By Ruheena Sangrar & Brenda Vrkljan
Losing the ability to drive can be a disheartening experience for adults aged 65 and older in North America. Driving has been identified as critical to maintaining independence and social engagement for older adults (1). Loss of licensure at this life stage is a major risk factor for health-related problems including depression (2) and social isolation (3). Such negative outcomes can trigger premature relocation from independent living to long-term care (2). In fact, two-thirds of older adults in Ontario indicate they would have difficulty accessing community services if unable to drive (4).
In 2010, an editorial in the Canadian Medical Association Journal (5) outlined a call for action on the issue of driving and community mobility in older adulthood. In their editorial, MacDonald and Hébert emphasized the need for proactive strategies aimed at driving and driving retirement to support seniors in their communities (5). Unfortunately, current approaches that address driving in older adults continue to reflect the medical model where fitness-to-drive discussions are often raised following medical diagnoses or adverse medical events. Within the medical model, clinical responsibilities can prioritize the identification of medically at-risk drivers rather than promoting strategies to maintain driving skills or to consider alternative transportation options. Almost seven years later, the recommendations first made by MacDonald and Hébert remain highly relevant and have become increasingly urgent given those aged 65 years and older are the fastest growing age group in Ontario (4). Hence, social and health care systems should consider replacing a medicalized approach to driving with a health promotion approach that supports aging-in-place.
Rehabilitation professionals are optimally positioned to address community mobility in older adulthood, which refers to the ability of this population to access viable transportation options that enable access to their communities (6). Our professions must consider how these topics are addressed across primary care, hospital, and public health settings. The Canadian Association of Occupational Therapists’ National Blueprint for Injury Prevention in Older Drivers (7) advocates for promoting safe driving practices alongside alternative community mobility options for the aging population. A recent follow-up publication, the National Blueprint for Injury Prevention in Drivers with Arthritis (8), also emphasizes a similar need for those affected by arthritis. Unlike the current medicalized approach, both driving and community mobility should be addressed proactively where possible.
The objective of this commentary is to prompt a reconsideration of driving and community mobility by rehabilitation professionals across clinical and research settings. A secondary objective is to raise awareness and change public discourse by identifying innovative ways to address driving-related issues. A clinical vignette is provided that sets the stage for this discussion. Within this case, three critical points are highlighted that signify key opportunities that aim to reduce the negative outcomes often associated with loss of licensure.
Opportunity 1: Improving understanding of the medical reporting process and fitness-to-drive
Rachel is a 76-year-old woman admitted to hospital following an episode of delirium due to a urinary tract infection. Rachel has a medical history of depression, Type 2 diabetes, osteoarthritis, and rheumatoid arthritis. Previously able to bathe, dress, eat, and go to the bathroom independently, Rachel now fatigues after each of these activities. Both her physiotherapist (PT) and occupational therapist (OT) assess Rachel once her delirium clears. The OT identifies that Rachel’s performance on cognitive assessments is consistent with “mild cognitive impairment.” Given the healthcare team’s concerns about her cognitive and physical status, her physician submits a medical condition report to the Ontario Ministry of Transportation (MTO). At discharge, Rachel is informed by the physician that her medical status has been reported to the MTO and that she should not be driving. Rachel becomes visibly upset and asks the doctor when she will be able to drive again.
Legislation and corresponding provincial policies in Canadian jurisdictions explicate that physicians are not responsible for determining licensure status. The medical review section of the transportation authority in question makes such a determination. Like many provinces and states in North America, legally-qualified medical practitioners in the province of Ontario are currently mandated to report health-related information regarding an individual who “…is suffering from a condition that may make it dangerous for such person to operate a motor vehicle” (9). However, limited public understanding of the medical practitioner’s reporting obligations can strain the patient-provider relationship. Understanding and enactment of their legal and professional responsibilities to address medical fitness-to-drive has been identified as a major challenge for healthcare practitioners involved in screening medically at-risk drivers.
A national survey of OTs in Canada found that only 19.1 per cent (n=131) of respondents reported feeling competent when it came to their understanding of relevant transportation policies (10). An additional 60.2 per cent (n=133) identified limited competence with addressing legal and liability issues associated with screening and assessing older drivers (10). All clinicians, including OTs and PTs, can play a role with informing individuals about the potential impact of their health condition on driving, as well as provide education on reporting processes.
Opportunity 2: Recommending driver refresher programs and supporting lifelong mobility
The OT informs Rachel that she will receive a letter in the mail from the Ministry of Transportation. The letter will outline the status of her license and the process of reinstatement if her license has been revoked. Driving allows Rachel to participate in aqua-fitness classes at the local seniors’ centre three times a week. She also drives to the farmers market to buy groceries and attends appointments with her rheumatologist in a larger town. Rachel has stopped driving at night, as glare from oncoming cars makes her uncomfortable. So, she has given up playing bridge at her friend’s home two evenings a week.
Many older adults report that they limit themselves to familiar roads and avoid driving at night, during bad weather, and outside of rush hour (11). Such strategies may occur alongside changes in driving confidence, impacting community mobility. Of significance, recent evidence does not demonstrate association between driving confidence and actual on-road driving performance (12). Given older adults are among the safest drivers on the road (4), improving their behind-the-wheel confidence is an important outcome to maintain their engagement in community activities.
Community-based health settings, such as Ontario’s Seniors Active Living Centres, are ideal environments where issues specific to driving and community mobility can be raised. In these environments, rehabilitation professionals can discuss maintaining driving skills as well as raise the topic of driving retirement. Clinically available programs aimed at refreshing driving behaviours range from educational approaches (e.g., pamphlets or information sessions) to task-specific training (e.g., physical exercise routines or simulated driving) (13,14). Programs can also include individualized on-road training (e.g., receiving feedback from driving instructors) (13,14). Ensuring the perspectives of older drivers and service providers are included in the co-development and design of such programs is key to ensure that they (a) are acceptable to older adults, and (b) promote collaboration across both health and transportation sectors.
Opportunity 3: Improving understanding of the use of in-vehicle technologies
The MTO informs Rachel that she needs to undergo a comprehensive driving evaluation by an Occupational Therapist at an MTO-approved Functional Assessment Centre (15). She passes the evaluation and her license is reinstated, but Rachel does not feel as confident behind-the-wheel as she did previously. Rachel participates in a healthy aging program provided by her family health team (FHT). The session on aging and driving prompts Rachel to discuss her concerns about driving with the OT who is part of the FHT. Her OT recommends taking a tune-up lesson with a driving instructor. After a few sessions, Rachel feels more confident behind-the-wheel. Rachel and the OT also identify alternative transportation options she can try using.
Rachel drives a 2016 mid-sized sedan, a recent gift from her son. She tells the OT that she has yet to fully understand how to operate the backup camera, navigation system, and other features of her car.
The OT helps Rachel find instructional videos developed for the devices that are in her car. In collaboration with a local driving instructor, the OT ensures Rachel learns to use the technologies safely. She also refers Rachel to CarFit: a proactive program that aims to optimize the fit between the vehicle and its driver (16).
Advancements in vehicle technology will inevitably change the task of driving and community mobility for all drivers, including older adults. The United States’ Society of Automotive Engineers has categorized advanced driver assistance systems (ADAS) into six levels (17). These levels range from no automation (Level 0), where the driver maintains full operation of the vehicle, to full automation (Level 5), where the technology is fully responsible for the driving task. While ADAS have the potential to enhance road safety for older drivers, it is imperative to understand their impact on driving. Reimer (18) emphasized that preparation of drivers for highly automated driving should entail processes that are “educational, [for] building trust and proficiency in today’s ADAS.”
Until all vehicles on the road are fully automated and associated environmental infrastructures are in place that supports this technology, drivers will remain responsible for vehicle operation. For older drivers, proactive approaches should aim to maintain their behind-the-wheel skills, as well as educate them on operating new technologies safely. Research in this area should consider the implications of ADAS on the driving behaviour of older drivers. Recent findings from a series of studies specific to the use of back-up cameras with older drivers illustrated differences in both perceptions and performance (19). A process emerged by which older drivers integrate the use of back-up cameras into their established driving habits (20).
Using a proactive approach, the rehabilitation professionals involved with Rachel’s care could have informed Rachel about the MTO medical review process, driver refresher and retirement programs, and provided instruction on using ADAS in her vehicle. Such initiatives may have allowed Rachel to extend her safe driving years. If such an approach had been undertaken, Rachel may have higher chances of staying in her home, as she would have been ready for life after driving.
Both clinical practice and research aimed at older drivers need to move beyond the medicalization of driving. Rehabilitation professionals must be prepared to discuss driving and community mobility. Using a health promotion lens combined with our understanding of the impact of age- and health-related changes on function and occupational performance, researchers and frontline clinicians in the rehabilitation sciences are optimally positioned to lead the development and discussion of innovative and evidence-based approaches that support the mobility of Canada’s aging population.
- Turcotte M. Profile of seniors’ transportation habits. Canadian Social Trends. Component of Statistics Canada Catalogue no. 11-008-X. 2012; 93:1-16.
- Chihuri S, Mielenz TJ, DiMaggio CJ, Betz ME, DiGuiseppi C, Jones VC, Li G. Driving cessation and health outcomes in older adults. Journal of the American Geriatrics Society. 2016; 1-10.
- National Seniors’ Council. Report on the social isolation of seniors [Internet]. Canada: Government of Canada; 2014 Oct [cited 2017 Dec 15]. Available from https://www.canada.ca/content/dam/nsc-cna/documents/pdf/policy-and-program-development/publications-reports/2014/Report_on_the_Social_Isolation_of_Seniors.pdf
- Government of Ontario. Aging with confidence: Ontario’s action plan for seniors [Internet]. Ontario, CA: Government of Ontario; 2017 Nov [cited 2017 Dec15]. Available from: https://files.ontario.ca/ontarios_seniors_strategy_2017.pdf
- MacDonald N, Hébert PC. Driving retirement program for seniors: long overdue [editorial]. Canadian Medical Association Journal. 2010; 182 (7):645.
- American Occupational Therapy Association. Occupational therapy practice framework: Domain and process (2nd ed). American Journal of Occupational Therapy. 2008; 62: 625-683.
- Canadian Association of Occupational Therapists. National blueprint for injury prevention in older drivers [Internet]. Ottawa, ON: CAOT Publications ACE. 2009 [cited 2017 Dec 15]. Available from: https://www.caot.ca/document/5639/National%20Blueprint%20for%20Injury%20Prevention%20in%20Older%20Drivers.pdf
- Canadian Association of Occupational Therapists. National blueprint for injury prevention in drivers with arthritis [Internet]. Ottawa, ON: CAOT Publications ACE. 2017 [cited 2017 Dec 15]. Available from: https://caot.in1touch.org/document/5643/Driving_Eng_FINAL.pdf
- Government of Ontario. Highway Traffic Act (R.S.O. 1980, c. 198, s. 203). Ontario: Government of Ontario; 2009 [updated 2016 Mar 14; cited 2017 Dec 15]. Available from http://www.mto.gov.on.ca/english/dandv/driver/medical-review/physicians.shtml
- Korner-Bitensky N, Menon A, von Zweck C, Van Benthem K. Occupational therapists’ capacity-building needs related to older driver screening, assessment, and intervention: A Canadawide Survey. American Journal of Occupational Therapy. 2010; 64: 316-324.
- Simões A, Pereira M. Older drivers and new in-vehicle technologies: adaptation and long-term effects. In Kurosu M, editor. Human Centered Design, HCII. Berlin, Germany: Springer-Verlag GmBH; 2009 [cited 2017 Dec 15]. p. 552-561. Available from https://pdfs.semanticscholar.org/4410/e240f7dcb6e24fcf9de49f0facf5ce84c110.pdf
- Riendeau JA, Maxwell H, Patterson L, Weaver B, Bédard M. Self-rated confidence and on-road driving performance among older adults. Canadian Journal of Occupational Therapy. 2016; 83(3): 177-183.
- Korner-Bitensky, N., Kua, A., von Zweck, C., & Van Bentham, K. Older driver retraining: An updated systematic review of evidence of effectiveness. Journal of Safety Research. 2009; 40: 105-111.
- Kua, A., Korner-Bitensky, N., Desrosiers, J., Man-Son-Hing, M, & Marshall, S. Older driver retraining: A systematic review of evidence and effectiveness. Journal of Safety Research. 2007; 38: 81-90.
- Ontario Ministry of Transportation. Approved functional assessment centres for drivers [Internet]. Ontario, CA: Queen’s Printer for Ontario; 2009 [updated 2017 Sep 08; cited 2017 Dec 18]. Available from: http://www.mto.gov.on.ca/english/safety/functional-assessment-centres.shtml
- Canadian Association of Occupational Therapists. CarFit: Helping mature drivers find their safest fit. Available from: https://www.caasco.com/~/media/community/images/2015/carfit/CarFit.pdf
- Society of Automotive Engineers. Automated driving: Levels of driving automation are defined in new SAE international standard J3016 [Internet]. [Place unknown]: 2014 Jan 16 [updated 2016 Sep 30; cited 2017 Dec 15]. Available from: http://standards.sae.org/j3016_201609/
- Reimer B. Driver assistance systems and the transition to automated vehicles: A path to increase older adult safety and mobility? Public Policy & Aging Report. 2014; 24: 27-31.
- Mueller A, Sangrar R, Vrkljan B. Rearview camera system use among older drivers: A naturalistic observation study. Transportation Research Part F: Traffic Psychology and Behaviour. 2017 [In Press].
- Sangrar R, Mueller A, Van Miltenburg B, Gish J, Vrkljan B. Exploring older drivers’ understanding of in-vehicle technologies: Impact for clinicians. Proceedings of the Canadian Association of Occupational Therapists’ Annual Conference; 2017 Jun 21-24; Charlottetown, CA: CAOT Publications ACE. 2017 Jun. p. 49.