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The Older Driver

By Peggy P. Barco, MS, BSW, OTD, OTR/L, SCDCM, CDRS, Assistant Professor of Occupational Therapy and Medicine, Washington University Medical School ; David B. Carr, MD, Alan A. and Edith L. Wolff Professor of Geriatric Medicine, Professor of Medicine and Neurology, and Clinical Director, Division of Geriatrics and Nutritional Science, Washington University School of Medicine

Driving provides freedom, independence, and key social interactions with their community that many people take for granted in their youth. But the privilege of driving is based on the ability to safely operate a motor vehicle. Drivers aged 70 and over have an increased motor vehicle crash risk per miles driven in comparison to middle-aged drivers. Those that drive infrequently are at the greatest risk. Thus, impaired function due to age-related disorders should be viewed as a flashing yellow traffic signal—a warning that driving privileges should be reassessed.

Many factors can diminish the driving performance of older adults. Among these factors are age-related changes in reaction time and visual, cognitive, and/or muscle disorders that become more common with age. Drugs are commonly used to treat disorders in older people and some classes can be quite sedating and also impair driving performance. Some of these factors can be managed and modified.

Did You Know...

  • Older people are more likely to have a motor vehicle crash (MVC) when making a left turn than other age groups.

  • Older drivers are more vulnerable and are more likely to be injured in a crash.

Crash Rates and Traffic Violations

On average, older drivers have fewer actual crashes per year than do younger drivers. However, because they drive fewer miles than middle age drivers, older drivers average more crashes per mile driven. Crash rates begin to increase after about age 70, and they increase more rapidly after age 80 years. For every mile driven, older drivers have higher rates of traffic violations, crashes, and fatalities than do all other age groups over age 25. It should be noted that the current generation of older people are driving farther distances than previous generations, and this trend is expected to continue.

Failure to yield right-of-way is one of the more common traffic violations committed by older drivers. Also, older drivers have more difficulty merging into traffic and may have problems at intersections, particularly when making left turns. These difficulties have been attributed to:

  • Difficulty evaluating several pieces of information simultaneously (multitasking)

  • Difficulty judging the speed of oncoming cars or objects

  • Reduction in field of view

Yet, older drivers are often more careful than younger drivers. They tend to avoid driving at night, during rush hour, or during inclement weather. Moreover, alcohol is much less likely to be a factor in crashes involving older drivers. Older drivers are also less likely to have crashes while driving on curved roads or at high speeds. For older drivers, crashes are less likely to involve a single vehicle. Multiple vehicles are more likely to be involved. Interestingly, crash rate tends to go down with the number of passengers that are in the vehicle for drivers over age 70 years.

Crashes involving older drivers are also more likely to result in serious injuries and fatalities. The increased vulnerability of older drivers may be due to physical fragility. Also, older drivers are more likely to be involved in a crash while making a left-hand turn, and such turns leave drivers vulnerable. Older drivers who are killed as a result of motor vehicle crashes tend to have older cars that may not be as safe. Thankfully, the number of older adults that have died in motor vehicle crashes has also decreased over the last decade. This is likely due to improved highways and increased crash-worthiness of vehicles, rather than improvements in fragility.

Reasons for Impaired Driving

Driving involves the precise execution of simultaneous tasks (such as braking and steering). These tasks require several attributes, including the following:

  • A clear mind

  • Attention and mental focus

  • Quick reaction time

  • Coordination

  • Adequate strength

  • Good range of motion in the upper body (upper trunk, shoulders, and neck)

  • Good vision and hearing

  • Good judgment

Deficits in any of these attributes can greatly affect driving performance. Such deficits can result from several causes. Virtually all these attributes are impaired to some degree as people age and become worse with the presence of medical illnesses.

Aging

Aging itself usually results in a gradual and subtle decline in strength, coordination, reaction time, ability to concentrate, and hearing. Older people may have less stamina and become fatigued more quickly, especially in situations that require concentration. Older people are less able to focus on more than one task at a time. However, most changes attributed to aging are modest and are often not the main reason for driving safety issues.

Medical conditions

Disorders that are more common among older people can be especially troublesome for older drivers. For example, the blood sugar level of drivers with diabetes may rise too high or drop too low. Such changes can interfere with clear thinking, attention and mental focus, vision, and sensation in the feet.

Older drivers with dementia (including Alzheimer disease) can have poor judgment, concentration, and slow reaction time, which is a dangerous mix when driving. Even when dementia is in its early stages, drivers may become more easily lost or more confused in congested traffic.

Strokes or so-called ministrokes (transient ischemic attacks, or TIAs) can slow reaction time, cause muscle weakness, impair vision, and reduce coordination. Seizures can abruptly cause people to become unaware of their surroundings or even lose consciousness. A recent heart attack may increase the risk of fainting or experiencing light-headedness.

Arthritis causes joint pain and stiffness, limiting range of motion and possibly interfering with the ability to operate a car’s controls. For example, pain and stiffness in the knees or hips may affect the ability to press the brake pedal or accelerator. Arthritis can make turning the head (as is necessary when turning or reversing a car) painful and difficult.

Glaucoma and macular degeneration are eye disorders that lead to problems when driving at twilight or at night. Glaucoma can also narrow the field of vision so that cars and other objects alongside the driver are difficult to see. Cataracts, which occur almost exclusively among older people, can cause glare from oncoming headlights or street lamps.

Medical literature and recommendations from many medical societies are available for clinicians to review and make decisions on whether someone should continue driving or be evaluated.

Drugs

Many older people take drugs that can have undesirable side effects. Side effects can include sleepiness, dizziness, confusion, and other symptoms that interfere with driving. Both prescription and nonprescription drugs can have these side effects. When starting a new drug that could affect visual, physical, or mental function, people should not drive for several days to be sure no side effects occur. Drugs that may interfere with driving include the following:

  • Alcohol

  • Anticonvulsants

  • Antiemetic drugs (used to manage nausea)

  • Antipsychotics

  • Benzodiazepines, or antianxiety drugs

  • Drugs used to treat glaucoma

  • Drugs used to treat Parkinson disease

  • Muscle relaxants

  • Antihistamines

  • Opioids

  • Sleep aids

  • Tricyclic antidepressants

Situations

Stress, particularly when driving in unfamiliar areas or in heavy traffic, may contribute to difficulty. Fatigue and distraction also decrease driving ability. The use of technologies such as cell phone and/or texting increase crash risk 4- to 8-fold respectively. Older adults should avoid using these devices in the car given age-related changes or decline in attention and/or multitasking. Seat belts and upgrading a car that is more crashworthy that has crash prevention technologies (MyCarDoesWhat.org) should be considered.

Falls in older adults have been associated with an increased risk of motor vehicle crashes and this makes sense since both activities require the integration of visual, cognitive and motor systems.  Thus, interventions to reduce fall risk (for example, reducing sedating medications, physical activity, and balance training) may have a role to improve driving mobility.

For some older adults, the only deficit in driving ability is simply a lack of driving experience. For example, an older person (usually a woman) may learn to drive only after a spouse dies. Both couples should continue to share driving activities, since infrequent drivers are at high risk for driving retirement.

Ways of Compensating

Many drivers begin to self-regulate their driving as they age.  For example, older drivers may self-regulate their driving by eliminating long highway trips, driving less at night, avoiding confusing intersections, and/or engage in risky driving behaviors (for example, speeding, tailgating, drinking and driving). There are many strategies older drivers can adopt to compensate for some of the age-related factors that can cause driving safety concerns.

Avoiding hazards

Older drivers can use their experience from years of driving to identify and avoid hazardous situations. For example, because stamina decreases with aging, older drivers may wish to drive shorter distances and take frequent breaks. They can avoid freeways and other areas where traffic is congested or known to be dangerous. They can avoid driving at night or twilight, when glare problems are most likely. They can avoid rush hour traffic and take fewer risks in traffic. They may prefer to drive only familiar routes and locations.

Avoiding distractions while driving

Avoiding distractions—an important consideration for all drivers—is essential for older drivers. Cell phones are an important safety feature for drivers who become stranded when a car unexpectedly needs repair. However, cell phone use (even hands-free models) while driving is strongly discouraged. States have different laws regarding cell phone use while driving; in some states it is illegal. Similarly, making adjustments to the stereo or another onboard system (such as climate control or seat position), eating or drinking, smoking (there are many other reasons not to smoke—at any age), reading maps, and even engaging in conversation with other passengers can be distracting and can impair driving performance. People should minimize distractions of all types while driving.

Using technology

Newer technology may assist older drivers. Parking aids, which use cameras or infrared systems to help with backing up, parking, and other maneuvers, are especially helpful for people who have difficulty looking over their shoulders. Other systems that are helpful to older drivers include cruise control, antilock brakes, and electronic stability devices that improve traction and steering. Advanced vision systems for night driving include curve lighting (lighting directed around a curve) and automatic dimming of headlights (high beams convert to low beams when there is oncoming traffic). Some cars offer rearview mirrors that automatically dim when hit by blinding headlights, thus reducing glare. Car manufacturers are experimenting with infrared night vision technology to enhance night driving.

Car manufacturers are also redesigning handles and knobs to make them easier for people who have arthritis to operate. Other car design features, such as lower door thresholds, lumbar supports, extended visors, adjustable seats and steering wheels, are available to all drivers but may be particularly helpful for older drivers. Self-driving cars are being experimented with across the nation and will likely become available for use in future years.

When crashes or other urgent situations occur, some emergency systems can automatically call and direct rescue teams to the car’s location. Global Positioning Systems (GPS) may help older drivers locate destinations. Many older drivers have smart phones which can have apps installed free of charge so that families can track their location using GPS technology if they become lost. Additionally, GPS technologies are available to monitor many types of driving behavior (routes taken and speed while driving) via the internet if families desire. Further innovations are anticipated in the future.

As more and more technologies become available, it will become important to recognize that older adults may need more individual time spent on training in the use of the newer technologies. Technologies will likely need to be individualized as to what is most helpful for each person.

Driver refresher courses

Another way that older drivers can help maintain or even improve their driving skills is through driver refresher programs. Several organizations—such as the American Association of Retired Persons (AARP) and American Automobile Association (AAA)—offer such programs to help older drivers adjust to the challenges of driving during old age. In addition, taking such programs can lower insurance rates. AAA offers Roadwise RX, a software program that older drivers can use to assess functional abilities for driving. It can be obtained online or through local AAA chapters.

Older drivers may also benefit from programs designed to ensure that their vehicle fits them correctly. For example, they should have the right distance from their steering wheel and right seat height for viewing traffic. Adjusting mirrors properly can help drivers compensate for blind spots. AAA’s CarFit, is offered at many sites across the country and provides useful information about how their personal vehicle can best “fit” them to improve safety.

There have been spates of computer programs to improve driving safety, some of which have been targeted for older adults. In addition to assessing functional abilities, the AAA's Foundation for Traffic Safety (FTS) product Roadwise Rx can review the medications associated with elevated crash risk. Posit Science Drivesharp and ADEPT Lifelong Driver also have products available for older adults. More research is needed in this area to determine the real take-home benefits of these courses.

Medical care

Lifestyle and medical care can help older drivers avoid driving difficulties. There are many reasons to stay fit in older age—including retaining driving ability. Doctors should regularly evaluate older people to identify any problems in vision, memory and thinking, or muscle strength that could impair their ability to drive.

Treatment of some disorders may improve driving performance. For example, cataract removal can be beneficial. Treatment of arthritis with drugs and physical therapy can improve flexibility and mobility. Good control of diabetes can prevent swings in the blood sugar level. Older drivers should review their drugs with a doctor or pharmacist to make sure that driving performance will not be compromised by side effects.

Many states have laws that prohibit people from driving for a specified time after certain disorders are diagnosed. This waiting period (moratorium) provides time for the disorder to be stabilized with treatment. For example, some states require a 6-month moratorium on driving after a stroke or transient ischemic attack. A 3- to 6-month moratorium may be required after a heart attack or cardiac bypass surgery. For people who have had a seizure, some states require a seizure-free period of at least 6 months before driving can be resumed.

A Driving Decision

At some point, most older drivers (especially those with significant medical impairment) face the decision of whether it is safe to continue to drive. A decline in the abilities required for safe driving may make driving dangerous. Many of the same factors that relate to driving safety concerns can also affect the older adult’s independence in utilizing public transportation resources. Not being able to drive may mean a loss of freedom and independence. It is very important to help an older adult who needs to stop driving find acceptable ways to get to important daily or weekly activities.

Sometimes the family doctor or a family member realizes that it is time for an older driver to “give up the car keys.” Dealing with these issues is always difficult, but ignoring them can bring even greater misery. There are some practical steps that may help older drivers feel more comfortable about giving up their car key:

  • Involve the driver in the decision to limit or stop driving

  • Help find other ways to get around

  • Investigate driving and delivery services

  • Make sure the person has rides to usual activities

  • Enlist the family doctor or a friend to discuss the issue

There are many publications and online resources that can help older drivers decide whether they should continue to drive. There are also resources available for family members and friends who may be concerned about an older driver.

Most older drivers, sometimes with advice from family members or their doctors, can determine when to stop driving. However, some drivers, for example people with dementia, may lack insight into their driving ability and continue to drive even after a doctor has recommended they stop. One approach in this situation is to suggest that the older driver be tested by a driving rehabilitation specialist or the state agency that oversees or regulates licensure. Testing by the state can be requested by the driver, an immediate family member, or a doctor. It can include both written and on-road evaluations. In a few states, doctors are required to report any driver believed to be unsafe. Some states have ways to confidentially report a family member for driving concerns. It is important to contact your own state licensing department (DMV) for regulations specific to your state. Laws regulating the possession and renewal of a driver’s license by older drivers vary from country to country and from state to state.

Often physicians refer an individual with driving concerns to driving rehabilitation specialists. These specialists are often occupational therapists that are certified by the Association of Driving Rehabilitation Specialists or the American Occupational Therapy Association in providing comprehensive driving evaluations and rehabilitation for individuals with medical concerns. They are often located at hospitals or in universities, but some have private clinics. They may be able to evaluate drivers for safety, provide vehicle modification or adaptive equipment, and give mobility counseling or advice on alternative methods of transportation.

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