Improving the Safety of Older Road Users (2005)

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This chapter summarizes available reports, documents, and articles that provide information on programs and policies to improve older road user safety. Its focus is on recent docu- ments, including web-based reports, providing information on current programs or activities. Research reports and arti- cles are only included if they relate to a specific program or program area. The overall intent of the chapter is to provide an historical background for the remainder of the report and to highlight key reference documents. The review encompasses activities by the federal govern- ment, state and local governments, as well as national non- governmental organizations, professional associations, and other private-sector organizations. In many cases, the refer- enced documents represent collaborative efforts across agen- cies, between public and private sectors, and among national, state, and local entities. The review provides a brief descrip- tion of each identified document. For further details of spe- cific programs or activities (e.g., with respect to roadway improvements or driver licensing), the reader is referred to the appropriate chapter of this report. In keeping with the emphasis of this synthesis on current programs and activities, pertinent web addresses are highlighted at the end of each chapter. TRANSPORTATION RESEARCH BOARD INITIATIVES In 1988, TRB published the landmark Special Report 218: Transportation in an Aging Society. This report helped to place older road users in the forefront of transportation safety agendas and served as a basis for research and programmatic activities over the ensuing years. Following its publication, both FHWA and NHTSA launched significant new older road user research programs that laid important groundwork for future programmatic activities. A decade later, TRB embarked on an effort to update Spe- cial Report 218 and convened a conference in Bethesda, Maryland, in November 1999. The commissioned technical papers from this conference are published as “Transportation in an Aging Society: A Decade of Experience” (2004). The papers review accomplishments during the 1990s with respect to both research and implementation, and make recommen- dations regarding future requirements for meeting the needs of aging road users. The full report is available on the TRB website. Report chapters address the following topic areas: 8 • Data and characteristics of older drivers; • Driver programs; • Mobility solutions; • Highway design, pedestrian facilities, and land use; • Vehicle design and intelligent transportation systems; • Public education and information; and • Policy. The published conference proceedings also report on the series of focus groups conducted before the conference to provide input to the development of a national agenda for safe mobility for a maturing society. FEDERAL GOVERNMENT INITIATIVES U.S.DOT In 1995, Secretary of Transportation Peña directed the U.S.DOT to begin work on a proactive plan for accommodat- ing an aging population of users of the nation’s transporta- tion system. The resulting report was Improving Transporta- tion for a Maturing Society (1997), which was the first document to set forth the challenge of “Safe Mobility, for Life.” Building on this foundation, the U.S.DOT launched efforts to develop a national agenda for promoting safe mobility throughout an individual’s typical life span. Drawing from a series of public forums, workshops, and professional gather- ings, the DOT further articulated a vision for our future trans- portation system and identified seven key strategies for achieving this vision (“Safe Mobility for a Maturing Society . . .” 2003). These strategies, reproduced here, outline pro- gram areas for improving the safety and mobility of older road users. More importantly, they demonstrate U.S.DOT support to the variety of programs and activities being high- lighted in this synthesis document. Safe Mobility for a Maturing Society: Challenges and Opportunities 1. Safer, Easier-to-Use Roadways and Walkways • Promote the use of guidelines and recommendations from the FHWA Highway Design Handbook for Older Drivers and Pedestrians (Staplin et al. 2001a) through continued training of traffic engineers and CHAPTER TWO REVIEW OF LITERATURE

9highway department personnel and by ensuring this guidance is incorporated into standard design manuals. • Promote the most cost-effective guidelines for the accommodation of pedestrians. • Identify and promote effective land use approaches for accommodating older people’s transportation needs. And, develop a clearinghouse of best prac- tices for planners and community developers. 2. Safer, Easier-to-Use Automobiles • Evaluate approaches to improve protection of older occupants in crashes. • Consider the need for new standards for exterior vehicle designs that are less injurious to pedestrians. • Evaluate older driver interactions with vehicle sys- tems that affect the occurrence of crashes. • Continue work on specialized vehicle systems to extend the driving capabilities of persons with disabilities. 3. Improve Systems for Assessing Competency of Older Drivers and Pedestrians • Continue to identify characteristics of older drivers who are at higher risk of crashing and those who self-regulate. • Develop and evaluate procedures to identify referral, testing, rehabilitation, and regulation programs to improve older driver safety. • Develop and evaluate procedures to enable people with functional disabilities to drive, walk, and use transportation options safely. • Provide materials to enable professional organiza- tions to conduct in-service training on effective pro- gram guidelines. 4. Better, Easier-to-Use Public Transportation Services • Develop and evaluate public transportation best prac- tices for older adults. • Develop comprehensive, one-call-does-it-all mobil- ity managers to coordinate local providers and their services. • Conduct demonstration programs of innovative transit and supplemental transportation systems for under- served and rural areas. • Strengthen the DOT/DHSS (Department of Health and Human Services) Interagency Coordinating Coun- cil to identify and remove programmatic barriers to the coordinated delivery of services for older adults. • Improve the ease of use of both transit and intercity transportation for older adults. 5. Targeted State and Local Safe Mobility Action Plans • Encourage formation of state and local consortia to address the transportation needs of elderly people. • Encourage state and local communities to develop and implement action plans. 6. Better Public Information • Educate older people and their caregivers on how to identify unsafe older drivers and extend safe driving, walking, and use of transit. • Train transportation, health, and social service per- sonnel to enable the safe mobility and well-being of elderly people. 7. Basic and Social Policy Research • Determine the relationships between mobility and age- related physical, cognitive, and functional limitations. • Establish the relationship between lost mobility, aging in place, and societal costs for older people. • Determine technology’s role in improving mobility and safety for functionally limited people as drivers, walkers, and public transportation users. FHWA In 1989, FHWA initiated a high-priority national program to determine whether existing highway design standards accom- modated the needs and capabilities of older drivers. An out- growth of this human factors research program is the High- way Design Handbook for Older Drivers and Pedestrians, first published in 1998 and revised and updated in 2001 (Staplin et al. 2001a). The Handbook provides recommen- dations and implementation guidelines for engineers to bet- ter accommodate the needs and functional limitations of older road users, including drivers and, in the revised version of the handbook, pedestrians. The recommendations are based on recent human factors research findings and are intended to supplement existing engineering standards found in the Man- ual on Uniform Traffic Control Devices for Streets and High- ways (MUTCD) (2003) and AASHTO’s A Policy on Geo- metric Design of Highways and Streets (Green Book) (2004). They are categorized under the following five topic areas: at- grade intersections, interchanges, roadway curvature and pass- ing zones, construction/work zones, and highway–rail grade crossings. The recommendations were selected to be rela- tively low cost, especially when implemented as part of new construction, reconstruction, or scheduled maintenance. To assist states in implementing the new guidelines, FHWA offers training workshops to planners, designers, traffic engi- neers, and other practitioners through its division offices and state and local DOTs. To date, more than 100 workshops have been conducted in 43 states, the District of Columbia, and Puerto Rico. FHWA’s human factors research program had earlier published two other reports offering guidance on traffic con- trol devices and roadway signage. A 1995 report, Traffic Oper- ations Control for Older Drivers and Pedestrians (Knoblauch et al. 1995) describes two studies, one of older adults’ under- standing of left-turn signalization and the other of response times for stopping at traffic signals. In the first study, it was reported that both older and younger drivers did not under- stand protected and permitted left-turn signalizations; there- fore, education or other program efforts in this area should target all drivers, not just older drivers. The second study showed no significant difference in stopping times for older

10 and younger drivers encountering yellow traffic signals, and on this basis concluded that there is no need to change the yellow signal phase timing to accommodate older drivers. The second FHWA report examined older drivers’ under- standing of symbols and signs, and identified modifications to improve their glance legibility, reaction time, and con- spicuity (Dewar et al. 1995). Many of this study’s recom- mendations (minimize complexity, maximize distance between sign elements, use representational rather than abstract symbols, etc.) have since been incorporated into updated revisions of the MUTCD. These and other research activities laid important ground- work for the Highway Design Handbook for Older Drivers and Pedestrians and other important FHWA programmatic efforts to improve safety, not only for older drivers, but for all drivers on our nations’ roadways. NHTSA NHTSA’s stated mission with respect to older road users is to keep them safely mobile through programs directed at reduc- ing traffic-related injuries and fatalities. Through its research and outreach activities, it aims to help aging adults recognize their changing abilities and to adapt their transportation prac- tices appropriately. It also seeks to involve family, friends, licensing officials, and physicians and other health-care pro- viders in identifying potentially at-risk drivers and directing them to safer transportation alternatives (see http://www.nhtsa. dot.gov/people/injury/olddrive). NHTSA has conducted an older driver safety and research program since the early 1980s and in 1988 prepared an action plan identifying specific research needs to address this area of growing concern. Five years later, the agency prepared a Report to Congress (Addressing Safety Issues . . . 1993) and released an updated Traffic Safety Plan for Older Persons (1993) that drew on the research carried out to outline spe- cific problem identification, program development, and pro- gram evaluation projects for improving older road user safety. The identified projects involved cooperation from other agen- cies within the DOT (Office of the Secretary of Transpor- tation, FHWA, FTA), as well as other government agencies (National Institutes on Aging, Administration on Aging, CDC) and nongovernmental organizations. Many of the older road user programs and activities described in this report have their basis in these early planning documents. One of the most significant accomplishments was the publication of the Safe Mobility for Older People Notebook (Staplin et al. 1999). This report provided a foundation for the subsequent development of a model driver screening and evaluation program. The primary focus of the report is on tools and techniques for identifying older adults at high risk of crashing. The report identifies programs and procedures for DMV identification of at-risk drivers (e.g., through obser- vation by counter personnel and analysis of driving records), external referral of at-risk drivers (e.g., by family members or friends, law enforcement officers, or physicians), and self- referral (e.g., through self-evaluation materials or automated testing in public venues). However, the more than 400-page document also reviews the state of the practice with regard to driver rehabilitation and the provision of alternative trans- portation. Thus, the report was a combination research syn- thesis and state-of-the-practice snapshot of available programs across North America for identifying at-risk older drivers and intervening to promote their safe mobility. The full report is available electronically from the NHTSA website. Subsequent to the publication of the Safe Mobility for Older People Notebook, NHTSA embarked on a multiyear research project to develop and evaluate a Model Driver Screening and Evaluation Program. This work was carried out in collaboration with AAMVA and the Maryland Motor Vehicle Administration (MVA). Although long-term follow- up was still underway at the time of this synthesis, the final results of the project have been published in a three-volume report that is available on the NHTSA website (Staplin et al. 2003). The report recommends a multifaceted approach to driver licensing that includes • Internal and external referrals of potential at-risk drivers, • Tiered screening and assessment at license renewals, • Driver education and counseling, and • Driver restriction and remediation. More recently, NHTSA funded a project to review the state of the practice with respect to state medical advisory boards, or MABs. An interim report from this project provides a detailed summary of MAB practices in all 50 states plus the District of Columbia, and is available on the AAMVA web- site (Lococo 2003). A second phase of the project developed recommended best practices for licensing drivers with med- ical conditions and functional impairments (Lococo and Staplin 2005). Results of both reports are detailed in later chapters of this synthesis. In addition to these larger projects, NHTSA has sponsored the development of a range of programs and safety materials targeting older drivers and family members or friends, often in partnership with other government agencies and with private- sector organizations. It has also linked with the private sec- tor to disseminate its materials and programs. Partnering agen- cies include the Administration on Aging, FTA, CDC, and state DOTs, MVAs, and offices on aging. A partial list of partnering organizations from the private sector includes AAMVA, AMA, AARP, AAA, AAA Foundation for Traf- fic Safety, American Society on Aging (ASA), American Occupational Therapy Association (AOTA), Association for Driver Rehabilitation Specialists (ADED), Community Trans- portation Association of American (CTAA), and N4A. The

11 outcomes from these many and varied collaborations are all documented in subsequent sections of this report. OTHER NATIONAL INITIATIVES AASHTO and NCHRP Older road user safety is also addressed by AASHTO as part of its Strategic Highway Safety Plan (SHSP). The plan, devel- oped in 1997, identified 22 key emphasis areas for reducing roadway fatalities; reducing crashes involving older drivers was one of these areas (The Strategic Highway Safety Plan 1997). To assist states in implementing the plan, NCHRP funded a project under its pooled fund arrangement with state DOTs to develop an implementation guide for each empha- sis area. The guideline in the older driver area was published as Volume 9 in the series of reports (Potts et al. 2004). This report, A Guide for Reducing Collisions Involving Older Drivers, identified 5 broad objectives and 19 strategies for a comprehensive approach to reducing older driver crashes and injuries. For each identified strategy there is a brief description of the approach, followed by a table that sum- marizes available information on the target audience for the strategy, expected effectiveness, keys to success and poten- tial difficulties in implementing the strategy, appropriate measures of effectiveness, organizational and institutional considerations, issues affecting implementation time frame, anticipated costs, training and personnel needs, and legisla- tive and other needs. The guide also provides information on agencies or organizations currently implementing the strat- egy, and the web-based version of the guide contains “hot links” to available resources and case studies. • Objective 1. Plan for an aging population – Establish a broad-based coalition to plan for address- ing the transportation needs of older adults. • Objective 2. Improve the roadway/driving environment to better accommodate the special needs of older drivers – Advance warning signs – Advance guide signs and street name signs – Increased letter size of roadway signs – Longer clearance intervals at signalized intersections – Protected left-turn lanes at intersections – Offset left-turn lanes at intersections – Improved lighting – Improved roadway delineation – Use of raised channelization – Reduced intersection skew angles – Improved traffic control at work zones. • Objective 3. Identify older drivers at increased risk of crashing and intervene to lower their crash risk – Strengthen the role of MABs – Update procedures for assessing medical fitness to drive – Encourage external reporting of impaired drivers to licensing authorities – Provide remedial assistance to help functionally impaired older drivers lower their crash risk. • Objective 4. Improve the driving competency of older adults in the general driving population – Establish resource centers within communities to pro- mote safe mobility choices – Provide educational and training opportunities to the general older driver population. • Objective 5. Reduce the risk of injury and death to older drivers and passengers involved in crashes – Increase seat belt use of older drivers and passengers. Another guidebook in the 22-volume series targets pedes- trians (Zegeer et al. 2004), and is also available electronically on the AASHTO Highway Safety Plan website. Although none of the identified strategies in this guide specifically tar- get older pedestrians, many could be expected to especially benefit the older pedestrian. Examples include • Providing sidewalks/walkways and curb ramps, • Installing or upgrading traffic and pedestrian signals, • Constructing pedestrian refuge islands and raised medians, • Installing traffic calming, and • Implementing road narrowing measures. Another recently funded NCHRP project directly relating to older road user safety is a study carried out for the AASHTO Standing Committee on Planning entitled Elderly Issues in the Transportation Planning Process. The study involved inter- views with transportation planning staff at a cross section of 10 state DOTs and 9 metropolitan planning organizations (MPOs) to gather information on current planning practices with regard to older road user safety and mobility. It also included a review of recent literature related to older drivers and development of recommendations in the highway plan- ning and public transportation areas (see Grimm and Horsley 2004). Findings from this study will be reviewed in greater depth in chapter three. TCRP and FTA Although excluded from the scope of this synthesis report, alternative transportation, including public transportation, is a vital component to improving the safety and mobility of older road users. Without viable alternatives to driving, older adults who are no longer capable of operating a motor vehi- cle safely will either continue to drive, placing themselves and others at risk, or stop driving and suffer health and quality of life consequences that often accompany a loss of mobility. TCRP, with support from FTA, has recently funded several studies to assist states and local communities in improving public transportation services. TCRP Report 82: Improving

Public Transit Options for Older Persons, outlines funda- mental changes transit agencies must make to be responsive to the growing older population, and offers specific short- term and long-term strategies for attracting more older rid- ers. Both Volume I: Handbook and Volume II: Final Report contain case study descriptions of good community practices designed to inspire action (Burkhardt et al. 2002). TCRP Report 91: Economic Benefits of Coordinating Human Service Transportation and Transit Services, not only presents the key economic benefits of service coordina- tion, but also provides the basic concepts behind coordina- tion and identifies specific strategies for achieving the eco- nomic benefits of coordinated services (Burkhardt et al. 2003). Strategy areas include tapping currently unused sources of funding (such as coordination with Medicaid transportation or school programs), reducing transportation service costs (e.g., by partnering with nontransit agencies to provide ser- vices or shifting paratransit riders to fixed-route services), increasing transportation system productivity (e.g., through ride sharing), and expanding transportation services (e.g., through local government or human service agency partner- ships). Again, case study descriptions illustrate and support the recommendations offered. A final TCRP report of particular relevance to the current synthesis effort is TCRP Report 101: Toolkit for Rural Com- munity Coordinated Transportation Services (Burkhardt et al. 2004). Recognizing the limited resources available, the authors identify improved coordination as a strategy for expanding transportation services in rural areas. They present the nec- essary steps for achieving a more coordinated transportation system and identify specific “success strategies” at both the state and local levels. The report draws from an in-depth review of the literature, analyses of large databases, focus groups with the elderly, focus groups and expert interviews with representatives from the transit industry, and case studies showcasing successful efforts across the country to improve travel options for older adults. All three of these reports are available electronically on the TRB TCRP website identified at the end of this chapter. Nongovernment Organizations In addition to these studies supported by traditional trans- portation safety agencies, numerous national organizations and professional associations have become involved in issues related to older road user safety and mobility, often partner- ing with the U.S.DOT and its sister agencies, as noted previ- ously, but also on their own as well. Included in this group are • AAA Foundation for Traffic Safety • AARP • AAMVA • AAA and AAA clubs 12 • Alzheimer’s Association • AMA • AOTA • ASA • CTAA • Emergency Nurses Association • GHSA • National Safety Council (NSC) • N4A • The Road Information Program (TRIP). The programs and activities of these organizations are gen- erally more narrowly focused and are discussed later in this report in the appropriate chapter. OTHER PUBLISHED LITERATURE A recent University of Michigan Transportation Research Institute (UMTRI) report, Promising Approaches for Enhanc- ing Elderly Mobility (Molnar et al. 2003), is an excellent com- plement to the current synthesis effort. The original intent of the report was to document Michigan programs and practices to help communities implement the state’s Elderly Mobility and Safety Task Force plan developed a few years earlier. However, the authors quickly realized that the document would be more valuable if it were expanded to include pro- grams from across the nation, and if it focused on those pro- grams that had either been proven or showed promise for enhancing elderly mobility. Because safety and mobility are closely linked, many of the programs identified in the Michi- gan report are relevant to the current effort. The programs are organized under the following five categories: • Screening and assessment, • Education and training, • Vehicle adaptations and advanced technology, • Roadway design, and • Alternative transportation. In addition, the report seeks to motivate community profes- sionals to implement programs and activities, choosing those from among the smorgasbord menu that best meet their needs. Thus, it provides greater background information than typi- cally contained in a synthesis document. The report is avail- able electronically at the UMTRI website. Again, specific programs appearing in the Michigan report are highlighted in subsequent chapters of the current report. Also related to the current effort, in the fall of 2004, the Michigan Governor’s Traffic Safety Advisory Commission hosted a 4-day conference to showcase “best practices from around the world” with respect to elderly mobility. Sessions were organized around the following five topics: alterna- tive transportation, education and training, housing and land use, roadway design, and screening and assessment. Infor- mation presented at this conference is being made available

13 on CD-ROM by the AAA Foundation for Traffic Safety. Much of the information presented in chapter four with regard to engineering practices for improving older road user safety draws from material specially gathered for presentation at this conference. Finally, the AAA Foundation for Traffic Safety has funded efforts by the Beverly Foundation to document transportation programs for seniors across the country and to identify best practices in this important area (Beverly Foundation 2004). The results of these activities are available on the AAA Foundation for Traffic Safety website. Links to this and other resource documents highlighted in this chapter can be found under Useful Web Resources at the end of this chapter. SUMMARY TRB Special Report 218: Transportation in an Aging Society marked the beginning of efforts in this country to address the safety and mobility needs of a growing population of older road users. Since its publication in 1988, the U.S.DOT and its FTA and NHTSA have undertaken significant research, pro- grammatic, and policy initiatives promoting the theme of Safe Mobility, for Life. Other national organizations, includ- ing TRB, NCHRP, AASHTO, and a wide range of private, nongovernmental organizations have contributed to the efforts. The result is a strong basis for the many programmatic activi- ties featured in the remainder of this report. Useful Web Resources Transportation in an Aging Society: A Decade of Experi- ence, Transportation Research Board, Washington, D.C., 2004 [Online]. Available: http://gulliver.trb.org/publica- tions/conf/reports/cp_27.pdf. Improving Transportation for a Maturing Society, U.S. Depart- ment of Transportation, Washington, D.C., 1997 [Online]. Available: http://www.volpe.dot.gov/opsad/mature.html. “Safe Mobility for a Maturing Society: Challenges and Oppor- tunities,” U.S. Department of Transportation, Washington, D.C., 2003 [Online]. Available: http://www.eyes.uab.edu/ safemobility/SafeMobility.pdf. Highway Design Handbook for Older Drivers and Pedestri- ans (Staplin et al. 2001a) [Online]. Available: http://www. tfhrc.gov/humanfac/01103/coverfront.htm. NHTSA older driver website: [Online]. Available: http://www. nhtsa.dot.gov/people/injury/olddrive. Safe Mobility for Older People Notebook (Staplin et al. 1999) [Online]. Available: http://www.nhtsa.dot.gov/people/ injury/olddrive/safe/. Model Driver Screening and Evaluation Program (Staplin et al. 2003) [Online]. Available: http://www.nhtsa.dot.gov/ people/injury/olddrive/modeldriver. Summary of Medical Advisory Board Practices in the United States (Lococo 2003) [Online]. Available: http://www. aamva.org/Documents/drvSummaryOfMedicalAdvisory BoardPractices.pdf. A Guide for Reducing Collisions Involving Older Drivers (Potts et al. 2004) and A Guide for Reducing Collisions Involving Pedestrians (Zegeer et al. 2004) [Online]. Avail- able: http://safety.transportation.org/. Transit Cooperative Research Program reports [Online]. Available: http://trb.org/news/blurb_browse.asp?id=1. Promising Approaches for Enhancing Elderly Mobility (Molnar et al. 2003) [Online]. Available: http://www. umich.umtri.edu (search on report 97337). Best Practices for Elderly Mobility Conference Proceedings [Online]. Available: http://www.aaafoundation.org. (or contact the AAA Foundation to order a CD-ROM). Supplemental Transportation Programs for Seniors (Beverly Foundation 2004) [Online]. Available: http://www.aaa foundation.org/pdf/STP2.pdf. Massachusetts Institute of Technology AgeLab, Cambridge, Mass. [Online]. Available: http://web.mit.edu/agelab/proj- ects_driving.shtml. Senior Transportation Safety and Mobility (special issue of the Journal of Safety Research, Vol. 34, No. 4, 2003) [Online]. Available: http://www.sciencedirect.com/. The Mobile Elder: Getting Around in Later Life (special issue of Generations, the journal of the American Society on Aging, Summer 2003) [Online]. Available: http://www. generationsjournal.org/gen28-2/home.cfm.