Service Providers for Older Adults (cont'd)

Working with Families, Partners and Caregivers

Even when family members, friends and providers are willing to tackle these difficult conversations, research indicates that they want more information with which to initiate a discussion. Providers can assist in preparing families and partners for the discussion by supplying:

• A list of signs indicating driving impairment
• Tips on observing the older driver's abilities
• An understanding of the meaning of driving from the loved one's perspective
• Suggestions on opening the driving discussion
• Ideas on how best to talk about appropriate driving and travel choices
• Materials to help older drivers plan for a change in mobility
• A list of community resources for driving evaluation and remediation
• Strategies for driving reduction or retirement
• Local transportation alternatives for the older driver

Families often question service providers about the signs of driving impairment. This opportunity allows providers an opening to talk about the spectrum of driving ability and to make suggestions on how to approach discussions with older drivers.

Preparing for the Conversation

Steps to Identifying Appropriate Assistance

To prepare for useful discussions with the older driver, have the family and partner focus on the older driver's functional capacity, not age or disease. People age at different rates and age-related problems known to affect driver performance do not occur in all people at the same rate or to the same degree.⁵ The discussion should:

• Clarify for the family and partner the transportation needs of the older person
• Highlight steps that the older driver has taken to ensure safe driving, such as limiting driving at night, in poor weather conditions or during high-traffic times
• Develop strategies to improve driving
• Result in positive action to ensure safety

Preparation for the conversation begins with fact finding. Have families and partners identify signs of driving problems. With concrete examples, you as a provider can help them consider positive approaches such as focusing the conversation on remediation and not on loss of keys. Provide families and partners with the following list of signs to identify driving problems.

Signs of Driving Problems6,7

Vehicle crashes New dents or dings in the car Observations by neighbors or friends of unsafe driving Police visits Two or more traffic tickets, warnings, collisions or "near misses" within the last two years Increases in car insurance premiums because of collisions Getting lost when driving on familiar streets

To prepare for the conversation with the older driver, have the family member or partner observe driving performance. Encourage the concerned family member or partner to ride with the older driver. Remind the observer to look for the strengths of the older driver's performance. Then consider how to strengthen the weaker areas. The observer should ride with the older driver two or three times at different times of the day and under different conditions. Suggest that the rider just observe and not comment while in the car.

After the ride, have the family member or partner consider factors that might have interfered with driving performance. Provide some of the following suggestions:

Contributing Factors to Driving Problems

Inappropriate adjustment of the seat, steering wheel, mirrors, safety belt Difficulty seeing Problems with neck flexibility in turning to see traffic on the left or right Difficulty hearing Medications reactions Alcohol misuse

Help the family and partner develop supportive strategies to respond to these challenges.

The second step involves the concerned family member or partner taking a ride with the driver. Instruct the observer to keep the following questions in mind during the drive:

• Did the driver wear glasses or contact lenses if needed?
• Did the driver use a safety belt without taking a cue from the rider? Was the belt used properly (across the shoulder and secure over the lap - not under the arm)?
  Safe driving begins with seeing clearly and putting on a safety belt.

• Was the driver sitting at least 10 inches from the steering-wheel airbag?
  Being 10 inches or more from the airbag will likely prevent injury or death if the airbag activates.

• Could the driver see the road adequately? (Some drivers need to sit higher to see properly out the vehicle's windows)
• Was the driver able to twist around or turn her head to see what was happening when backing up, or was she able to rely on the mirrors? Were the mirrors adjusted to decrease blind spots?
  Proper seating position and mirror settings are needed for safe maneuvering.

• Could the driver reach and satisfactorily operate the gas pedal, brake pedal, clutch pedal, steering wheel and directional signals? Did he or she select the proper transmission gear?
  Reaching and satisfactorily operating the vehicle's controls are prerequisites for safe driving.⁸

During the drive, the observer will watch the driver for the following signs of good driving:

• Stops fully at all traffic signals or stop signs and looks both ways to check for cross-traffic
  Bringing the vehicle to a standstill for stop signs and red lights is automatic behavior for all drivers and especially those who have been driving most of their lives. When this behavior is absent or intermittent, the driver's unsafe habits pose a high risk of injury to the driver and others sharing the highway.

• Easily merges onto highways, or turns onto busy streets

• Yields right of way
  Yielding the right of way, especially when merging, requires a driver to interact with changing traffic patterns rather than giving an automatic response. Repeated failure to yield right of way signals unsafe driving.

• Reacts appropriately (not too slowly or too suddenly, cutting off traffic) to sirens and flashing lights of emergency vehicles
• Avoids weaving, straddling lanes, drifting into other lanes or changing lanes without signaling
• Does not get lost or disoriented easily in familiar places
• Obeys traffic signs (no left turn, no turn on red)
• Drives fast enough not to impede the safe flow of traffic but not so aggressively that others are endangered
• Pays attention to other vehicles, bicycles, pedestrians and road hazards
• Drives decisively - avoids canceling directional signals, for example

Beginning the Discussion

Encourage the family to talk about the drive(s) and the observations made. Emphasize that the discussion should provide helpful feedback for the driver, not punishment. Counsel that productive conversations result when family and partners:

• Make the goal of the conversation preserving independence (not necessarily by driving)
• Ask the older driver how he or she felt about the drive
• Take responsibility for concern by sharing how they feel, not how they want the driver to respond
• Use words such as safe "conditions," not "restrictions"
• Listen with respect and sensitivity to feelings a person may have about the situation
• Open up options such as an outside assessment or taking a driver refresher course
• Prepare for negative reactions such as anger

If the family or partner can't arrange to ride with the older driver, the above suggestions can still act as an opener for discussion about driving. Emphasize giving the older driver room to talk about perceived driving performance and feelings about driving.

Here are a few ways not to approach the subject:

• Make the goal of the conversation to "get him/her off the road"
• Make accusations of unsafe driving
• Have a big family discussion so the driver feels "ambushed"

In order for the observer to see the older driver at his or her best, encourage the rider to make this a comfortable drive with little stress. The rider should just observe and not comment while in the car.

If the driver did well, it is good news for both the older driver and concerned loved ones. But if the driver had some problems and knows it did not go well, he or she may not want to hear about it at that moment. Here are some tips on providing feedback:

• Reinforce examples of competent driving as well as areas of concern
• Base the timing of the discussion on knowledge of the older person's responses and receptivity to this sensitive issue. For some, there is no good time to talk, while for others the discussion is a welcome chance to express concerns about driving in today's busy world. Ask the driver when the best time to talk about the ride would be - right after the drive or later in the day
• Come to the discussion prepared with driving options and a knowledge of resources to improve driving or to provide alternatives

Coping with Reactions

Reactions to the discussion can vary from acceptance to denial. Families may express to service providers concern over the older driver's reactions to driving discussions.

In surveys conducted by the New York State Department on Aging, families, friends and caregivers reported the following range of responses from older drivers:

Allow family members and partners to identify their emotions and those of the older driver. Explain that reactions can be expected and may be unpleasant. Listen and provide support without taking sides. You may want to respond with phrases such as:

• "I understand that this reaction is upsetting"
• "You obviously care a great deal about your (partner, father, etc) and want to keep him safe."

You can help families and partners by sharing the following tips on coping with reactions.

What do I say if the driver is hostile or angry?

If the result of the discussion is recognition of diminished capacity for driving or retirement from the wheel, family members and partners should be encouraged to check in frequently and provide ongoing support for the elder. Developing a plan to meet the mobility needs of the older person assists in keeping older adults connected to the community.

After the Discussion

Leaving the wheel is often a watershed event for an aging driver. It represents the end of a unique form of individual freedom that the driver may have known and counted upon for most of his or her life. Suddenly, that freedom and all it conveys disappears forever. This passage can bring forth the strong emotions of any major loss. Driving cessation is one of the greatest predictors of depression.⁹

Families and partners can help with the loss of driving by:

• Encouraging involvement with friends and continuation of usual activities outside the home
• Listen and acknowledge the feelings of loss
• Help with transportation needs
• Arranging for a DMV nondriver identification card. Replacing a surrendered license with a DMV nondriver photo ID card does more than just continue the driver's primary form of identification - the card can create a feeling of connection to society
• Making plans for visitors either through family, friends or a friendly-visiting program

Keep in mind that, especially in cultures where older family members are revered, families may shy away from questioning the driving ability of the head of the family or elder. The spouse may introduce the discussion, but, depending on gender and status of the older motorist, the spouse may abandon the attempt after the motorist's first "No."

⁵ Stressel, D.L. (2000) "Driving Issues of the Older Adult." OT Practice: AOTA Continuing Education Article 1-9.

⁶ Sterns, H.L., Sterns, R., Aizenberg, R. and Anapole, J. (2001) Family and Friends Concerned About an Older Driver. National Highway and Safety Administration Research Report No. DOT HS 809 307. Washington, DC: U.S. Department of Transportation. Also available on the World Wide Web: www.nhtsa.dot.gov/people/injury/olddrive/FamilynFriends/faf_index.htm.

⁷ LePore, P.R. (2000) When You Are Concerned - A Handbook for Families, Friends and Caregivers Worried About the Safety of an Aging Driver. Albany, NY: New York State Office on Aging.

⁸ Ibid.

⁹ Marottoli, R.A., Mendes de Leon, C.F., Glass, T.A., Williams, C.S., Cooney, L.M., Jr., Berkman, L.F., and Tinetti, M.E. (1997) "Driving Cessation and Increased Depressive Symptoms: Prospective Evidence from the New Haven Established Populations for Epidemiologic Studies of the Elderly." Journal of the American Geriatric Society 45(2):202-06.