Service Providers for Older Adults (cont'd)

Working with Older Drivers

Staff members of community-based organizations can work with both families and older drivers to help older motorists stay behind the wheel. By offering programs based on driving longevity rather than driving cessation, the agency develops trusting relationships with all parties. Community-based agencies can encourage and assist the older person to continue driving safely by:

• Developing opportunities to assess the driving environment
• Creating or providing referrals to driving programs that assess capability and provide on- and off-road training programs
• Providing assessments for driving function
• Distributing information on safe driving and self-assessment
• Creating supportive options for older drivers who must reduce driving or retire from the wheel
• Collaborating with transportation and service providers to ensure that transportation options are available for drivers who reduce or stop driving

Developing Opportunities to Assess the Driving Environment

Fitting the Car to the Driver

Reducing or retiring from driving does not automatically mean giving up the car. The car may have great meaning to the older adult. Suggest that the car be used by others to transport the older person to the doctor or the store. Being able to offer the use of the car can help retain the sense of independence.

Anecdotal evidence suggests that a surprisingly large number of older drivers do not know how to adjust steering wheels, car seats or safety belts to meet their needs. To improve driving safety and comfort, with the help of trained professionals older drivers can add devices (such as special equipment for steering and foot-pedal operation) to their cars. Having a car with an automatic transmission, power steering and power brakes can transform an uncomfortable vehicle into a more accommodating environment.

Ask families or partners to consider supporting the older driver by ensuring that he or she drives under the best possible circumstances. Have loved ones investigate adaptive equipment. These can include:

• Safety-belt adapters to make belts easy to reach, improve fit, and make release buttons easier to operate with arthritic hands
• Special torso restraints to hold the driver upright
• Pedal extenders to better reach the brake and accelerator while keeping the seat back at a safe distance (11 inches) from the airbag in the steering wheel
• Full-view inside mirrors and side "spot" mirrors to minimize blind spots
• Steering-wheel spinners, turning devices, and reduced-effort power steering (helpful for drivers who have use of one arm only)
• Directional-signal crossovers to shift operation of directionals to the other side or to the foot (to use the driver's stronger arm or leg)
• Extra-loud turn-signal "clickers" or relocated/brighter turn-signal indicators
• Left-foot accelerator for those with limited or no use of the right foot
• Touch pads or voice-scan activation systems for car controls and electronic joystick controls for steering, gas pedal and brake
• Scooter- and wheelchair-loading devices and transfer assists to help the person in and out of the vehicle
• Keyless ignition and doors that automatically lock and open

Caution that one does not simply buy and install the equipment. A professional assessment by an occupational therapist or a certified driving rehabilitation specialist determines that the equipment is necessary, in order to save money and ensure safety. Proper installation by trained staff ensures proper fit and safety. And finally, training by an occupational therapist or certified driving-rehabilitation specialist on the use of the new equipment increases the likelihood of safe vehicle operation.

For more information on adaptive equipment, turn to ABLEDATA on the Web at www.abledata.com. A federally funded project sponsored by the National Institute on Disability and Rehabilitation Research (NIDRR), which is part of the Office of Special Education and Rehabilitative Services (OSERS) of the U.S. Department of Education, the ABLEDATA database contains information on more than 30,000 assistive technology products.

Community agency staff can invite occupational therapists, certified driving-rehabilitation specialists and professionals from rehabilitation facilities to assist with community education on proper car adjustments and adaptive equipment. As with any new activity, just providing the tools does not guarantee proper use or comfort. Training followed by practice leads to success. Community agencies can support such training programs.

Older adults living on low incomes may not have extra money to buy and install adaptive equipment. Community-service providers could develop a referral list of low-cost programs, or initiate a campaign to develop resources for low-income elders to receive equipment. Consider making the information available in languages spoken in the local community.

Creating or Providing Referrals to Driving Fitness Programs

Refreshing the Driver on the Rules of the Road

The majority of mature drivers today never attended a formal driver-education class. They passed the tests by reading the DMV's booklet and practicing with a family member in a parking lot or field. Automobiles, roads and driving have changed over the past 40 years, and drivers have had few opportunities to refresh their knowledge aside from on-the-job training.

To help older drivers review safe driving practices, community agencies can sponsor a course called the AARP Driver Safety Program (formerly called 55 Alive Mature Driving Program) at local public facilities. The AARP classroom program introduces the latest information about traffic laws, road signs and safe driving practices. Unlike most of the other approved accident-prevention courses, this eight-hour, two-session classroom program tailors the topics and presentation to seasoned drivers. Most states offer point and insurance-premium reductions to those completing the program.

Referrals to the AARP course and others sponsored by AAA (formerly known as the American Automobile Association) and the National Safety Council allow older drivers to stay current on today's driving practices and laws.

Encouraging Both Physical and Mental Fitness

Driving a car requires strength to depress the brake and gas pedals, turn the steering wheel, shift gears, and even to enter and exit the vehicle. Flexibility is essential in looking over one's shoulder to change lanes or looking left or right to check for traffic. Reaching for a safety belt requires a certain range of motion in the shoulders. The driver must also have the endurance to physically perform and remain alert. Any driver education program for older adults should include information on the physical and mental requirements of driving and referrals to local physical activity programs.

Example - Driving Physical Fitness

Good nutrition and adequate water intake affect mind and body health needed for safe driving. Just consider water - every body system depends on water.

Lack of water can lead to dehydration. Even mild dehydration of as little as 1 percent to 2 percent loss of body weight can impair concentration and cause fatigue and headaches.

Poor nutrition can affect proper blood circulation important for supplying cells with the "building materials" they require for proper function. The decreased flow of blood in the brain results in slow starvation of brain cells and, in the extreme, blockage that causes stroke. Additionally, good nutrition provides the fuel to repair damage caused by stress-induced hormones.

Maintaining mental agility as one ages is as important as maintaining physical dexterity. Intellectual stimulation promotes brain growth in animals and protects against cognitive decline in humans. Animal studies show brains can shrink if deprived of thought-provoking toys and enriched environments. These results lead researchers to infer that, in humans, age-associated memory loss could be partly attributed to lack of mental stimulation.

Some medications can affect alertness and vision. The more medications that are consumed, the greater the risk for side effects and interactions that affect the ability to focus on driving. Older adults as a group are more susceptible to adverse reactions to medications because of the number they take each day - more than any other age group - and because of physiological changes due to aging. Therefore, optimal management of medications becomes even more crucial for older drivers. Ideally, older adults should have medications reviewed annually by a healthcare provider. Community organizations can sponsor lectures and individual counseling on medication use and its effect on driving.

Example - Medications Management

Community agency professionals can develop physical-activity programs - such as walking groups, stretching and resistance-training classes - to encourage strength, endurance and flexibility. Communities can sponsor worthwhile prevention programs, enhanced by information and counseling by professionals on medication use.

Providing Assessments for Driving Function

Taking a driving "test" can stir anxiety in the bravest driver. Therefore, a driving assessment conducted by staff from a trusted organization can make the process more acceptable. Driving assessments are helpful to people who:

1. Want to confirm their level of driving fitness
2. Are able to drive safely but lack confidence
3. Seek a plan for the future when driving may no longer be possible
4. Could potentially endanger themselves and others

Example - Driving Assessments

Although lengthy (over 750 questions with helpful feedback comments), the Driving Decisions Workbook from the University of Michigan Transportation Research Institute is a useful tool for discussion purposes in a training group or for individuals to evaluate their own driving.¹¹

Ideally, driving assessment should be offered in languages spoken in the community.

Distributing Information on Safe Driving and Self-Assessment

Promoting Safe Habits and Preparation for the Trip

Community agency staff can promote safe habits and preparation for road trips or jaunts to the grocery store. Driving requires dividing one's attention among multiple activities and being able to react quickly. The following table outlines some of the driving challenges that may come up for the older driver and the solutions that contribute to a safe journey.

Driving Challenges	Solutions
Overwhelmed by proliferation of signs, road markings, pedestrians and vehicles	Plan the trip route. Drive in familiar areas.
Lacking confidence in handling the demands of high speeds and heavy traffic	Drive during the day. Avoid rush hours. Find alternative routes with less traffic.
Challenged by judging gaps in traffic, making it more difficult: To turn left at intersections or To merge with traffic when turning right	Drive during the day. Avoid rush hours. Find alternative routes with less traffic Remind yourself to look both ways when approaching an intersection Find routes where left turns have green-arrow signals. Avoid left turns by taking routes that require right turns Avoid highways, where speed makes distance judgment more difficult
Concerned about seeing and reacting too slowly to cars coming out of driveways and side streets or cars ahead slowing down	Scan far down the road continuously to anticipate future problems and plan actions Ride with a passenger who acts as a "second pair of eyes" To keep a safe distance behind another car, find a marker (tree, sign, lamppost) and, as the car in front passes it, count: 1001, 1002, 1003, 1004. Leave enough space to reach the same marker at the count of 1004
Troubled about seeing traffic and street signs	Always wear glasses with current prescription. Avoid eyewear with side pieces that block your vision Visit an eye doctor every year to check for cataracts, glaucoma, macular degeneration and diabetic retinopathy Avoid sunglasses or tinted lenses at night Avoid car windows that are darkened or tinted
Challenged to see lane lines and other pavement markings, curbs, medians and other vehicles, especially at dawn, dusk or at night	Always wear glasses with current prescription Visit an eye doctor every year to check for cataracts, glaucoma, macular degeneration and diabetic retinopathy Avoid sunglasses or tinted lenses at night Avoid car windows that are darkened or tinted Keep windshield, mirrors and headlights clean During car inspections, check for correct headlight aim Turn the brightness up on the instrument panel
Uncomfortable at night from glare of oncoming headlights	Sit high enough in the seat to see the road for at least 10 feet in front of the car Look to the lower right side of the road when there is oncoming traffic When choosing a car, look for rearview mirrors that automatically filter out glare

Adapted from NHTSA, Driving Safely While Aging Gracefully.

Using Safety Belts at All Times

Safety-belt campaigns over the past 20 years have ingrained in most Americans the importance of buckling up. However, the functional limitations an aging person experiences creates barriers to complying with the safety-belt message. In particular:

• Restricted flexibility may lessen the driver's ability to reach over the shoulder to grab the belt
• Reduced strength may inhibit ability to pull a safety belt over the chest to the latch on the seat
• Loss of dexterity due to arthritis may present difficulty in securing the belt buckle into the seat latch
• Compromised bone density can result in broken bones if the safety belt binds the chest during the sudden force of a crash

Community agencies can encourage use of safety belts through adaptive equipment. For example:

• Safety-belt adapters make belts easier to reach
• Improving the belt's fit and access makes release buttons easier to operate with arthritic hands
• Special torso restraints can hold the driver upright
• New styles of safety belts feed out more gradually and work with airbags to reduce bone injuries during crashes

Promoting these devices will assist in making safety-belt use a habit.

Creating Supportive Options for Older Drivers Who Must Reduce Driving or Retire from the Wheel

Just as people close to the older driver can assist in the emotional transition to alternative mobility, community-based organizations can take a prime role in developing supportive programs. These include:

• Helping to arrange transportation so the retiring driver can maintain involvement with friends and activities
• Arranging for a DMV nondriver identification card, or replacing a surrendered license with a DMV nondriver photo ID card
• Providing counseling. Lots of older persons stop driving voluntarily. Some assist in counseling others who have just given up the wheel
• Arranging for visitors either through family, friends or friendly-visiting programs (a community-organized service matching volunteer visitors to isolated older adults).

Example 1 - Helping with Loss

Example 2 - Helping with Loss

Collaborating with Key Transportation and Service Coalitions for Positive Change

Even with exceptional programs, educational campaigns and outreach, one organization cannot create the conditions for change in driving behavior. Older adults who need to change their driving habits must:

1. Believe in the importance of change. They must feel:

   • There is a reason to change - to prevent harm to either self or others
   • There is a high personal risk
   • The benefits of the change are worthwhile
   • The pros outweigh the cons

2. Have confidence in their personal ability to make change and cope with the difficult aspects.

3. Be ready for change. They must:

   • Feel prepared to make the change
   • Decide when to make the change
   • Give it a priority

Belief in the Change

Collaborations among community organizations can influence older drivers by presenting a convincing public campaign based on function and ability, not age. Community organizations, such as healthcare providers, that directly influence the behavior of older adults can reinforce community messages about safe driving.

Confidence in the Ability to Change

Older-driver transportation expert Helen Kerschner from the Beverly Foundation believes that communities must work together to develop benefits for reducing or ceasing driving by providing alternatives that are:

• Available
• Acceptable
• Accessible
• Affordable
• Adaptable¹²

The desirability of personal cars presents a challenge to the consideration of attractive alternatives. Our cars wait in the garage for us night and day; they are our most available source of transportation. Even older adults with physical limitations (e.g., difficulty climbing steps or walking to the bus stop) that restrict their ability to use public transportation find cars more accessible.

To convince the older driver that he or she can maintain independence after reducing driving or retiring completely requires a collaboration of many professionals to create viable alternatives. See section on Transportation and Safety Organizations.

Readiness for Change

For older drivers to make the right decision for their futures at the right time, a community of service providers, family member or partner, law-enforcement officers and healthcare professionals can help them plan for changes, look at options and reinforce the importance of their decisions.

The probability that communities can become responsive to older members in their preparation for change increases when concerned organizations address the issue together. Who should meet? Transportation planners, highway engineers and car manufacturers can collaborate with government planners, private transportation research firms and transportation providers to help establish more responsive and creative mobility options while strengthening their advocacy of a system that works for everyone.

Example - Collaborations

¹¹ Eby, D.W., Molnar, L.J., and Shope, J.T. (2000) Driving Decisions Workbook. Ann Arbor, MI: University of Michigan Transportation Research Institute. Available on the World Wide Web: www.umtri.umich.edu/library/pdf/2000-14.pdf.

¹² Kerschner, H. (2003) "Supplemental Transportation Programs for Seniors (STPs)." STPs Mobilizer Project: White Paper Series. Retrieved from AAA Foundation for Traffic Safety on the World Wide Web: www.seniordrivers.org/STPs/whitepaper1.cfm.