Safe Mobility for Older Americans (2005)

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3Committee Findings and Recommendations The committee members reviewed available data, deliberated among themselves,and used professional judgment to synthesize findings and recommendationsfrom the technical papers, discussions, and information provided at the interna- tional conference, in numerous focus groups, in Special Report 218, and from other sources. The resulting recommendations are directed to policy makers, the research community, government agencies, older persons and their caregivers, the private sec- tor, and other stakeholders. The committee’s findings and recommendations are presented under five headings: strategic considerations, drivers, vehicles, the roadway environment, and alternative transportation. Two types of recommendations are offered: (a) actions that should be considered now to improve older adult safety and mobility and (b) future research needs. In some cases action was thought essential, but the committee recognized the need for more research before effective initiatives can be designed and implemented with confidence. STRATEGIC CONSIDERATIONS Actions for Current Consideration Meeting the transportation needs of older people will require a comprehensive strategy. At the national level it will be necessary to focus the nation’s attention on issues such as the following: educating policy makers on aging and transportation concerns, consider- ing the need to support remediation and training to keep older drivers safely on the road, and encouraging the design of better highways and more crashworthy vehicles. At the state level, the establishment of statewide consortia could be encouraged, including members from most state agencies, professionals (medicine, social services, safety groups, law enforcement, AARP, American Automobile Association, area agencies on aging, etc.), nonprofit agencies involved with seniors, transportation services, academic institutions, and others. Key goals of these consortia would include the following: • Ongoing improvement of driver assessment practices, including identification and counseling of the at-risk driver (linking research to practice); • Ongoing improvement of the remediation and training programs available to the at-risk driver (linking research to practice); 17

• Coordination of user-friendly mobility options for drivers who are restricted or must cease driving; • Coordination of effective public and private systems for the delivery of services; • Development of public information and education programs on the functional capacity changes that may occur with aging, how these changes may affect driving, and the importance of planning for driving limitations or driving cessation; • Ongoing implementation of roadway design and rehabilitation improvements; • Ongoing improvements of vehicle crashworthiness; and • Encouragement of land use designs that will provide senior-friendly housing choices. A comprehensive strategy is recommended in which national, state, and local gov- ernment agencies work in partnership with private-sector institutions, organizations, and older persons themselves to develop and implement practical, affordable, and effective solutions that preserve safe and independent mobility for older Americans while serving the public health and safety needs and promoting the quality of life and economic vitality of society as a whole. Research Needs The quantity and quality of research addressing safe mobility for older persons that has been accomplished over the past decade are remarkable. However, even with the publication of the current update report, gaps continue to exist. An ongoing initiative to identify and catalogue research needs will ensure a reduction in overlap and a focus on projects with the greatest and most immediate benefit. Accordingly, the committee believes that a continuing effort is needed to review research accomplishments, identi- fy gaps in the knowledge base, and develop research agendas to help guide the efforts of researchers and focus scarce resources where they will produce the greatest benefit. Providing safe mobility for older persons presents a multifaceted and complex series of issues to be addressed. To succeed, a comprehensive policy supported by effective implementation strategies is required. Yet, the past decade has produced little in the way of a comprehensive policy to address the mobility needs of an aging nation. Without leadership and intervention, transportation policy making appears likely to continue its struggle for serious attention from the public and policy makers (Cobb and Coughlin 2004). To contribute to progress on this front, existing research and research applications should be reviewed and catalogued with the goal of identi- fying potentially effective policy initiatives. DRIVERS Actions for Current Consideration Much older driver safety research over the past decade has focused on identifying fac- tors that increase crash risk among older drivers. Such factors include some medical SAFE MOBILITY FOR OLDER AMERICANS 18

conditions and the medications used to treat them, as well as visual, cognitive, and physical impairments that become more prevalent among older adults. In addition, research has evolved from simply identifying aging adults with functional deficiencies and removing them from the driving population to identifying those with specific con- ditions that place them at increased crash risk and intervening to promote safe mobili- ty (Owsley 2004). It is a myth that aging makes all older persons high-risk drivers. Owsley (2004) summarizes recent research concerning which functional impairments, medical condi- tions, and medications place some older drivers at increased risk and discusses efforts to develop interventions that reduce their impact on older-driver safety and mobility. Many older persons do not differ significantly in their driving skills from their mid- dle-aged counterparts, who statistically are the safest group on the road per mile driv- en (Staplin and Hunt 2004). Seniors suffer a profound loss of quality of life when their mobility becomes signif- icantly restricted, with cascading costs to families and to society. Since the dominant form of transportation remains the personal automobile, retaining one’s driving privi- lege is presently, and for the foreseeable future, the strongest determinant of mobility. Hence, the inherent conflict for practitioners is to balance quality-of-life issues for the individual with public safety considerations (Staplin and Hunt 2004). Ultimately, responsibility for removing unfit drivers from the roadways lies with the motor vehicle licensing and regulation agencies in each state. However, many of these agencies are poorly equipped to meet this obligation in terms of enabling leg- islation, training personnel, and other resource issues. Accordingly, consideration should be given to the following approaches: • Encouraging motor vehicle agencies or departments of public safety responsible for driver licensing, license renewal, and vehicle registration to adopt practices that reflect an understanding of the functional declines in key safe driving abilities that occur with normal aging and the diseases associated with aging and that place older persons at risk for crash involvement. This effort would require appropriate administrative and medical staff within these agencies or departments to allow for fair, competent, and timely review of all cases in which a fitness-to-drive determination is required. • Cataloguing the laws and capturing the actual practices for reporting at-risk driv- ers in different states and comparing the consequences for public safety and personal mobility from one jurisdiction to another. An effective way to accomplish this might be to establish a national organization made up of administrative and medical staff from each jurisdiction to seek harmonization of reporting and review practices. • Continuing the development of a model licensing process that emphasizes a cost- effective driver screening and assessment program to help ensure a minimal level of fitness for all licensed drivers referred to medical advisory boards. Through preven- tion and remediation activities, this process aims to extend the safe driving years for as long as possible. COMMITTEE FINDINGS AND RECOMMENDATIONS 19

Certified driving rehabilitation specialists drawn principally, though not exclusively, from the occupational therapist profession constitute perhaps the largest group of practitioners in the United States with the expertise necessary for identifying and counseling high-risk older drivers. There are, however, far too few such specialists nationwide to meet the need. Occupational therapists are integral members of the health care system and com- bine in-depth understanding of the functional requirements for driving with insights about the extent to which clients rely on driving to meet their everyday needs. They may be in an ideal position not only to evaluate fitness to drive but also to identify and provide referrals for specialized treatment or appropriate rehabilitation/remedia- tion programs (Staplin and Hunt 2004). To provide enhanced expertise in this area, consideration should be given to expanding in-service medical education for professionals in driver assessment, reha- bilitation, and referral options. The number of occupational therapists and others trained as certified driving rehabilitation specialists could be expanded, as could the role of driving schools that are interested in increasing their technical competence through special training programs to focus on the needs of older drivers. Assistive technology refers to equipment that can be used to increase, maintain, or improve the functional capabilities of individuals with disabilities. One of the most active areas in this field is the development of automotive adaptive equipment and vehicle modifications. While age is not considered a disability, there are conditions associated with aging that can be effectively managed with the use of appropriate assistive technology (Koppa 2004). Much may be known by the disability community that could be extended to the older-driver population more generally. In this regard, it would be useful to catalogue and disseminate information about assistive devices that can help compensate for functional changes associated with the aging process. Public opinion draws its primary perceptions from the occasional tragic crash involving an older driver. Research clearly demonstrates that these episodes are not representative, but it also serves to identify the physical and cognitive problems many older drivers eventually face. The pace of age-related debilitating change cannot be predicted for the individual, but for older drivers as a group, many characteristics can be anticipated and responses developed. A public information and education program could disseminate accurate knowledge, distribute specialized information and correc- tive strategies to help older people stay safely on the road longer, alert seniors to the possibility that one day they may have to move out of the driver’s seat into an alterna- tive means of transportation, and enlighten the interest groups with a particular stake in the safety and mobility of seniors (Milton 2004). The committee believes that it would be useful for current research findings to be summarized and synthesized to provide a basis for developing and implementing pub- lic information and education campaigns targeted to increase awareness of the trans- portation challenges facing older adults. Such campaigns could focus on SAFE MOBILITY FOR OLDER AMERICANS 20

• Providing information on strategies for maintaining mobility through driving or the use of alternative transportation options, • Informing older persons about the importance of planning for driving limitations or cessation, and • Encouraging individuals to plan and save for their future mobility needs. Research Needs It is well established that the range of performance for older age cohorts dramatically exceeds the range for younger ones, and as the distribution of abilities flattens and elongates with advancing age, characterizing an individual in terms of a group average is prone to error. Thus, the use of a person’s chronological age alone as a surrogate for driving risk has been fairly and consistently criticized (Staplin and Hunt 2004). Research should be continued to identify the precise characteristics that distinguish safe drivers from those who are at elevated crash risk or who are no longer capable of driving safely. These results can assist in developing more effective and efficient screening and intervention methods. As treatments, countermeasures, interventions, policies, and programs affecting older- person driving and mobility are developed, evaluation of their effectiveness is crucial. It is important to understand the safety implications, as well as the potential societal and personal costs and benefits. An effort is needed to rigorously evaluate and document the effectiveness of interventions for reducing crash risk by overcoming functional impair- ments such as treatment of eye conditions, training in specific cognitive skills related to driving, physical training, exercise regimens, and driver education programs. The evidence indicates that most older drivers have a general awareness of their diminishing capabilities and make appropriate strategic and tactical adaptations to compensate. The result is that their absolute crash involvement rates, calculated per million drivers, remain at the levels of middle-aged drivers until advanced age. Older drivers can be assisted in making appropriate adaptations through driver education efforts, but research is needed to develop specific advice on how best to reduce risk (Smiley 2004). This effort will entail • Further identifying and defining the characteristics (physical, emotional, social, cognitive, etc.) of persons who appropriately modify their driving behavior in response to declining functional abilities, and the types of modifications they use; • Developing materials and methods, such as self-assessment tools, to make drivers more aware of how functional declines can affect their driving performance and pro- viding them with specific steps they can take to modify their driving behavior and reduce their crash risk; and • Developing supporting materials (screening tools, evaluation guides, etc.) for the medical community, caregivers, licensing regulators, and others to assist older drivers in appropriate modifications of driving behavior. COMMITTEE FINDINGS AND RECOMMENDATIONS 21

Finally, there is little doubt that “volunteer bias” is present in at least some of the stud- ies of older travelers. Given the assumption that better-educated and healthier people are more likely to volunteer as participants in research projects, logic dictates that the sam- ples tend to be slightly biased toward the “cream of the crop” (Schieber 2004). To avoid this bias, promising findings should be replicated in larger field studies. Population-based evaluations of screening, assessment, and intervention methods (proved in smaller field or laboratory studies) should be conducted in real-world settings. VEHICLES Actions for Current Consideration Vehicle-related safety improvements are designed to prevent crashes (crash avoid- ance), protect vehicle occupants and pedestrians in the event of a crash (crashworthi- ness), and assist vehicle occupants and other road users after a crash has occurred (postcrash assistance). Crash avoidance technologies can be direct, such as speed controls that automati- cally reduce speed if the vehicle is too close to another in front, or indirect, such as comfort and convenience features designed to reduce fatigue, aid concentration, and generally improve driver attentiveness and performance (Pike 2004). Crashworthiness refers to the safety performance of the vehicle in the event of a crash and relates to concepts such as safety belts, air bags, and head restraints. It may also include attention to a vehicle’s impact on striking a pedestrian (Pike 2004). The greater physical frailty of older persons leads to a greater likelihood that they will be killed or injured in a crash. It is estimated that at least half of the increased fatality risk of drivers age 75 years or older compared with 30-year-old drivers might be due to frailty, which brings about a higher susceptibility to being killed in a given crash, rather than to a higher probability of crash involvement (Hakamies-Blomqvist 2004). Furthermore, the disproportionate fatality rate of older pedestrians who are struck by motor vehicles is mainly due to increasing fragility of people as they age. Characteristics of vehicle design can have a marked effect on the nature and severity of the injuries sustained by a pedestrian struck by a vehicle. One area currently being addressed for pedestrian protection internationally is the design of vehicles to effec- tively provide the pedestrian with “optimum” crash conditions (Oxley et al. 2004). Consideration should be given to older-person characteristics, capabilities, and limita- tions in designing the driver–vehicle interface in order to minimize the occurrence of crashes. In the development and testing of occupant restraint systems, the physical characteristics and, in particular, greater fragility of older persons’ bodies should be considered to maximize the level of protection provided while minimizing the risk of inducing injury. Technology to improve the safety performance of motor vehicles holds promise for protecting older persons. Intelligent transportation systems (ITS) rest on various com- binations of advances in wireless communication technologies, automotive electronics, SAFE MOBILITY FOR OLDER AMERICANS 22

computing, and the Global Positioning System. A number of ITS applications may have importance for older drivers (e.g., route guidance, emergency vehicle location and response, vision enhancement systems, and collision warning systems) (Caird 2004). Accordingly, the committee believes that industry research into and development of ITS should be promoted and that automakers should be encouraged to provide educa- tion in new technologies. In addition, the insurance industry should give consideration to offering technology discounts for use of proven “safety technologies.” Research Needs Areas for future vehicle-related research include the following: • The role of advanced technologies in the safe mobility of older persons could be defined and evaluated. Findings from these inquiries could be applied in vehicle and system design and operation. • Vehicle technologies that address the unique safety and operational issues (slow- er reaction times, poorer nighttime vision, loss of joint flexibility, etc.) associated with older drivers, passengers, and pedestrians could be studied. ROADWAY ENVIRONMENT Actions for Current Consideration By 2020, adults aged 65 and older will account for an estimated one-fifth of licensed U.S. drivers. “In effect, if design is controlled by even 85th percentile performance requirements, the ‘design driver’ of the early 21st century will be an individual over the age of 65” (Staplin et al. 2001). The good news is that roadway improvements intended to help the older driver generally benefit all road users. The most widely used guidelines for highway design in the United States are those published in A Policy on Geometric Design of Highways and Streets, the “Green Book,” created by the American Association of State Highway and Transportation Officials (AASHTO). Many of the design formulas in the the Green Book are based on assumptions about the perception–reaction time of the “design driver.” Special Report 218 presented evidence suggesting that the perception–reaction time assump- tions of the models of driver behavior used in the AASHTO Green Book may not allow sufficient time to accommodate the general behavioral slowing seen in older road users (Schieber 2004). Several major categories of research in the area of highway geometric design and operations received considerable attention during the decade following the issuance of Special Report 218. Perhaps the most critical work in this area dealt with research that evaluated whether commonly applied models of human driving performance accommodate the capabilities of representative older drivers. The accumulated wis- dom of this research was published in the Older Driver Highway Design Handbook (FHWA 1998) and updated in Highway Design Handbook for Older Drivers and COMMITTEE FINDINGS AND RECOMMENDATIONS 23

Pedestrians (Staplin et al. 2001b) and its companion, Guidelines and Recommen- dations to Accommodate Older Drivers and Pedestrians (Staplin et al. 2001a). What is needed now is implementation of the Highway Design Handbook in roadway con- struction and rehabilitation initiatives and through modification of current design practices and standards. Similarly, the handbook guidelines for sidewalk and walkway construction in areas populated by older adults merit implementation, and walking should be promoted as a transport mode as well as for exercise and recreation. Research Needs Since publication of the Highway Design Handbook, many states and communities have implemented some of the recommended infrastructure improvements. However, evaluation results are nearly nonexistent. Evaluation efforts are needed to determine the effectiveness of specific provisions, such as improved delineation for night driv- ing, as well as to provide support for expanded implementation. Such efforts could include • Cataloguing and evaluating the impact of state and local efforts to apply FHWA’s Highway Design Handbook for Older Drivers and Pedestrians (these results can help identify future research and development needs), and • Identifying and publicizing state and local best practices in the area of roadway improvements to accommodate older drivers and pedestrians. ALTERNATIVE TRANSPORTATION Actions for Current Consideration Significant research efforts have examined travel behavior, technological innovation, and service provision, but the true challenge may be to understand personal lifestyle and transportation decision making as people age. Where people choose to age and how they allocate their resources are personal decisions that will influence the range of mobility choices they will have when they are old (Cobb and Coughlin 2004). Older persons have shown a strong preference for privately owned automobiles as their transportation mode of choice. However, mobility alternatives to the private automobile may first be sought for the trips that older drivers choose to avoid (e.g., nighttime, congested areas, and peak times), and they later may be sought for all trav- el by people who have stopped driving entirely. These options allow older persons to maintain their dignity, independence, and choice for as long as possible (Suen and Sen 2004). The key characteristics of mobility options to the automobile have been described in terms of “the five A’s”: availability, accessibility, acceptability, affordability, and adaptability (Kerschner and Aizenberg 2004). Transportation alternatives must be available when they are needed, including evenings, weekends, holidays, and specific SAFE MOBILITY FOR OLDER AMERICANS 24

days of the week. They must also be accessible: bus stairs must be negotiable; chair seats must be high enough, the bus stop must be within walking distance; pickups must come all the way up the driveway. To be acceptable to older adults, transporta- tion alternatives need to be clean, safe, and user-friendly. To make them more afford- able, they can incorporate a coupon or voucher system for those who cannot pay the normal user-based fees. Finally, alternative transportation systems for older adults need to be adaptable to meet the special needs of the older population. Examples are accommodating wheelchairs and making multiple stops in a single trip. On the basis of these characteristics, consideration should be given to the following approaches to improving transportation alternatives for older adults: • Identifying and publicizing model programs from across the United States and abroad that best serve the transportation needs of older adults and promoting more widespread implementation of successful programs; • Providing access to “mobility managers” at the state and community levels who assist older persons in identifying accessible alternatives for their transportation needs; • Taking steps to ensure that the lighting, visibility, and personal security needs of older persons are addressed in transit and paratransit2 systems; and • Reviewing and, if appropriate, amending state liability statutes to provide protec- tion to volunteer driver networks, and educating volunteers about these protections. Well-trained, sensitive, and helpful staff are at least as important as high-quality equipment and infrastructure and can make up for many deficiencies in equipment. Transport personnel often do not adequately understand the mobility needs of seniors or the mobility limitations and abilities of those with impairments. Sensitivity training and certification, with the aid of gerontologists who are familiar with age-related mobility declines, could be expanded for transportation personnel (including manage- ment, operations, and frontline staff) who are involved in the provision of services for the aging. Licensing bureaus or some other entity could be reinvented to serve as mobility resource centers. COMMITTEE FINDINGS AND RECOMMENDATIONS 25 2 “Paratransit” does not have a standard definition, but it has come to mean public or group transportation, usually provided by automobiles, vans, or minibuses, organized to complement standard fixed-route transportation. Paratransit services often provide mobility to specific population groups, such as the elderly or people with disabilities, who have some difficulty relying entirely on fixed-route transit services. Because paratransit services are in many places offered to comply with requirements of the Americans with Disabilities Act (ADA), the term has come to have a close association in the minds of many with that important law. There are, however, many paratransit services that are independent of those required to com- ply with the ADA.

Many organizations deliver transportation-related services to older persons—the medical community and health care providers, consumer-oriented businesses, senior centers, churches, and so forth. However, these organizations rarely work collabora- tively. Identifying an agency to coordinate these services would reduce overlap and improve transportation alternatives in general. Significant benefits would ensue from improved communication, coordination, and cooperation methods among the diverse agencies involved in serving the older population’s transportation needs. Finally, although many agencies and organizations within a community, region, or state can and should contribute to an integrated alternative transportation system, it is critical that one agency or group assume ownership of the program to ensure its effi- cient operation and long-term viability. In addition to documenting model programs, the policies and structure that are in place to support such programs need to be identified. Successful approaches for mar- keting and promoting such programs should be documented, as well. Research Needs Public and private investment in transportation innovation is vitally important. These investments should increase automobile safety for drivers and passengers but also stimu- late new ways of providing alternative transportation or entirely new service concepts that may fall outside the current institutional capacity of providers. When these solutions are available, decision makers will more likely address the mobility needs of older adults. Policy making most generally links problems to solutions. It is less likely to focus on identifying problems where there are no known, acceptable, and affordable solutions (Freund 2004; Cobb and Coughlin 2004). Research is therefore needed to develop and test innovative solutions for meeting the transportation needs of older adults, including greater use of technology and the linking of available resources in new and creative ways. To complete the picture, there is need for additional research on the economic costs to the individual, family, and community of driving cessation and the loss of mobility, as noted at the conference. In addition to the possible depressive symptoms from the loss of autonomy and social contact, more information is needed about the direct and indirect costs of new demands for time by family caretakers or others to provide mobility; possible earlier admissions to residential care facilities; the loss of participa- tion in the economy; and the impact on local, regional, and national social services and health care sectors. These evaluations will be difficult analytically, but whatever estimates are established would be of substantial use in cost–benefit or policy analy- ses, to put into context higher levels of transportation expenditures for maintaining safe mobility (U.S. Department of Transportation 2004). REFERENCES Caird, J. 2004. In-Vehicle Intelligent Tranpsortation Systems: Safety and Mobility of Older Drivers. In Conference Proceedings 27: Transportation in an Aging Society: SAFE MOBILITY FOR OLDER AMERICANS 26

A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 236–255. Cobb, R. W., and J. F. Coughlin. 2004. Transportation Policy for an Aging Society: Keeping Older Americans on the Move. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 275–289. FHWA. 1998. Older Driver Highway Design Handbook. U.S. Department of Transportation, Washington, D.C. Freund, K. 2004. Surviving Without Driving: Policy Options for Safe and Sustainable Senior Mobility. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 114–121. Hakamies-Blomqvist, L. 2004. Safety of Older Persons in Traffic. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 22–35. Kerschner, H., and R. Aizenberg. 2004. Focus Group Participants Reflect on Transportation. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 293–301. Koppa, R. 2004. Automotive Adaptive Equipment and Vehicle Modifications. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 227–235. Milton, K. 2004. Impact of Public Information on Safe Transportation of Older People. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 259–272. Pike, J. 2004. Reducing Injuries and Fatalities to Older Drivers: Vehicle Concepts. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 213–226. Owsley, C. 2004. Driver Capabilities. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 44–55. Oxley, J., B. N. Fildes, and R. E. Dewar. 2004. Safety of Older Pedestrians. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 167–191. Schieber, F. 2004. Highway Research to Enhance Safety and Mobility of Older Road Users. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 125–154. COMMITTEE FINDINGS AND RECOMMENDATIONS 27

Smiley, A. 2004. Adaptive Strategies of Older Drivers. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 36–43. Suen, S. L., and L. Sen. Mobility Options for Seniors. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 97–113. Staplin, L., and L. Hunt. 2004. Driver Programs. In Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience, Transportation Research Board of the National Academies, Washington, D.C., pp. 69–94. Staplin, L., K. Lococo, S. Byington, and D. Harkey. 2001a. Guidelines and Recommendations to Accommodate Older Drivers and Pedestrians. FHWA-RD-01- 051. FHWA, U.S. Department of Transportation, Washington, D.C. Staplin, L., K. Lococo, S. Byington, and D. Harkey. 2001b. Highway Design Handbook for Older Drivers and Pedestrians. FHWA-RD-01-103. FHWA, U.S. Department of Transportation, Washington, D.C. U.S. Department of Transportation. 2004. Volpe Project Memorandum: Quantifying the Relationships: Aging, Driving Cessation, Health, and Costs. Jan. SAFE MOBILITY FOR OLDER AMERICANS 28