelines for better occupant packaging and protection of elderly from
trauma both as vehicle operators and users. The experimental modeling work would
build on the expertise in biodynamics developed by NHTSA as well as work done by
DOD, universities, and the private sector. It should also seek to continue
formal and informal public/private partnerships with researchers from the
automotive industry, academic institutions and military research facilities.
Some of the results of this research can be expected to be transferable to other
situations where elder fragility can be a problem, such as transit buses, rail
passenger trains, architectural designs for transportation terminals, and
designs and procedures for emergency evacuation of aircraft.
3.5.2 Present DOT Supporting Programs
NHTSA has a strong biodynamics program aimed at the reduction of
crash related injuries for all passengers. There are plans to investigate the
safety of airbag deployment for children and small adults. NHTSA also is
analyzing crash data to compare injuries received by older and younger motor
vehicle occupants restrained by lap and shoulder belts and/or air
bags.
3.5.3 Initiatives for Consideration
3.5.3.1 Countermeasures for Fragility of Elders - Establish a
substantial research program to develop countermeasures to compensate for the
fragility of older adults as described in Section 3.5.1.
This research should also have transferability to other modes where the
fragility of older adults can be a problem, such as transit buses and emergency
evacuations (including aircraft).
3.6 TECHNOLOGICAL PROGRAMS
New technology holds great promise for developing older-friendly systems. These systems have the capacity to augment and extend the mental and physical capabilities of older transportation users and operators. There are numerous performance-aiding technologies which will become available over the next ten years to enhance the safety and ease of operating vehicles, and thus directly support older operators. Development and introduction of these new technologies in all modes is being supported by DOT and other agencies, as well as private organizations, many under the ITS program. ITS America, Inc., has become increasingly concerned about older adult issues and has established an older driver subcommittee to address the opportunities and constraints ITS presents to older operators.
Development of technological enhancements that support older adults should be driven by their identified needs rather than technological availability. There is a need to limit the tendency to introduce complex technology for its own sake, since such complexity can also have the capacity to confuse or burden many elderly operators.
It is often the case that innovations that benefit older adults
benefit other users as well. Some technologies, however, will have the
capability to help individuals to compensate for specific functional
impairments, only if they are designed with those particular individuals in
mind. This may result in problems of higher cost and reduced availability.
Further, some technologies designed for the broader public could conceivably
impair the functioning of some older operators.
3.6.1 Highway Design
An increase in the time required to process new information frequently accompanies aging. As a result, older operators have greater difficulty in performing certain driving tasks, such as reading signs clustered at an intersection. Better signs and road marking allow increased braking and sight decision times. Providing the driver with additional time for such decisions increases the probability that he or she chooses the safest and most appropriate maneuver.
Although older operators may drive very cautiously, they can still encounter situations that require substantial time-critical mental processing and decision making (e.g. crossing traffic to execute a left turn on a busy street). The complexity of congested highway systems coupled with the faster moving traffic accompanying recently increased speed limits also represent serious challenges to the older driver.
In order to be ready well in advance of the coming influx of older
drivers, FHWA established a high priority research program in 1989 dedicated to
improving travel for an aging population. It has conducted extensive research on
a host of older adult subjects, including traffic maneuver problems for older
drivers, the relative visibility and information transfer characteristics of
different signing designs, different forms of lane markings and delineations,
the older pedestrian's ability to cross signalized intersections, and older
driver freeway needs and capabilities. This research is continuing but is at the
stage where much useful information is now available, and the results will soon
be compiled into a Preliminary Older Driver and Highway Safety
Handbook, for distribution to highway engineers and planners in the
communities. The next efforts will include development of an implementation
program to help educate the users on both what information is at their disposal
and how to put the recommendations into practice for a safer, more mobile older
population.
3.6.2 Vehicle Design and Ergonomics
By 2010, baby boomers will account for 57 percent of car buyers. This
demographic trend emphasizes the need for continuing attention to elderly
limitations in eyesight, strength, flexibility, agility, etc., in designing
vehicle doors, seats, controls, and instrument panels, and understanding
complicated instructions given verbally. Enhanced mirrors and ways to avoid
headlamp glare problems must be sought, as well as to avoid driver information
overload. This work will be a challenge to automobile, truck, airframe and other
vehicle manufacturers. Re-learning how to use the systems of each new vehicle
also presents a particular problem for older adults. The efficacy of guidelines
for the design of elderly-friendly standardized vehicle interfaces for
equipment and systems needs to be assessed. However, standardization of controls
and displays should not be permitted to stifle critical innovation. Where
complexity is unavoidable, mitigation might be provided through short term
supplemental training.
3.6.3 Simulator Development
Simulators have the potential to be supportive in many functions: for
screening, as an aid for evaluation, in training older adults to use new
technologies, and in research to establish test requirements or develop new
driving aids. Much of the most critical research and the most important aspects
of on-line operator screening are too dangerous to be conducted in traffic with
real vehicles. Today's simulators have the potential to permit research and
screening to be conducted safely. Continued development of advanced
sophisticated simulations such as the National Advanced Driving Simulator, at
the University of Iowa, will support such research, particularly work to
establish test requirements or develop new driving aids. Developments of low
cost simulators designed to be used in field settings have been made possible by
personal computer technology. Such a low cost simulator would be especially
helpful to DMVs and the health community. One particular problem with automobile
simulators that incorporate motion or elaborate multiple screen displays is that
a significant proportion of test subjects experience motion sickness and
kinetosis. This is a particular problem for older subjects. The use of advanced
driving simulators for the study of older drivers will be limited until the
problem is surmounted.Any simulator must yield data that are predictive of
real-world performance in safety-critical situations, and are accepted by the
public as a fair and valid indicator of driving competency.
3.6.4 Fitness for Duty Testing
Many elements of DOT are sponsoring research with the goal of finding alternatives to or enhancements of hours of service regulations, and identifying the impact of debilitating factors such as illicit drugs, medications, stress, and workload. The development of practical "fitness for duty" testing device(s) is intended to address these issues. To date this technology has not been proven to be useful and development of such systems remains a challenge.
Computer based performance tests and batteries are available to assess the effects of aging, workplace stress, and work schedules on performance, but these systems have not reached a level of utility which would make them useful in an operational setting .(28)
The FAA has one such tool under development, Cogscreen-AE.(29)
It is a computer-administered test for use in the medical recertification
evaluation of pilots with known or suspected neurological and/or psychiatric
conditions. It measures the underlying perceptual, cognitive and information
processing abilities associated with flying. This tool has potential for use in
testing the mental capacities of all operators of all ages but can be used to
identify mental changes more common to older pilots. If this tool is successful
it may be adaptable for other modal applications.
3.6.5 Research on Operator Capability Requirements
There is insufficient information on the causal relationship between certain medical conditions or functional abilities and operator performance and crash involvement. We are thus limited when trying to develop clear guidelines on who should or should not drive. For instance the relative importance of strategic and tactical decisions as compared to operating skills and cognitive speed needs to be assessed.
A better understanding of the relationship of external factors to the
impairments to older adults due to drug use, alcohol, and fatigue is needed.
Older adults may be more affected since they have fewer resources to cope with
the effects of drugs and their overall effects may be longer lasting. More
research is needed to gain a better understanding of how the use of commonly
prescribed medications can impair vehicle operation. Today, persons 65 and older
receive 29 percent of all prescriptions. More than 80 percent take one or more
medications. Information is needed on the effects of commonly used medications
taken alone and in combinations. Polypharmacy is already known to be causing
numerous falls and injuries among the elderly. Of particular concern are
medications such as tricyclic antidepressants, benzodiazepines, and opioid
analgesics. The effects of fatigue and sleep apnea are also important
considerations for older commercial operators.
3.6.5.1 Performance-Based Standards - Decisions on who can operate should be performance based, but the science by which functional performance standards can be established is still lacking. For all modes, a better understanding is needed of the minimum requirements to perform driving, piloting, and way-finding tasks safely. This is very important if we are to be successful in assessing the significance of age-related cognitive, sensory, and motor declines. It has been difficult to quantify the relationships between debilitating conditions and risk of a crash. The complexity of this problem is compounded by the way the effects of impairments may be mediated by strategic and tactical decisions by the operator. Progress in these areas has varied by mode; for example, an extensive data base exists for aviation tasks. NHTSA is sponsoring work to assign levels of severity of accident risk to medical conditions. This work is being conducted through AAAM. This work is complicated by the need to recognize and define the difference in functional level and content of tasks required by commercial and non-commercial operations.
Research into the risk of crashes from the diagnosis of debilitating
medical conditions will be extremely difficult. It is likely to be complex,
expensive, and long term. To be practically useful to the health care and
licensing communities, it must go far beyond the current state of the art. This
research will require the development of: 1) improved clinical, physical and
mental assessment/screening methods; and 2) objective links between physical
conditions and/or impairment, and crash risk.
3.6.6 Present DOT Supporting Programs
As noted above, research into the identification, development, introduction, and evaluation of these new technologies in all modes is being pursued by DOT's internal organizations, i.e., FHWA, NHTSA, ITS Joint Project Office, FAA, and FTA and other agencies, as well as private organizations, many under the ITS program. These are too numerous to enumerate, but the following examples offer insight into their obvious promise.
3.6.6.1 Collision Warning/Avoidance Systems - Detection of objects in the forward path of the vehicle (as well as when backing-up) has the greatest potential to save lives, not only because a substantial number of occupant collision injuries will be avoided, but because it also represents a major new countermeasure for reducing vehicle crashes involving pedestrians and bicyclists.
3.6.6.2 In-Vehicle Signing - Advance notice in the vehicle, visual or audible, of what caution, speed change, and road contour signs will shortly be encountered may afford the older driver more time to process this information and react. Included in this advance notice grouping will eventually be automatic notices of upcoming rail grade crossings, flooding, fog, and weather alerts. These systems may be even greater use to senior truck and bus operators than to private operators and will be applicable to all modes.
3.6.6.3 Security - Mayday rescue systems and collision notification systems, which automatically alert authorities of the locations of vehicles experiencing emergencies, can expedite aid to older travelers and bring some relief to their security concerns. As is true today, however, its success will depend on the location of the incident, and the response infrastructure of emergency service providers available.
3.6.6.4 Rural Public Transportation - Better use of
information system technologies has the potential to improve rural transit and
ride sharing services for older adults. Customer paging systems, combined with
vehicle location and tracking systems, can lead to real time, more personalized
and rapid service, through demand responsive (paratransit, route deviation)
systems. Such systems are now being evaluated in a number of states.
3.6.7 Initiatives for Consideration
The various operating administrations have already launched a number of exemplary technological programs to accommodate and support the increasing number of older adults within the system. Proposed new technological applications have been limited here because so many projects are already ongoing.
3.6.7.1 Improve our Understanding of the Relationship Between
Medical Conditions, Functional Disabilities and Operator Performance -
Current information on the role of medical conditions and functional ability on
crash involvement and operator performance is insufficient. Consequently we can
not develop clear guidelines on who should or should not drive. Furthermore,
evidence on the role of medications and safe driving is insufficient to enable
physicians to prescribe the most cost effective and safe medications. The
Department needs to continue supporting and conducting epidemiological research
on the relationship between and among medical conditions and functional
disabilities vs. crash involvement and driving practices. Current knowledge does
not permit clear guidelines because risk ratios for various conditions are
either contradictory, too low or not actually appraised. There is an interaction
between crash involvement and driving cessation that makes it difficult to
provide clear guidance to physicians or to their patients. There is also a need
to determine how performance of operator tasks are related to medical conditions
and functional disabilities. In addition to crash risk ratios, the actual
driving behavior of individuals with functional disabilities needs to be better
understood. There are those who believe that the strategic and tactical decision
that an individual makes are more important than their operating skills. There
is a need to conduct research into these decision processes. (See Appendix
C-III for additional discussion of this issue).
3.7 IMPROVE DATA BASES TO EVALUATE THE SUCCESS OF THE PROGRAM
Strategic planning requires not only the setting of long term goals,
but also establishing metrics to determine if they are being achieved. The goals
here are for a positive program that invests in the elderly as users and
providers of transportation services, while also improving our screening and
evaluation systems to keep them safe. We need to improve the content and nature
of our data bases to make better use of existing programs, to monitor the
progress of continuing initiatives and to help plan new initiatives. With regard
to present data bases, we must evaluate the extent to which we can meaningfully
add items such as medical data, prescription drug use, travel data, residential
data and (when available) the results of performance evaluations.
3.7.1 Data Base on Elderly Characteristics and Scenarios for Aging
The baby boomer cohort is predicted to have more extensive mobility needs as it ages than does the present elderly cohort. Its members currently live further from central business districts, have less access to public transit and are less likely to have been using these facilities. Furthermore, this group is composed of more two wage earning families and may in the future be able to retire at a younger age. This last point is debatable because the increasing Social Security eligibility age, and reductions in vested retirement programs, may impact retirement patterns.
Extensive socio-demographic research is needed to get a clearer
picture of the true transportation needs of this growing and important segment
of the population. This can be accomplished by DOT working with the Forum for
Aging Related Statistics and related gerontological statistical organizations.
Another important information base would deal with characteristics of older
adults as related to transportation. Ideally this data base would contain
information in a consistent and accessible framework on topics such as: well
elderly vs. disabled elderly; and common elderly transportation need categories.
(See Appendix
C-II for additional discussion of this issue).
3.7.2 Fiscal Base to Evaluate Program Effectiveness
The Department also needs to build comprehensive data bases which allow us to compare relative costs and other performance measures, in order to monitor the efficacy of our systems and policies and respond to the Government Performance Review Act. With these systems in place, we can compare public outlays that enhance elder mobility to the likely costs to society if no systematic enhancements are made. Two aspects of this fiscal data base are critical:
- Outlays for programs such as alternative mobility systems, enhanced screening and evaluation; promoting education, training and rehabilitation programs; and/or technology investments.
- Costs of elder-caused crashes (injuries, fatalities, and health
care and social service costs), costs associated with non-emergency medical
transportation, and medical costs associated with premature health declines due
to reduced mobility.
3.7.3 Present DOT Supporting Programs
No comprehensive fiscal data bases of this sort are known, although
partial data on these topics are available from sources such as HHS.
3.7.4 Initiatives for Consideration
3.7.4.1 Long Range Transportation Needs of the Elderly - Conduct research to evaluate what the long range transportation needs of the elderly actually will be, and to what extent they will be met with our Federally sponsored systems.
3.7.4.2 Data Bases - Undertake establishment of the data bases
outlined immediately above.
4. IN CONCLUSION
Secretary Peņa, concerned about the quality of life of the future older population, initiated this comprehensive overview of what needs can be anticipated from the changing demographic demands on the Nation's transportation system, and what improvements might be made in order to accommodate them. These demographics will find us with a large population of older adults, who are more widely dispersed, and more accustomed to a life style of full mobility. The problems highlighted above encompass the perspective of older adults as users and providers of transportation in all modes, and more than 20 possible remedial initiatives have been offered for consideration. The specific recommendations, relative priorities, and budget estimates, which would be part of a definitive long term strategic plan, are the next step.
Most of the problems discussed are part of a long term agenda. There is time to work on them before we feel the impacts of the 20 million increase in the over-65 population projected for 2020. Extensive research is needed in many areas, e.g., the need for improved understanding of exactly how older adults function and compensate for age-related differences in physiology, what the true transportation needs for older adults will be, and how they can be accommodated. New forms of mobility alternatives need to be developed and tested. Potential safety problems for certain segments of the older adult population have been noted and they will warrant continued monitoring.
Some of the problems cited, however, should be part of a shorter term agenda. The effectiveness and productivity of our testing, evaluation and rehabilitation programs need to be improved. Rapid growth in the over-80 population is already under way, and we must ask ourselves what kind of comparable growth in transportation services for them are possible. Since we cannot count on new resources, it is necessary that we get maximum efficiency out of the resources available now -- thus the emphasis on best practices in the mobility planning area. Further, we must develop more effective countermeasures to deal with the higher levels of fragility for this group.
The Department's leadership role in responding to the transportation needs of older adults is unquestioned and will continue. It has had effective, even exemplary, programs under way for a number of years. It is of paramount importance that these programs be well coordinated within the Department, as well as with HHS and all the other agencies that have programs for older adults at the state and community level. This extends as well to working closely with the private sector, with the various Transportation Research Board Committees, and the professional communities of other countries.
How well the Department meets the many challenges catalogued above
will have far ranging impacts on the quality of life for future older adults, as
well as overall safety performance for the transportation community.
5. ADDITIONAL REFERENCES
Burkhardt, Jon E. and Hayes, Elisabeth, "Innovative State Medicaid Transportation Programs," Prepared for Joint Department of Transportation/Department of Health and Human Services Coordinating Council on Human Services Transportation, Ecosometrics, Inc., Bethesda, MD, 1995.
Cifu, David X., "Rehabilitation of the Elderly Crash Victim," Clinics in Geriatric Medicine, May 1993, 9(2): 473-483.
Cobb, Roger W. and Coughlin, Joseph F, "Who is Driving Miss Daisy?", Policy Project: Examiner Survey Results, Department of Political Science, Brown University, Providence, RI, 1996.
Cole, Thomas R., The Journey of Life: A Cultural History of Aging in America, Cambridge, Cambridge University Press, 1992.
DeMaria, Eric J., "Evaluation and Treatment of the Elderly Trauma Victim," Clinics in Geriatric Medicine, 1993, 9(2): 461-471.
Dial, Robert, "Autonomous Dial-A-Ride Transit: Introductory Overview," Transportation Research, 1995, Vol. 3, No. 5, pp. 26 17-275.
Dychtwald, Ken and Flower, Joe, The Challenges and Opportunities of an Aging America, Age Wave, Los Angeles, CA.
Fell, J. C., "A Motor Vehicle Accident Causal System: The Human Element," Human Factors, 1976, 18, 85-94.
Hunt, Linda A., "Evaluation and Retraining Programs for Older Drivers," Clinics in Geriatric Medicine, May 1993, 9(2):439-447.
Jette, A.M. and Branch, L.G., "A Ten-Year Follow-Up of Driving Patterns Among Community Dwelling Elderly," Human Factors, 1992, Vol. 34, pp. 25 -31.
Katz, Peter, Remarks in Choices for Our Future: Finding Transportation Alternatives for Our Aging Population: A Final Report in the White House Conference on Aging, Alliance for Transportation Research, Pennsylvania State University, and the Surface Transportation Policy Project, Administration on Aging, Department of Health and Human Services, November 1995.
Koepsell, Thomas D., Wolf, Marsh E., McCloskey, Lou, Buchner, David M., Louie, Douglas, Wagner, Edward H., and Thomson, Robert S., "Medical Conditions and Motor Vehicle Collision Injuries in Older Adults," Journal of the American Geriatrics Society, 1994, 42:695-700.
Kunstler, James H, The Geography of Nowhere: The Rise and Decline of America 's Man- Made Landscape, Simon and Schuster, New York, 1993.
Malfetti, J. L. and Winter, D.J., Drivers 55 Plus: Test Your Own Performance, AAA Foundation for Traffic Safety, Washington, DC, 1986.
Retchin, Sheldon M., and Jackie Anapolle, "An Overview of the Older Driver," Clinics in Geriatric Medicine, May 1993, 9(2), 279-295.
Rosenbloom, Sandra, "Travel by the Elderly," Travel Mode Special Reports, U.S. Department of Transportation, 1990 NPTS Report Series, Washington, DC, U.S. Government Printing Office, 1995.
Rosenbloom, Sandra, Remarks in Choices for Our Future: Finding Transportation Alternatives for Our Aging Population: A Final Report in the White House Conference on Aging, Alliance for Transportation Research, Pennsylvania State University, and the Surface Transportation Policy Project, Administration on Aging, Department of Health and Human Services, November 1995.
Shinar, D., Driver Performance and Individual Differences in Attention and Information Processing: Volume I. Driver Inattention, Technical Report DOT HS 8-801819, US Department of Transportation, National Highway Traffic Safety Administration, Washington, DC, 1978.
Staplin, L. And Lyes, R.W., "Age Differences in Motion Perception and Specific Traffic Maneuver Problems," Transportation Research Record 1325, Transportation Research Board, National Research Council, Washington, DC, 1992.
Thompson, Mary Ann, The Older Person as a Former Driver: Quality of Life, Mobility Consequences and Mobility Adaptation, Doctoral Dissertation, Columbia University School of Public Health, New York, New York, May, 1996
Tull, A., "The Older Driver and Highway Safety," World Traffic Safety Symposium, New York, NY, 1995.
Underwood, Michael, "The Older Driver: Clinical Assessment and Injury Prevention, " Archives of Internal Medicine, April 1992, 157:735-740.
65+ in the United States, Current Population Reports, Special Studies, P23-190, U.S. Bureau of the Census, U.S. Government Printing Office, Washington, DC.
Age 60 Rule, FAA Rule, 14 CFR 121.383.
Analysis of Area Agency on Aging Transportation Survey, National Eldercare Institute on Transportation, Washington, DC, April 1993.
Best Practice Profiles for Model Transportation Systems Serving the Elderly, National Eldercare Institute on Transportation, Washington, DC, September 1992.
Coordinating Community Transportation Services: A Planning and Implementation Handbook,Community Transportation Assistance Project, U.S. Department of Health and Human Services, Washington, DC, May 1992.
Coordinating Transportation in Your Community, Issue Brief No. 4, National Eldercare Institute on Transportation, Washington, DC, September 1992.
Community Transportation: Facts and Figures, Community
Transportation Association of America, Washington, DC, January 1995.
Current Population Survey, Bureau of the Census, 1995.
Highway Statistics, FHWA-PL-95-042, Federal Highway Admin., 1994, pp. III-10, III-13.
"The Identification and Management of High Risk/Unfit Drivers," from University of Massachusetts Medical School Seminar, Boston, MA, March 22 & 23, 1996.
Memorandum to U.S. Department of Transportation, Volpe National Transportation Systems Center, from International Taxicab and Livery Association, April 2, 1996.
Section 18 Transportation Providers: Sources of Operating Funds, Fact Sheet 7, Community Transportation Association of America, Washington, DC, November 1994.
Section 18 Transportation Providers: An Overview, Fact Sheet 8, Community Transportation Association of America, Washington, DC, December l994.
South Carolina Specialized Transit Needs Assessment and Statewide Coordination Plan,Garter Goble Associates, Inc. and Comsis Corporation,, June 1992.
Transit Operations for Individuals with Disabilities, TCRP Report 9, Transportation Research Board, National Research Council, National Academy Press, Washington, DC, 1995.
Transportation in an Aging Society, Special Report
218, Transportation Research Board, National Research Council, Washington,
DC, 1988.
1. See Figures 3 and 4 in the main text.
2. The definition of an older adult used in this paper is anyone 65 years of age or older to conform to common practice in Social Security, the Census, etc.
3. U. S. Bureau of the Census. Current Population Reports. Special Studies. P23-190, 65+ in the United States. U.S. Government Printing Office, Washington, DC, 1996. p. 2-1.
4. U. S. Bureau of the Census, 1996. p. 2-2.
5. Dychtwald, Ken and Joe Flower. Age Wave. The Challenges and Opportunities of an Aging America. Los Angeles: Jeremy P. Tarcher, p. 6.
6. U. S. Bureau of the Census, 1996. p. 1-1.
7. U. S. Bureau of the Census, 1996. p. 1-1.
8. U. S. Census, 1996, p. 4-16.
9. U. S. Census, 1996, p. 4-8.
10. U. S. Census, 1996, p. 4-14.
11. A number of elements for these programs were proposed in 1988 by a Committee of the Transportation Research Board; see "Transportation in an Aging Society, Special Report 218," National Research Council, Washington, DC, 1988.
12. DeMaria, Eric J. "Evaluation and Treatment of the Elderly Trauma Victim." Clinics in Geriatric Medicine. 9(2):461-471 (May, 1993).
13. Retchin, Sheldon M., and Jackie Anapolle. "An Overview of the Older Driver," Clinics in Geriatric Medicine. 9(2), 279-295 (May, 1993).
14. Underwood, Michael. "The Older Driver: Clinical Assessment and Injury Prevention," Archives of Internal Medicine. 152:735-740 (April, 1992).
15. Koepsell, Thomas D., Wolf, Marsh E., McCloskey, Lon, Buchner, David M., Louie, Douglas, Wagner, Edward H., and Robert S. Thompson. "Medical Conditions and Motor Vehicle Collision Injuries in Older Adults," Journal of the American Geriatrics Society. 42:695-700 (1994).
16. Cifu, David X., "Rehabilitation of the Elderly Crash Victim," Clinics in Geriatric Medicine. 9(2):473-483 (May, 1993).
17. Hunt, Linda A, "Evaluation and Retraining Programs for Older Drivers," Clinics in Geriatric Medicine. 9(2):439-447 (May, 1993).
18. Eberhard, John W., "Safe Mobility for Senior Citizens," Journal of the International Association of Traffic and Safety Sciences, Volume 20, Number 1, 1996.
19. The Safety Record of Heavy Trucks and Older Drivers: An Analysis of Five Years of Large - Scale Accident Data, Prepared for the Association of American Railroads by R.D. Mingo and Associates, January 1996.
20. Human Factors Research in Highway Safety, Transportation Research Circular 414, National Research Council, Washington, D.C., Sept. 1993, p. 37.
21. Fell, J. C. 1976. A Motor Vehicle Accident Causal System: The Human Element. Human Factors, 18, 85-94.
22. Malfetti, J. L. and Winter, D.J. 1986. Drivers 55 Plus: Test Your Own Performance, AAA Foundation for Traffic Safety. Washington, DC.
23. Shinar, D. 1978. Driver Performance and Individual Differences in Attention and Information Processing: Volume I. Driver Inattention. (Tech. Report DOT HS 8-801819) Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration.
24. Staplin, L. And Lyes, R.W. 1992. Age Differences in Motion Perception and Specific Traffic Maneuver Problems. Transportation Research Record 1325. Transportation Research Board, National Research Council, Washington, DC.
25. The Older Americans Act (OAA) established the HHS Administration on Aging ( AoA). The Act authorizes funding for transportation services for persons age 60 and older under Title III-- State and Community Programs on Aging. The AoA distributes Title III funds to the State Units on Aging, which in turn provide them to the Area Agencies on Aging and Title VI organizations. These agencies then award grants or contracts to local service providers to cover their operational and capital costs.
26. Olds, Jacqueline, Schwartz, Richard S. and Harriet Webster. Overcoming Loneliness in Everyday Life. New York: Carol Publishing Group, 1996.
27. Fatality Reduction by Air Bags, Analysis of Accident Data through Early 1996, NHTSA Technical Report DOT HS 808 470, August 1996.
28. e.g., FHWA project with Truck Research Institute.
29. CogScreen was developed as a test of cognitive function (and not flying
skills) in response to the documented observation that traditional clinical
screening tests were insensitive to detection of cognitive deficit of relevance
to functioning as an airman. However, the test development was intentionally
structured to assess brain functioning, and not to assess flying skills per se.
CogScreen is now used as a supplemental test option by neuropsychologists doing
evaluations of airman on behalf of the FAA; other applications include both
military and civilian entities that use CogScreen as a baseline documentation of
cognitive performance on entry into an aviation job. The test is available
commercially from PAR, POB 998, Odessa, FL 33556.
RETURN TO: Appendices --- Index --- Contents --- Executive Summary
