Safe Mobility for Older Americans (2005)

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4Crosscutting Issues The preceding chapter organized the committee’s findings and recommendationsunder five headings: strategic considerations, drivers, vehicles, the roadwayenvironment, and alternative transportation. However, safe mobility for older persons as an issue cannot be so succinctly categorized; there are facets that cut across the boundaries of any taxonomy that might be created. Effective solutions to the transportation safety and mobility needs of an aging population will depend on more than research programs, demonstration projects, and professional discussions that point toward technically feasible solutions. Responsible discussions will entertain more than transportation-related solutions and, for that matter, will go beyond a focus on older persons. This chapter presents the following crosscutting issues: policy, planning, cost–bene- fit considerations, and technology. These issues do not affect any single part of the transportation system, the population, or the political process; rather, they cut across all topics and boundaries. POLICY Assumptions about the future transportation desires and needs of older persons have been made on the basis of a combination of research studies, surveys, focus groups, and professional dialogue. One common theme emanates from researchers, practition- ers, and policy makers: mobility reduction is not a solution to the safety problem that might be generated by more older adults taking more trips and driving more miles. Nor is it a solution to the larger issue of the social and political trade-offs implied by using the nation’s limited resources to create transport systems and options that keep America’s seniors moving. The technical papers by Freund (2004) and Cobb and Coughlin (2004) both address policy as a separate issue, but many of the other papers commissioned for the confer- ence also have policy implications. Without clearly articulated and widely supported policy decisions that promote and encourage the development, implementation, and evaluation of programs, and the dissemination of knowledge gained from these efforts, the objectives may be difficult if not impossible to achieve. The allocation of limited resources across all ages and across all issues requires a delicate balancing act, and there are always winners and losers to some degree. The best options are often those that benefit more than one age group or those that affect more than one issue. Therefore, consideration might focus on how transportation 29

enhancements benefit not just older recipients but also the larger society. The follow- ing are examples: • With earlier retirements and improving health and life expectancy, older citizens are enjoying increasing numbers of potentially productive years (Bass 1993, 6). The availability of transportation can enable many of them to access goods and services that enhance a community’s economy. Furthermore, they may continue to participate in the workforce, which contributes to the overall economy, as well as Social Security and Medicare funding. • Older persons contribute hundreds of thousands of volunteer hours. They give back to society in ways that amount to millions of dollars worth of labor and expert- ise. Loss of mobility would seriously affect the ability of seniors to access locations where these hours are donated. • Senior-friendly land use policy may lead to sidewalks and crosswalks that allow older persons to walk more easily and safely. Policies that support the design of “liv- able communities” can ultimately improve quality of life for all citizens. Regardless of the difficult decisions that lie ahead with respect to balancing com- peting interests and scarce resources, providing safe mobility for older persons at some level is vital to the future of the nation. To accomplish such a goal, one overrid- ing issue outweighs all others: leadership or decision making in the political context. While considerable progress has been made since the publication of Special Report 218 (TRB 1988), a highly visible agency or organization has not appeared to assume ownership of the issue and coordinate advocacy on its behalf. Furthermore, a compre- hensive, coordinated, and communicated transportation policy has not been forthcom- ing (Cobb and Coughlin 2004). The issue of older-person safety and mobility is owned by a group of unwilling participants, including physicians and other health care practitioners, families, and law enforcement. A small group of passionate researchers and advocates continue to study and speak out, but they lack the visibility and coordination to be heard convinc- ingly. Sustained, articulate, and highly visible leadership is necessary to the develop- ment and implementation of effective solutions. One encouraging sign is the recently published Physician’s Guide to Assessing and Counseling Older Drivers (www.ama- assn.org/ama/pub/category/10791.html), which was developed by the American Medical Association in cooperation with the National Highway Traffic Safety Administration. It was developed to assist physicians in evaluating the ability of their older patients to operate a motor vehicle safely as part of their everyday personal activities. The previous discussion leaves unanswered the question of “formal” regulation through licensing agencies. However, a primary trade-off in using licensing regula- tions to ensure safety may be a reduction in mobility. As has been discussed else- where in this document, loss of mobility certainly leads to degradation in the quality SAFE MOBILITY FOR OLDER AMERICANS 30

of life, more illness brought on by isolation and depression, and losses to the econo- my in terms of opportunities to work and volunteer for programs that enhance the community. Beyond their implications for driver licensing, policy initiatives will determine the broader distribution of resources, which affects the decision to build roadways and vehicles that are safer and easier to use, to develop new technologies, to create trans- portation alternatives, and to provide the training and technical assistance required by older populations and their caregivers. PLANNING Safe mobility for older persons requires planning at all levels: federal, state, local, and individual. Planning experts and institutions are quite capable in terms of analyzing data, predicting future conditions and outcomes, and developing solutions. However, their recommendations are ultimately subject to a political process that makes deci- sions incrementally and is subject to political trade-offs (Cobb and Coughlin 2004). Many proposed initiatives, such as building safer roads and vehicles and reinventing licensing agencies, will take many years to design and implement effectively and suc- cessfully. The planning process is a crucial first step. For example, careful land use planning could result in at least three desirable options for seniors: more pedestrian- friendly communities, communities with convenient transportation options, and commu- nities designed to include basic life-supporting and social services. The process, howev- er, requires collaboration and cooperation among a variety of agencies and the private sector. Such partnerships are not commonly found in this culture; progress will be slow and, in some cases, require entirely new ways of thinking, planning, and operating. At the very least, older persons can be encouraged to plan for their future trans- portation needs—something that far too few are currently doing—at the same time that they plan for retirement housing, health insurance, medical care, and the eventual disposition of their assets. Lawyers, physicians, and others can be brought into the mix of advocates to assist seniors in planning for their future transportation needs. The costs of elder isolation in terms of health care, personal well-being, human capital, social connectivity, and the stress and productivity losses of caregivers are pressing societal issues that demand attention. COST–BENEFIT CONSIDERATIONS Maximizing personal mobility carries both costs and benefits. It is enlightening to examine the costs and benefits of maintaining mobility as people age, whether by continuing to drive or by seeking alternatives to driving. For example, while roadway enhancements and vehicle design improvements that specifically target older road users are costly, such enhancements ultimately can yield significant cost savings because of the safety benefits accruing to all road users. However, it must be recog- CROSSCUTTING ISSUES 31

nized that the benefits of maintaining driving in the face of age-associated functional declines often come at a cost in terms of safety. While no one would deny the impor- tance of driving as the premier means of mobility for all adults, not just older adults, driving will be accompanied by crashes, injuries, and deaths. The primary purpose of the transportation system is mobility; however, for the sake of safety, mobility is lim- ited by speed limits, required stops at red lights, suspension of the licenses of those who drive while under the influence of alcohol, and so forth. Society places great value on the level of personal mobility afforded by the private automobile, and most people, older adults included, are willing to accept a certain level of risk to maintain this high level of mobility. For older adults facing declining functional abilities, the question is at what point the cost of increased crash risk exceeds the benefit of contin- ued freedom of mobility and the opportunity to continue contributing to society. The functional changes that increase with age, certain medical conditions, and cer- tain treatment regimens can produce mobility losses associated with a number of neg- ative consequences that must be adequately addressed. What happens when driving oneself is no longer a viable option? Just as there are costs associated with continued driving in terms of increased crash risk, there are costs associated with limiting or stopping driving. The result of driving restriction or cessation is often a reduction in overall mobility, which has been associated in the literature with decreased activity levels, increased loneliness and depression, increased incidence of certain negative health outcomes, and lower life satisfaction (Marottoli et al. 1997). Thus, once again, there are trade-offs between personal safety and personal mobility. The suburbanization of America and the phenomenon known as “aging in place” have resulted in the majority of older persons living out of the range of public trans- portation alternatives. Even when these alternatives are accessible, many older per- sons are uncomfortable or physically unable to take advantage of them. In many instances, the situation is further complicated by fears for personal safety. Yet it is essential to understand the cross-sector benefits of senior mobility options in order to comprehend their importance. A 1994 British study showed that the savings in health care and social service costs achieved by making transport fully accessible to older and disabled persons might reach as much as $55,000 per 1,000 people per year, ignoring any additional transport costs (Carr et al. 1994). Training and accompanied practice in the use of public transit have increased its use among the older population in some communities. Such approaches will undoubtedly be identified, studied, and documented for technology transfer to other areas. Using friends and family (when in proximity) for transportation may well become part of any universal policy on transportation alternatives for older persons, since reports show that riding with friends and family is the first transportation alternative of choice. The associated costs include the costs and inconvenience to the “chauffeur” and the feelings of inadequacy felt by the driver-turned-rider. Current young and mid- dle-aged adults have become known as the “sandwich generation” because they are responsible for their elder parents as well as their children. Providing transportation for SAFE MOBILITY FOR OLDER AMERICANS 32

older relatives can become extremely burdensome when it is mixed with home, work, and other responsibilities. At the same time, older persons report that they are uncom- fortable relying on others to meet their transportation needs and are reluctant to do so, even at the expense of their own mobility. In some cases, the personal and social costs may simply be too high for both the older adult and his or her family members. Paratransit or door-to-door on-demand transportation is the mostly highly desired transit option. However, there are many problems associated with this alternative, including the lack of regional coordination, the lack of sufficient personnel and vehi- cle capacities, the cost and difficulty of providing the service, and the limited purpos- es for which it may be provided (e.g., only for medical appointments and grocery shopping). Some champions of paratransit services believe that a local policy based on sophisticated technology, public funding, and volunteerism can provide these serv- ices effectively and efficiently (Freund 2004). This option deserves further investiga- tion; its implementation will depend on (a) clearly stated and supported policy deci- sions, (b) an effective communication and dispatching system supported by a mobility manager, (c) efficient coordination to preserve resources and promote sustainability, and (d) impassioned leadership at the local level. As described earlier, the Maryland MVA Older Driver Program encourages a com- monsense approach to understanding the needs of its citizens, regardless of age, and recognizes the benefits of safe mobility for life. Future discussions might profitably focus on changing existing public perceptions of older-driver competency, shifting the focus from driving cessation to maintaining independence while helping aging drivers and their families prepare for stages of driving cessation, and promoting alternative transportation resources as aging drivers become unable to remain independent through driving. Supplemental transportation programs for drivers who may be restricted or are unable to continue driving could be augmented by programs to assist low-income drivers with the costs of driver assessment and remediation. TECHNOLOGY The past decade has been marked by technological advances in assessment and inter- vention approaches aimed at extending safe driving among older adults. Technological advances have occurred in the assessment of higher-order information processing, other functional abilities, and driving behaviors via increasingly refined and computer-based measurement tools as well as simulator-based technology. In addition, major developments have occurred in the area of intervention approaches since Special Report 218 was published, including cognitive rehabilitation approaches and the rapid growth in ITS research and development. As discussed previously, degradation in visual information processing skills has emerged as a strong predictor of unsafe driving. These skills have long been suspected to play a role in automobile crashes, and this relationship has been extensively explored in recent years with the use of automated testing (Ball et al. 2002; Ball and Owsley CROSSCUTTING ISSUES 33

1991; Owsley et al. 1998). Through advances in the use of computerized testing to measure functional abilities in drivers, new tests have been developed that have proved much better at identifying crash-involved drivers than screening tests of the past. Indeed, where preference was given a decade ago to paper and pencil–based approaches to assessment, the prevalence of technology today in virtually every setting has led many investigators to transform these tests into an automated format. For example, the screen- ing battery currently in use in the Maryland MVA Older Driver Program is entirely automated, which streamlines the data collection and analysis functions.3 Technological advances have also had an impact in remediation approaches for the functional abilities associated with increased crash risk. For example, the significance of UFOV performance to driving has led to an intervention approach that is based on UFOV assessment technology. Known as speed of processing training, this interven- tion uses a 10-session, computer-based program targeting improvement in the speed with which older adults can process information in a variety of everyday contexts, including driving (Ball et al. 2002; Edwards et al. 2002; Roenker et al. 2003). This approach has been shown to improve the UFOV, choice reaction time, and the time taken to perform instrumental activities of daily living, and has also been shown to reduce the number of dangerous maneuvers committed on the road by older adults with pretraining impairments in the UFOV.4 These effects have been shown to endure for at least 18 months to 2 years (Roenker et al. 2003). Other cognitive training proto- cols have been designed for improving memory and problem-solving skills. Recent research has shown that improvements in these abilities that are related to certain demands of the driving task are indeed possible (Ball et al. 2002), although no trans- fer of these improvements to mobility improvements has been indicated. These train- ing programs are now also under development in an automated format. Many mobility and safety problems result from a poor fit between the older road- way user and the highway infrastructure. Such problems may be amenable to remedi- ation through the strategic application of ITS technology, which synthesizes advances in wireless communication, computing, and GPS. However, ITS technology offers the potential to increase the burden of older travelers if the information-processing demands of in-vehicle interfaces are engineered without regard for their emerging needs and changes in capacity. Special care is needed to ensure that older road users are not engineered out of next-generation vehicle–highway systems (Schieber 2004). The automobile industry has responded to the needs of older drivers through a vari- ety of initiatives. In-vehicle navigation, automated emergency response, night vision SAFE MOBILITY FOR OLDER AMERICANS 34 3 This screening battery is called the DrivingHealth Inventory. Additional information on this battery can be found at www.drivinghealth.com. 4 The interventions, however, have not been tested extensively on older adults with dementia. The interventions have been shown to work on older adults with processing speed impair- ments but without dementia.

enhancement, crash avoidance warning signals, and improved occupant protection are some of the innovations produced in recent years. Few ITS applications are now used by drivers and fewer still are used by older drivers, but this situation is likely to change in coming decades. These improvements can assist older persons in driving longer and improve the crashworthiness of the vehicle, which increases the likelihood of survival and reduces the incidence and severity of injury in the event of a crash. However, for new technologies to be truly effective and enhance the safe mobility of older persons, manufacturers must provide education and instruction to facilitate safe use. While some older adults welcome new technologies, many are less confident in their abilities to operate new technologies. Fear of technology, difficulty in operating a device while driving, display information legibility, and the need for specific training are likely to be persisting difficulties for older drivers using ITS technologies (Caird 2004). Further- more, there are serious and unanswered questions about the workload capacity of all drivers. These technologies may overload the driver and result in inattention or distrac- tion, factors that are associated with many accidents. Thus, while the number of ITS applications continues to grow, the value and functional advantage of new driver infor- mation, for older drivers in particular, have yet to be determined. CONCLUSION Policy makers at all levels of government in the United States must seriously consider and decide when, what, and where safe mobility options for older persons will be pro- vided. They must understand that the cost of providing services to help maintain safe mobility may occur in an arena different from the benefits. For example, savings in health care costs to the nation as the result of maintained mobility will not directly benefit driver assessment or remediation practices. In the near term, coordination of services and widespread communication about available services, technology options, and other assistance are necessary. For the future, comprehensive public policy and sustained, forceful leadership will be required to address and provide solutions for the safe travel of the nation’s older citizens. There will most certainly be trade-offs in the allocation of resources; however, some options can enhance the welfare of not only older persons but also society in general. It is wise to identify these options and use them as the foundation for other building blocks to develop a comprehensive set of policies and strategies that will keep America’s older citizens on the move. REFERENCES Ball, K., D. B. Berch, K. F. Helmers, J. B. Jobe, M. D. Leveck, M. Marsiske, J. N. Morris, G. W. Rebok, D. M. Smith, S. L. Tennstedt, F. W. Unverzagt, and S. L. Willis. 2002. Effects of Cognitive Training Interventions with Older Adults: A Randomized Controlled Trial. Journal of the American Medical Association, Vol. 288, pp. 2271–2281. CROSSCUTTING ISSUES 35

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