Driver Rehabilitation: A Growing Niche
Occupational therapy practitioners can help older drivers stay safely on the road for as long as possible—and create alternatives to maintain mobility when necessary.
As the baby boomer generation ages, the United States faces a safety and social dilemma with a growing older population for whom driving is as natural as breathing or walking. The number of Americans aged 65 years and older will double from 35 million today to 70 million by 2030, when there will be 60 million licensed drivers aged 70 and older.1 In the decade leading up to 2001, the number of older licensed drivers increased 32% to approximately 19.1 million. In contrast, during this period the number of licensed drivers overall only increased by 13%.2 Unlike previous generations, today's older population and the boomers who follow grew and matured during the last century, when driving motor vehicles became an integral aspect of daily American life. For the majority of adults, driving has become an instrumental activity of daily living (IADL), the absence of which can leave one feeling disabled.
With these demographic shifts, millions more older Americans will be driving in the coming decades as they seek to maintain their independence and avoid isolation in far-flung suburban and rural communities dependent on the private motor vehicle.
Older Americans comprise 12% of all crash fatalities but only 9% of the general population. The current rate of traffic fatalities among older drivers, combined with their growing population, means that the number of traffic fatalities among the elderly could double—or even triple—by 2015. These fatalities are mostly the result of physical frailty, making them less able to recover from minor injuries.1
In addition to increased frailty, drivers over 65 years of age experience more intersection collisions than do younger drivers.1 A key contributing factor is their difficulty with dividing their attention among all the concurrent activity in an intersection: oncoming traffic, vehicle and pedestrian traffic to the left and right, traffic signs and signals, along with judging distance and speed. Impeded perception might also contribute to misjudging gaps in oncoming traffic, for example, whereas a decline in motor skills might result in an inadvertent swerve or wide turn.
The decision by family and friends to intervene in an elder's life—whether to convince the elder to "slow down" or to quit driving altogether—can be very painful as the older person contemplates life in America without wheels. Though the vast majority of older drivers self-regulate their driving—by not driving at night and avoiding poor weather or congested roads—some fail to realize that their skills have diminished and that they need to make changes or even stop driving.
Reflecting broad public and clinical opinion, the National Highway Traffic Safety Administration (NHTSA) believes that ability, rather than age, should be the deciding factor in determining whether an elder should continue to drive. The agency promotes both safety and mobility for older Americans, emphasizing that many older drivers can—and do—safely compensate for declining physical and mental abilities in driving. At the same time, NHTSA works with partners to encourage the development of services that can help extend the period of safe driving as well as the development of alternative transportation for those who cannot continue to drive.
During the past 12 years, NHTSA has funded a coordinated research and development program to identify screening tools that help detect drivers at increased risk of crash involvement, medications that may increase a driver's likelihood to be involved in a crash, and programs to evaluate and rehabilitate older drivers. The agency has also partnered with the American Medical Association (AMA), the American Occupational Therapy Association (AOTA), the American Society on Aging, and numerous other professional organizations by offering training and materials to their members who serve an older population.
Many other research and service organizations have also become involved in driving and mobility. Researchers at the University of Florida, for example, have found that occupational therapists are well suited to evaluate and, when possible, provide intervention for older drivers whose performance skills seem to have declined following a traffic crash, hospitalization, or family intervention. "OTs can do anything—they try to make sure that a person is happy and well and can fully function in society, even around a permanent disability," says Essie Wagner, a NHTSA staffer who manages older driver projects.
Further, occupational therapists specializing in driver rehabilitation can serve as a missing link between medicine and social work and can offer services and interventions that other allied health practitioners are not trained to provide.
The OT Role
Older drivers who begin to sustain more health problems are increasingly likely to interact with occupational therapists, whether or not the therapists specialize in driver rehabilitation. And although the lay public remains generally unaware of occupational therapy driver rehabilitation services, the medical community increasingly recognizes this role because occupational therapists specializing in driver rehabilitation can evaluate the entire picture, from physical health to cognition.
Occupational therapists generally provide driving services to older clients at one of three levels. At the first level, therapists in a wide range of clinical settings may evaluate clients and refer them to programs that provide driving assessments or guide access to community resources that offer alternative mobility programs.
At the second level, occupational therapists with some specialized training in driver rehabilitation-perhaps through a continuing education course-might help older drivers, as well as younger clients, to incorporate goals specifically related to driving and community mobility into their rehabilitation program to strengthen subskills in preparation for resuming driving, if at all possible.
All occupational therapists can be of use to the older driver; however, only occupational therapist driver rehabilitation specialists can actually take a client out on the road to evaluate skills and provide training-usually while sitting in the passenger seat of a car equipped with dual break pedals. At this third level, occupational therapists have received specialized training and have often become certified driving rehabilitation specialists (CDRSs) through the Association of Driver Rehabilitation Specialists. Although all declining performance skills and performance factors cannot be overcome, compensations can be made in some areas by using adaptive equipment (e.g., extra mirrors for clients who cannot turn their heads to check their blind spots). Other compensations might include behavior changes such as making left turns only at controlled intersections (i.e., with a dedicated turn lane and left arrow), taking only preplanned routes through simple traffic situations, and restricting driving to daylight hours.
AOTA estimates that there are 300 occupational therapists across the country certified as driver rehabilitation specialists, though this specialty is one of the top 10 emerging practice areas.
Deciding To Stop Driving
When it comes to making decisions about driving, the vast majority of older drivers regulate themselves by scaling back or quitting altogether as driving becomes more challenging. However, some elderly drivers are either unwilling or unable to recognize that they can no longer drive safely.
Even among those who voluntarily cut back on driving, the decision to intervene in the life of an older driver is usually not easy for relatives or friends. The perceived loss of freedom and independence that comes with not driving is simply too powerful. To an elder who has driven in the fast lane for decades, waiting for the bus can seem like a big step down.
Health care professionals such as occupational therapists can help make the transition easier. "Family members may have less leverage-especially if it's adult children," says Vicki Schmall, PhD, a gerontology and training specialist who runs a company called Aging Concerns based in West Linn, Oregon. "Physicians have the most leverage. The real benefit is that they can cite medical evidence" in such a way that the older driver might perceive his or her deficits to be medical in nature, without the emotional baggage of adult children usurping the elder's parenting role.
Schmall agrees that the vast majority of older drivers curtail their driving and later take themselves off the road, but that drivers with certain cognitive deficits might require a more medical-style intervention—conducted by a practitioner with the professional authority to convince even the most recalcitrant older driver to "retire" from driving. "People who are compromised with their memory really don't have the insight to make the correct decision [about driving]," she says. Such older drivers might literally remember only the good times, when they were competent drivers, unable to recall and integrate the recent evidence that their driving abilities have declined. Schmall says that she uses her expertise in family communication and caregiving to work with families to intervene with elders who pose a threat to themselves and others on the road.
Many states require physicians and other medical practitioners to report patients to the Medical Review Board who are not medically qualified to drive. However, many are either too busy or are unwilling to make such reports, leaving the problem to the family. In response, with support from NHTSA, the AMA recently published a physician's guide for counseling older patients. The guide advises physicians to "normalize" the experience by using the term driving retirement rather than quitting or hanging it up. The AMA recommends that physicians also counsel these patients about alternatives to driving such as public transportation and community resources specifically tailored to seniors. Most important, however, is the recommendation that physicians follow up with the patient in 1 month because some clients will disregard such advice, even from a physician.
AOTA has been working with the medical community to recognize that occupational therapists have the skill set to work with physicians to address the needs of older patients who have questionable driving ability. "AOTA believes there is a significant and growing demand for the expertise that the OT brings to driving intervention in the area of older driver rehabilitation," says Elin Schold Davis, MS, OTR/L, CDRS, AOTA's Driving/Driver Rehabilitation Network coordinator. "OTs understand the changes related to aging and the disease process. The problems presented by a person who survives a stroke must be treated much differently from problems caused by dementia. It is imperative that the underlying medical condition is understood to provide the most appropriate and effective rehabilitation, equipment, or training." Moreover, occupational therapists have the psychosocial training to make recommendations more specific to the individual, she says. For example, an occupational therapist might conclude that an older adult lacks the cognitive ability to take public transportation (never mind driving a motor vehicle) and must turn to more specialized community transportation resources—if available—for help.
Keeping Older People "Transportation Independent"
Dennis P. McCarthy, MEd, OTR/L, codirects the National Older Driver Research and Training Center at the University of Florida, which has a research contract with the Federal Highway Administration and the Centers for Disease Control and Prevention (CDC). McCarthy says it is important for occupational therapists to realize that driving is an IADL, as important to independent living in America as preparing meals, managing finances, shopping, and using the telephone. Therefore driving rehabilitation is a natural fit for occupational therapy and falls within the scope of practice regardless of employment setting. "OTs possess the knowledge and skills to recognize when a client may have difficulty performing an IADL, such as driving, and can provide remediation or referrals to others, including occupational therapist driving rehabilitation specialists, when needed," McCarthy emphasized.
The center's primary goal, says McCarthy, is to keep elderly persons "transportation independent" for as long as possible, whether or not they drive. Although occupational therapists trained as driver rehabilitation specialists are skilled at assessing a person's combined physical and cognitive ability to drive, researchers at the center are working to develop more reliable assessment tools and are examining the efficacy of current interventions used by occupational therapists and others. The researchers are focusing on assessment and intervention because the preliminary step—identifying risk factors associated with unsafe driving—is fairly well known to them, McCarthy says.
"Many of the risk factors that are associated with unsafe driving have already been identified, [such as] particular medical conditions, decreased vision, decreased cognition, etc.," McCarthy says, adding that researchers would likely discover, as a matter of coincidence, some new information about risk factors for unsafe driving among older populations.
"Driving is a very complicated task that requires simultaneous coordination of many body systems. Therefore, there are many factors that may impede safe driving ability, [such as] physical, sensory, and/or cognitive deficits," McCarthy reiterated. Driver rehabilitation works to address functional declines among older drivers to at least a proficiency level required of all licensed drivers. "Identification of specific problem areas, say vision for example, provides an opportunity for remediation rather than an excuse for license revocation," McCarthy says. "Referral to an eye specialist for the correct glasses prescription may result in a particular person being able to drive safely for a longer period."
Whether by driver rehabilitation or referral to community resources, NHTSA and its partner organizations are committed to improving the ability of older adults to remain mobile as they age in place in their communities.
Developing the OT Driver Rehabilitation Role
NHTSA and AOTA are using four main strategies to develop the driver rehabilitation specialty, following a strategic plan created during a joint conference on older drivers in late 2002. These are to: (a) develop a marketing campaign to educate occupational therapists about this growing specialty; (b) devise ways to bring together occupational therapists and older drivers; (c) continue to develop educational kits to help state occupational therapy associations educate their members; and (d) work with occupational therapy program directors across the country so that rehabilitation of older drivers becomes a more standard part of the educational curriculum.
The increased role of the occupational therapist in evaluating driver ability has become a key component of the U.S. Department of Transportation's overall goal of "safe mobility for life." Though mobility includes all aspects of transportation, such as walking and taking the bus, experts agree that the privilege of driving can often be safely extended into one's old age. Despite stereotyping, the data show that older drivers are no more likely than younger drivers to cause crashes. In fact, although older drivers have more intersection collisions, they experience fewer crashes per 100,000 licensed drivers than their younger counterparts.1 They also have the lowest rate of drunk driving and the highest rate of safety belt use.1
Whether keeping older drivers safer for longer, or helping them to find alternative transportation, public and private organizations must work together to ensure that the needs of older drivers are met. Without serious intervention in the area of driver rehabilitation and community mobility for seniors, a greater percentage of older Americans will either die in crashes or will give up driving and become increasingly isolated from the communities in which they have worked and lived.
1. U.S. Department of Transportation. (2003). Safe mobility for a maturing society: challenges and opportunities. Washington, DC: Author.
2. National Highway Traffic Safety Association. (2003). Safety facts 2002: Older population. Washington, DC: Author. (DOT HS No. 809611)
This article was written by staff at the National Highway Traffic Safety Administration, which is partnering with AOTA to address older driver safety and community mobility.
For More Information
The Association for Driver Rehabilitation Specialists
711 S. Vienna Street
Ruston, LA 71270
Defining OT Roles in Driving
By E. Schold Davis, 2003. OT Practice, 8(1), 15-18.
Keeping Older Drivers Safe (AOTA Fact Sheet)
Available at http://www.aota.org/
National Highway Traffic Safety Administration (NHTSA)
Numerous materials, booklets, and scientific reports on older drivers http://www.nhtsa.dot.gov/
Older Driver Screening and Evaluation: The Forgotten IADL (AOTA Online Course)
Earn .5 AOTA CEUs or 5 contact hours. For information go to www.aota.org. Click on Continuing Ed, then Online Courses.
Ready To Go? Helping Older Adults Address Community Mobility
By A. Brachtesende, 2003. OT Practice, 8(18), 14-25.
©Copyright 2004. The American Occupational Therapy Association. All rights reserved. This article was originally published in the May 10, 2004 issue of OT Practice.