Week # 6

SPECIAL FEATURES: CLINICAL CONCEPTS

Supporting Safety in the Older Adult Driver: A Public Health Nursing Opportunity Lisa Kirk Wiese, PhD, RN, APHN-BC, CNE,1 and Logan Wolff, MS,2 1C.E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida; and 2College of Psychology, Nova Southeastern University, Fort Lauderdale, Florida

Correspondence to:

Dr. Lisa Kirk Wiese, C.E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33431. E-mail: [email protected]

ABSTRACT The effective operation of a motor vehicle encompasses a wide range of cognitive pro- cesses that can decline due to age-related changes in neuroanatomical structures and cognitive function- ality. The increasing number of older adult drivers in our rapidly aging population heightens the public safety concern of unsafe driving associated with these changes. Nurses caring for older adults in public health settings are well positioned to make a difference in the management of older patients who may be at risk of endangering themselves or others on the roadways. In this article, information is provided for increasing nurses awareness of the cognitive factors inhibiting effective driving, recognizing older adults who may be at risk for unsafe driving, and facilitating a patient/family to seek a driving evaluation.

Key words: age-related changes, driving, older adult.

Almost half of all drivers on the roadways are over age 65 and this number is projected to increase by 77% in the next 30 years (Federal Highway Admin- istration, 2015). Despite the 23% rise in drivers over age 70 (Insurance Institute for Highway Safety [IIHS], 2014), older adult car crash rates have decreased dramatically (47%) since 1975. The 65–74 age group has less fatal crashes than the 35–54 age group.

However, older adults (aged 65+) overall still have the highest crash rate per mile compared to any other age group (IIHS, 2014). Of the estimated 36 million older adults driving, a daily average of 15 are killed and 586 are injured in crashes (National Highway Traffic Safety Administration [NHTSA] Department of Transportation [US], 2014). Drivers over age 65 are predicted to be responsible for 25% of total driver fatalities in 2030 compared to 15% currently (IIHS, 2014). Pas- senger vehicle fatal crash involvements per 100 million miles traveled by the age 80+ driver

group exceeds those of 16- to 29-year-old drivers (IIHS, 2014). Older driver fatalities are highest in Florida, California, and Texas (NHTSA, 2014).

Fatal crashes by drivers over age 70 were asso- ciated nearly 100% with a failure to yield safely (Dickerson, 2014). Other frequent errors such as failing to check the blind spot and excessive speed were viewed as “normal bad habit driving behav- iors” in studies targeting older adults (Selander, Lee, Johansson, Falkmer , & H€ogskolan i J€onk€oping, H€alsoh€ogskolan, & HHJ, Aldrande – livsvillkor och h€alsa, 2011). Operating a motor vehicle requires simultaneous and accurate execution of numerous cognitive and physical skills often affected by age- related changes (Iverson et al., 2010).

Age-related changes that contribute to driver frailty are most often the cause of older adult crash fatalities, not crash severity (Cicchino, 2015). Age- related changes include deteriorating vision, decreasing hearing, and diminishing motor reflexes, coordination, and strength. Older adult drivers are

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frequently aware of these physical changes and take precautions (Marshall & Man Son Hing, 2010).

Older adults’ attention to environmental factors also plays a role in driving safety. For example, although 65+ driver fatalities increased during the first snowfall of the season, consequent snow days reflected a decrease (Eisenberg & Warner, 2005). Researchers investigating over 100,000 households across the United States as part of the Center for Disease Control’s (CDC) second Injury Control and Risk Survey (ICARUS-2) study found that older adults are much more likely to cease driving due to bad weather (59.0%), at night (57.0%), on long trips (49.6%), in traffic (49.0%), and on high-speed roads (33.6%).

In contrast, older adults are much less likely to cease driving due to medical conditions (15.4%) (Betz & Lowenstein, 2010; p. 1932). Chronic dis- eases such as stroke, chronic obstructive pulmonary disease, heart arrhythmias, hypertension, arthritis, depression, chronic renal failure, cancer, diabetes, and pain amplify the risk of driving errors (Carr, Schwartzberg, Manning, & Sempek, 2010). Increased susceptibility to central nervous system side effects of medications to treat these illnesses can also hinder safe driving (Carr et al., 2010).

Importantly, it is not a person’s chronological age itself that places the older driver at increased risk for driving accidents, but rather the changes in functionality and skills necessary for safe driving (IIHS, 2014). The National Health and Transporta- tion Safety Association (NHTSA) issued “Driver Fit- ness Medical Guidelines” (Carr et al., 2010) for providers that offers specific protocols for assessing the functional impact of numerous age-related medical conditions ranging from diabetes to dementia. Instructions for persons suspected of being cognitively impaired emphasize the need for functional assessment prior to issuing a driving ces- sation recommendation. It is important for nurses caring for older adults in public health settings to understand which cognitive mechanisms inhibit effective driving and identify older adults who may be at risk for unsafe driving and therefore would benefit from a driving evaluation.

Cognitive Skills Needed in Driving

Driving is arguably one of the most complex proce- dures humans engage in on a routine basis. It

involves multiple mechanisms that are all working together to produce effective driving. Drivers must be able to judge distances, manage multiple stimuli simultaneously, maintain attention for long periods of time, react quickly in an emergency, and cor- rectly interpret traffic signs and signals (Iverson et al., 2010). Driving environments can vary from moment and to moment and the driver must there- fore be able to integrate the continuously changing visual-perceptual stimuli and quick process infor- mation (Gagnon, Hickey, & Marshall, 2012). The cognitive components of executive functioning, visual mechanisms, memory, and insight must be accurately functioning to ensure safe driving.

Executive Function Executive function is a construct that encompasses a wide range of higher order regulatory cognitive processes (Anderson, Jacobs, & Anderson, 2011), and is an area of cognitive function that must per- form optimally for driving competence (Martyr & Clare, 2012) especially during new, challenging, unstructured situations (Demireva, Mcinerney, & Suhr, 2012; Gillen & Rubio, 2011). In a study of 266 drivers aged 70–88, all types of executive func- tion errors such as processing speed and selective attention increased with age (Anstey & Wood, 2011). These researchers suggested that healthy older adults may not have the executive functions necessary to handle complex driving scenarios. Executive functioning skills particularly relative to driving include attention, cognitive flexibility, and hazard perception.

Attention. Attention is an important executive function and cognitive mechanism in driving com- petence. There are three types of attention and each has its own designated purpose (Holly, 2011). Selec- tive attention is the ability to highlight areas of importance and shift focus when necessary. This helps the driver to prioritize important stimuli, such as cars, pedestrians, and traffic signals, while blocking out extraneous variables or distractions. Divided attention is the ability to attend to two or more stimuli simultaneously. This process is acti- vated when changing lanes because the driver is operating the motor vehicle while focusing their attention on driving forward and checking for clear traffic (Holly, 2011). Sustained attention refers to maintaining an alert state for a long period.

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In a sentinel study examining the cognitive variables associated with poor road test perfor- mance in 84 car drivers over age 65, selective attention accounted for approximately a third of poor driving performances (De Raedt & Ponjaert- Kristoffersen, 2000). Later studies demonstrated a correlation between attention deficit and a dimin- ished ability to change lanes and maintain lane position (Munro et al., 2010). These studies high- light that adult drivers often have difficulty paying attention to important stimuli while ignoring irrele- vant stimuli.

Cognitive flexibility. Cognitive flexibility, also known as set-shifting or mental flexibility (Eti- enne, Marin-Lamellet, & Laurent, 2013) is a fluid mechanism that involves the aptitude to switch sets, that is, rapidly program the mind to respond to new input. With driving, this includes the ability to shift from one behavioral strategy to another. Mental flex- ibility contains many complexities, all related to higher level cognitive processes. An investigation of 148 drivers between the ages of 70 and 89 (M = 75) with and without neurodegenerative disease revealed that older adults’ ability to engage in secondary tasks while driving, such as navigating a brief route and identifying signs and landmarks predicted the dri- ver’s on-road safety risk, and this was significantly impacted by set-shifting deficits [F(8,124) = 19.14, p < .001] (Aksan, Anderson, Dawson, Uc, & Rizzo, 2015). Others examined the effectiveness of cognitive and psychomotor tests in 50 persons without cognitive impairment with an average age of 73.1 (�7.0 years) found that declining mental flexibility was a predictor of unsafe driving (Ferreira, Sim~oe, & Marôco, 2012).

Hazard perception. Hazard perception abil- ity has been defined as the ability for individuals to anticipate potentially dangerous situations on the road. Hazard perception ability declines with increasing age (Ferreira, Sim~oes, & Marôco, 2013). This decline in hazard perception ability from age- related deficits is specifically due to cognitive slow- ing, inhibition difficulty, and task-switching deficits (Horswill, Anstey, Hatherly, Wood, & Pachana, 2011). Cognitive slowing can lower reaction time, inhibitory deficits can alter hazard perception per- formance due to the inability to distinguish relevant

from irrelevant cues, and task-switching deficits impair the ability to attend to multiple stimuli.

Visual Mechanisms and Driving

The ability to clearly see and interpret one’s sur- roundings is critical for safe driving. In addition to increased eye disease, vision deterioration from increasing cloudiness and yellowing, alterations in macular pigment and neural integrity, and decreased pupil size are major concerns for aging drivers (Gentzler & Smither, 2012). Aside from hav- ing accurate visual acuity, there are other visual ele- ments that are fundamental in safe motor vehicle operation, such as useful field of view, speed in processing visual information, visual perception, and visuospatial and visuomotor skills.

Useful field of view Useful field of view (UFOV) is a domain that mea- sures motor, visual sensory functioning, and visual attention. UFOV determines whether the driver is able to detect peripheral threats while simultane- ously seeing what is directly in front of them, and has been an important factor in driving safety out- comes (Barrash et al., 2010). UFOV significantly predicted older adults’ driving ability both in the presence and absence of visual or auditory distrac- tions (Wood, Chaparro, Lacherez, & Hickson, 2012). Older adults who demonstrated poor UFOV were significantly more likely to make blind spot errors, which overall compromises safety (Anstey, Horswill, Wood, & Hatherly, 2012). These and other investigations (Anstey, Horswill, Wood, and Hatherly, 2012; Owsley, 2010) have led to the gen- eral acceptance of UFOV tests as a reliable test for assessing visual cognitive skills (Wood, Horswill, Lacherez, & Anstey, 2013).

Visual processing speed The visual information-processing system can be compromised when there are structural and physio- logical changes to the eyes, which occur during aging (Gentzler & Smither, 2012). This system influences higher order processing skills, such as rapid visual processing speed (Gentzler & Smither, 2012). If drivers have slow information-processing speed, they may be unable to react quickly enough to avoid collisions. Testing this mechanism has

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proven to be an effective means of identifying high- risk older drivers (Owsley & McGwin, 2010).

Visual perception Visual perception includes the accurate interpreta- tion of visual information. This cognitive function allows drivers to read traffic signs, become oriented to traffic, and maintains directional stability on the road (Wagnera, M€urib, Nefc, & Mosimannc, 2011). Poor performance on visual perception measures was found to be a significant predictor of driving cessation, moving violation, and motor vehicle col- lision in older adult drivers (Scialfa, Ference, Boone, Tay, & Hudson, 2010).

Visuospatial skills Visuospatial skills increase the driver’s ability to perceive accurate depth perception, lane alignment, and overtaking (Carmody, Traynor, & Iverson, 2012). In a meta-analysis of neuropsychological functioning and driving ability in dementia, visu- ospatial skills were most related to driving abilities across various types of driving tests (Iverson et al., 2010).

Visuomotor skills Visuomotor skills rely on hand-eye coordination, which involves the ability to perceive and then per- form a certain function. Dawson, Uc, Anderson, Johnson, and Rizzo (2010) showed that measures assessing visuospatial and visuomotor skills had the strongest correlations with poor driving perfor- mance for older adults, and that both visuomotor processing and accuracy were important predictors for unsafe driving. This suggests that both the speed and precision of visuomotor abilities con- tribute to the risk for older adult drivers.

Memory and Driving

Memory plays a significant role in driving compe- tence. At a basic level, memory provides drivers with the knowledge of how to operate a motor vehi- cle (Carr, Barco, Wallendorf, Snellgrove, & Ott, 2011). Procedural memory refers to the ability to use a learned skill in an unconscious manner. Turning the key in the ignition, shifting gears, and distinguishing between the brake and gas pedal all involve procedural memory. Individuals need to remember what the destination is and what route

to take to successfully navigate their way to their objective. This involves episodic memory, or the registration, acquisition, and encoding of informa- tion (Wagnera et al., 2011). Along the way to their destination, they also need episodic memory to assist them in recalling recently passed road signs, remember the speed limit, or know if they just passed a school zone (Wagnera et al., 2011). Drivers also need semantic memory to interpret the mean- ing of the recently passed signs and to determine what the colors mean on the traffic lights.

If an individual’s episodic, semantic, or proce- dural memory is impaired, they may also have diffi- culty with keys, brakes, or steering (apraxia), becoming lost while driving (topographic agnosia), and inattentiveness to other cars, pedestrians, or objects in the road (Jett, Tappen, & Rosselli, 2005). Therefore, a decline in memory signals the need for a driving evaluation.

Insight

Researchers have reported that self-rated driving ability fails to predict older drivers’ functional per- formance on measures of cognitive, visual, and physical abilities (Ackerman et al., 2011; Horswill et al., 2011). For example, investigators found that older drivers were confident with their driving abil- ities in a range of potentially hazardous situations, regardless of cognitive ability. Furthermore, drivers who demonstrated greater discrepancies between their perceived abilities and actual abilities were less likely to self-regulate their driving Wong, Smith, and Sullivan (2012). This finding suggests that older adults may lack insight into their driving abilities.

Driving with Dementia

Older adults diagnosed with dementia are more sus- ceptible to impaired driving skills and as the demen- tia severity increases, the individual will eventually be unable to drive safely (Ott & Daiello, 2010). Research indicates that it is common for persons with dementia to drive and that the risk of accident or collision is substantially increased (Barco et al., 2015; Wheatley, Carr, & Marottoli, 2014). Drivers with dementia have at least a two-fold greater risk of crashes compared to nondemented age-matched individuals (Carr & Ott, 2010). Public health nurses

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are increasingly being called to care for the esti- mated 5.1 million persons of age 65 and older who are living with Alzhiemer’s disease (AD), the most common dementia type. This number is projected to increase by 40% to 7.1 million in 2025, and 31.5 million individuals will be affected by 2050 (Alzheimer’s Association, 2015).

Executive functioning and driving in persons with dementia Individuals with AD display regional pathology on brain scans in areas involving executive processing and attention skills, which appear to directly impact driving competence (Ott & Daiello, 2010). Research- ers examining executive functioning found a 62% increase in errors among persons with AD, most notably in the attention skills of driving straight (32%) and in making left-hand turns (21%). Martyr and Clare (2012) conducted a meta-analysis of 49 studies to examine executive functioning and driving in 3,663 individuals with AD. Due to the complex and cognitively-demanding skills needed for driving, they found a moderate estimated effect size between executive functioning and older adult drivers with AD. The researchers also note that executive func- tioning measures may be beneficial as preliminary screening for driving competence in early-stage AD.

Visual skill deterioration in persons with dementia Individuals with AD have pathological changes in visual processing areas, including the lateral occipi- tal and prefrontal regions in the right hemisphere (Ott & Daiello, 2010). This significantly impacts visual processing, and consequently, driving perfor- mance. Older adults with dementia have also demonstrated a decrease in the UFOV skill (George & Crotty, 2010). Individuals with AD had more lane observant errors than controls, and this finding was significantly predicted by poorer UFOV (Dawson et al., 2010). The visuospatial difficulties have been highly correlated with AD individuals, and these can manifest themselves through impaired driving (Caselli & Tariot, 2010).

Memory and driving skills in persons with dementia The core feature of early AD is the deterioration of episodic memory (Dickson et al., 2011), whereas semantic and procedural memory are typically

affected later during the progression of the disease (Wagnera et al., 2011). People with AD therefore can become disoriented in unfamiliar environments and the confusion eventually extends to familiar environments (Dawson et al., 2010). From a func- tional perspective, these drivers may forget where they intended to go, not recognize their own neigh- borhood, and consequently become lost (Hunt, Brown, & Gilman, 2010). If these individuals were to receive directions on how to return home, they might not recall the instructions, thus perpetuating the confusion. Individuals with AD may maintain basic vehicular control skills, but their memory def- icits place them at an increased risk for successfully operating a motor vehicle.

Insight and persons with dementia Nurse researchers interviewed over 200 police offi- cers, counselors, patients with mild cognitive impairment, and their family members throughout the State of Florida. The investigators demonstrated that persons with dementia often have diminished insight about their own capabilities and will con- tinue driving when skills are impaired. Conditions leading to unsafe driving included the presence of a codriver, not just need or desire to drive, and avail- ability of a vehicle (Jett et al., 2005, p. 113). Drivers with dementia and even their caregivers may lack the insight needed to limit and eventually discon- tinue driving. For example, a common phrase often spoken by patients is “I have never had an acci- dent” which is confirmed by their loved one, and thus both are in denial that they could be an unsafe driver.

The Public Health Nurse’s Role in Promoting Safe Driving in Older Adults

For many older adult drivers, independence is equated with the freedom to drive oneself and the fear of losing that independence can be paralyzing (Flanagan, 2011). Public health nurses can support patients in maintaining independence by including the measures listed in Figure 1 during wellness exams to help older drivers stay healthy (National Institute on Aging, 2015).

If there is concern by the family member, loved one, or the patient about declining driving skills, public health nurses can teach family

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caregivers and concerned friends to explore the need. This is done through self-assessment ques- tions (see Figure 2; National Institute on Aging, 2015), and by observing if the driver exhibits the difficulties listed in Figure 3 when driving (National Institute on Aging, 2015). The next step is starting a conversation between family members, providers, and the patient about the need for a formal driving evaluation.

Initiating the conversation about declining driving skills The task of helping older adults who are unaware of decline in cognition impacting road safety to accept a decision that driving cessation is needed

can be overwhelming for family members. Researchers (Byszewski et al., 2013) recently vali- dated strategies suggested by participants in research by Jett et al. (2005) that can minimize distress include (1) refrain from pointing out speci- fic errors when they occur, such as “you just went through that stop sign”, (2) involve the person at risk for driving in the decision, (3) avoid or delay imposing direct action such as removing the car or the keys to prevent the cognitively impaired person to stop driving, (4) acknowledge the losses occurred when one stops driving, (5) arrange alternatives to driving, and (6) speak calmly without frustration or a judgmental attitude. Jett et al. (2005) also found that persons at risk are also more likely to consider

• Maintain annual eye exams and annual wellness visits

• Limit driving to daylight hours

• Refrain from driving during inclement weather

• Participate in regular exercise

• Determine safest routes (intersections with left turn arrows and well-lit streets)

• Establishing a habit of keeping a large distance between yourself and the car in

front of you

• Avoid distractions in the car such as cell phone use and eating

Figure 1 Health Habits to Teach Older Adults for Promoting Safe Driving (National Institute of Aging, 2015)

• Do cars or people appear out of nowhere?

• Do people blow their horn often at me?

• Do I forget where I am or how to get somewhere even in a often-

traveled area?

• Do I have trouble staying in my lane?

• Do I sometimes confuse the gas pedal with the brake pedal?

Figure 2 Questions to Ask in Self-Assessment of Unsafe Driving Risk (National Institute on Aging, 2015)

Wiese and Wolff: Supporting Safety in the Older Adult Driver 465

driving cessation if their potential for causing harm to others rather than to themselves is a focus.

A complete guide “We Need to Talk: Family Conversations with Older Drivers” is available from the Hartford Center for Mature Market Excellence (2012). This guide includes points for “Crafting Caring Conversations”, such as assessing who is the best person to initiate the conversation. Older adults living alone prefer to hear news about driv- ing cessation from their doctor, while about 50% of married adults, and men more than women, prefer to hear it from their spouse.

A calm rather than strong approach using statements that emphasize health and safety first is essential. Examples include “that was a close call today; I worry about your safety on the road”, “driving today is not what it used to be”, “did you hear about that accident in the news today”, and “did you ask your doctor about the effects of your new medication on driving” (Hartford Center for Mature Market Excellence, 2012). The Hartford Center for Mature Market Excellence (2012) guide also includes a list of warning signs for unsafe driv- ing, such as increases in honking by other drivers, signaling errors, hitting curbs, and near misses. Worksheets for identifying alternative modes of transportation and calculating benefit/cost ratios are also provided. For families coping with a diag- nosis of dementia, video vignettes of family mem- bers holding conversations about driving cessation and a list of communication techniques are pro- vided by the Alzheimer’s Association (2015).

The Automobile Association of America (2015) has various resources to guide families in managing

this difficult topic, such as self-rating tools, interactive driving evaluations, and advice in seeking professional clinical evaluations. The Hartford Auto Association (2010) lists reasons to consider driving assessments such as a change in medical conditions or medications or observations of unsafe lane changes.

What Happens During a Driving Assessment

A three-pronged approach to driving assessment is helpful for identifying persons who are at risk for causing harm to themselves or others when behind the wheel of a car. These facets are (1) patient assessment and medication review, (2) a computer- ized simulation using a touch screen interface, and (3) a road test with a certified road test examiner. Public health nurses may be involved in any or all of these assessments.

History and Physical Examination Office personnel should verify that a driver’s license is active, which is easily verified online. A history and physical examination begins with an inquiry into any past motor vehicle accidents, speeding citations, or other moving violations. In addition to a health history, the person’s work and social his- tory may divulge clues about personal stress, depression, or life events that may impact driving ability. Vision and hearing screenings are important in ruling out sensory causes of impaired driving. A review of medications is important in determining polypharmacy effects. Physical examination should include tests for:

• Failing to yield to other drivers

• Changing lanes without looking

• Ignoring stop signs or traffic lights

• Not seeing cars or pedestrians entering intersections

• Complaining about other drivers suddenly changing lanes or speed

• Receives two or more driving citations in 12 months

Figure 3 A List of Observations for Assessing Risk of Unsafe Driving (National Institute on Aging, 2015)

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• Rapid pace walk: timing a person as he/she walks 10 feet and returns A time less than 7 s indicates no deficit in general mobility and leg strength.

• Muscle strength: performing active range of motion and tests for muscle resistance These tests to assess general mobility can identify physical weaknesses that may impair a person’s ability to drive or be able to quickly exit a car safely.

• Head and neck flexibility: asking the person to turn and look over the shoulder and identify a shape held by the examiner 10 feet behind This tests the ability to turn and look over one’s shoulder and see the side and rear of the car prior to changing lanes.

Cognitive function assessment. The profes- sional nurse can conduct an initial brief assessment of cognitive function (Wiese and Williams, 2015). If screening results suggest possible impairment, a referral to a nurse practitioner or other provider spe- cializing in neuropsychological evaluations is needed. Strategies for nurse practitioners and other providers for conducting the annual wellness visit in the pri- mary care setting are available from Hain (2014).

Computer Simulation Computer programs are commercially available that will assess a driver’s working memory, visualization of missing information, directed visual search with divided attention, and speed of information pro- cessing. These programs include a touch screen interface that does not require users to have a working knowledge of computer applications. Mem- ory and wellness facilities or memory disorder clin- ics are appropriate locations for conducting the driving evaluations and can often support the use of computer simulation programs. Computerized simulations are desirable as they test the subject’s ability to react in a timely manner to various unex- pected situations occurring while driving as well as identify partially hidden objects that may suddenly appear on roadways. These exercises test hazard perception. The participant’s results are normalized with persons of the same age who are known to be safe drivers, and recommendations regarding driv- ing cessation are given based on these national averages.

The road test Finding certified road test examiners can be a chal- lenge, but the first step is to contact local public high schools that offer driver education courses. Another option is to contact the Association of Driving Rehabilitation Specialists which maintains a list of persons trained to evaluate safe driving. These driving rehabilitation specialists (DRS) can assist with driving assessments. A DRS may make suggestions such as limiting driving to daytime hours, on local areas with minimal speed limits, use of special mirrors, or enrolling in a driving improvement course. However, evaluations con- ducted by DRS are usually conducted with the office and computer simulations only.

After the Driving Evaluation

The results of the driving evaluation may indicate a need to restrict driving or participate in a driving rehabilitation course. Regardless of a determination that the driver does not need to cease driving, eval- uations every 6 months for persons at risk of dementia are recommended by the American Medi- cal Association and NHTSA (2010), as longitudinal studies show that most persons with dementia by a neuropsychiatric nurse practitioner or other provider.

Referral to a gerontology provider Gerontological advanced practice nurses or geriatri- cians trained in neuropsychology who can evaluate cognitive impairment are a good fit for meeting the increasing need of driving evaluation services at memory and wellness centers and memory disorder clinics. These facilities may also have the resources, including physical therapists and social workers, to support older adults and their families in coping with the findings, in addition to offering day pro- grams. If no centers are available in the area, a nurse gerontologist, neuropsychologist, neurologist, or occupational therapist specializing in driving evaluations should evaluate the older adult. The dearth of nurse practitioners and physicians trained in geriatrics, especially in our rapid aging popula- tions, creates a gap in services that our profession can address.

If driving cessation is recommended, it is essential that driving evaluations include personal counseling and evaluation of coping mechanisms

Wiese and Wolff: Supporting Safety in the Older Adult Driver 467

and presence or absence of support systems for both the patient and family. Social workers, physi- cal therapists, occupational therapists, pharmacists, and nutritionists are critical members in establish- ing a team-based care plan to meet these needs. The cognitive or functional status of an older adult may begin to decline at any time. A thorough assessment every 6 months that includes the above components is recommended for older adults who are driving (Flanagan, 2011).

Implications for Research, Policy, Practice, and Education

The topic of older adults and safe driving is becom- ing more important as efforts are made to help decrease health care costs by assisting the nation’s senior residents to “age in place.” Combining this effort with the increase in older adult licensed dri- vers is likely to lead to a significant portion of dri- vers that have AD or another type of dementia. Even in cases of aging adults without dementia, persons may still evidence cognitive decline that may impact driving functionality. Public health nurses are well positioned to lead health care research, legislation, and practice in establishing solutions to this growing problem.

Dickerson (2014) points out that as a small number of studies (25) have been conducted regarding driving among persons with dementia between 1992 and 2010, more investigation is needed in drivers with beginning or mild cognitive impairment. Indeed, the majority of the studies here in this article involved small samples, and other researchers often highlight the need for fur- ther research with larger samples (Yaari, Ayutya- nont, Fleisher, Brand, Burke, & Tariot 2013).

One way to limit this growing public health concern is by creating an empirically validated screening process to assess for unfit older adult dri- vers. The results of the screening would indicate whether driving limitation or cessation is war- ranted. Researchers have attempted to identify established neuropsychological measures that detect driving impairment. However, there is currently no universally valid measure or battery used solely for driving purposes.

Interventions such as showing videos of car crash incidents have been shown to be effective in younger drivers (Carney, McGehee, Lee, Reyes, &

Raby, 2010) and applying event-triggered video interventions with older adults at risk for unsafe driving may also be helpful (Horswill, Sullivan, Lurie-Beck, & Smith, 2013). One study demon- strated that hazard perception interventions using validated video-based hazard perception training were effective in changing perceptions of older adults toward driving (Horswill, Kemala, Wetton, Scialfa, & Pachana, 2010). Public health nurses could lead a public safety campaign that includes further development of video interventions and research in this arena.

A gap in services is the lack of locations that offer driving evaluations for persons suspected to be in cognitive decline. The local Alzheimer’s Asso- ciation and agencies on aging, the Division of Motor Vehicles, and the National Highway Trans- portation Safety Administration, and senior or memory centers often have information on loca- tions for driving evaluations. The DriveAble web site offers a comprehensive list of licensed testing sites by State, as well as in Australia, Canada, and New Zealand (driveable.com, 2015). Also, for a les- ser fee, providers and lay persons can access the Roadwise ReviewTM Automobile Association of America Test Battery, which requires about 30 min to complete, and includes testing for vision, reac- tion time, and memory. It also includes a self- assessment of driving skills and short video clips explaining the tests’ relevance to safe driving. Rec- ommendations for seeking assessment by a trained health care provider are given based in test results (Gentzler & Smither, 2012). Public health nurses caring extensively for older adults may want to seek training and certification in neuropsychology.

More effective public transportation systems or no cost services for older adults are also needed. Models of other countries such as Sweden can be considered, where a “pensioner” and one compan- ion can travel without charge to grocery stores, air- ports, downtown, etc. free of charge by taxi. Public health nurses can pursue policy changes by working with state legislators to design and introduce bills to establish transportation services for older adults.

Another method for limiting the growing health concern of older drivers and road safety is to pro- mote clinician awareness. It is important for clini- cians to know the cognitive trends that are characteristic of both types of aging and how they can manifest. Clinicians should also become more

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aware of the skills needed for effective vehicle oper- ation and how cognitive decline may limit driving ability.

Effective education of providers, caregivers, and patients regarding management of safe driving in persons at risk for age-related cognitive impair- ment is an important need due to the increasing number of older adults on the road. Researchers investigating physician management of patients at risk for driving have revealed that the majority do not feel qualified to identify unfit drivers, yet believe it was important to do so (Brooks et al., 2011; Marottoli, 2010). This is an area where trained public health nurses can meet a gap in pub- lic health safety and lessen provider burden. For example, educating caregivers in managing the issue of driving cessation in their cognitively impaired family member or friend was effective (D’Ambrosio et al. (2013). Seventy-nine caregivers reported increased confidence levels in determining that their loved ones were driving at an unsafe level and in following steps needed to achieve driving cessation. Bryanton and Weeks (2014) conducted research for the purpose of informing the develop- ment of educational programs based on participant feedback. The recommendations from over 200 participants aged 70 and older included ways in which to help an older adult choose to cease driv- ing, identify alternate modes of transportation, and cope with the loss of independence. Approximately 71% of the respondents stated their belief that edu- cational programs would help older adults to begin planning for driving cessation, although only about half said that they would attend such a program. Nurse researchers (Jenkins & Holston, 2015) con- ducted a meta-analysis of 558 articles written between 2009 and 2012 using the terms “choice behavior” and concluded that choice, not decision, should be the method of achieving driving cessa- tion. Educational programs that increase perception of risk as well as education are needed to help older adults in making that choice.

Increasing the public’s awareness of mecha- nisms to report potentially unsafe drivers is needed. Concerned citizens can report unsafe driv- ing through many State sponsored programs. States will then notify the driver, and in some instances, such as in the State of Florida, a letter will be sent requesting the driver to submit evi- dence of a driving evaluation within a designated

time or the license will be suspended. A list of requirements by States, such as shortened renewal times or mandatory reporting by physicians of driving risk related to physical health, or diagnosis of dementia, is available online (IIHS, 2015). Addi- tional information for individual State programs is readily available on the Internet using the search terms of “reporting unsafe driving” or by contact- ing the State driver’s license facilities or police departments.

The cost of a thorough driving examination, which includes a history and physical examination, cognitive or neuropsychological assessment, stan- dardized computer simulation, and road test, can reach several hundred dollars and is often not cov- ered by insurance. This is an opportunity for public health nurses to advocate for policy change in this arena.

Summary

Driving requires insight into abilities, memory for where the person is headed, capacity to sustain attention, visual scanning, quick decision-making skills, and ability to engage and shift between mul- tiple stimuli. Executive functions, visual mecha- nisms, memory, and insight are complex cognitive skills needed to ensure safe driving. Most of the older adults will inevitably experience a decline to some degree in each of these cognitive functions as they age (Salthouse, 2010). When a neurocognitive disorder such as AD is present, this decline is exac- erbated and driving risk is increased.

Public health nurses are called to educate fami- lies and other providers as to the importance of observing driving behaviors and of initiating com- passionate conversations regarding unsafe driving practices in persons at risk for cognitive impair- ment. Annual cognitive screening, referrals for driv- ing evaluations, neuropsychological consults, participating in driving evaluations, and political actions to support driving screenings are in the purview of the professional nurse in promoting public road safety.

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