Safe Mobility for Older Americans (2005)

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APPENDIX Summary of Research Recommendations from Technical Papers Conference Proceedings 27: Transportation in an Aging Society: A Decade of Experience Mobility of the Elderly: Good News and Bad News (Rosenbloom) • Investigate the extent to which older drivers reduce, as opposed to modify, driving activities. • Examine the extent to which older persons drive themselves or depend on other care providers to engage in activities. • Investigate the relationship between older persons’ living arrangements and their dependence on friends and family for providing transport. • Create a comprehensive national strategy that includes attention to effec- tive driver evaluation and retraining programs, crashworthy vehicles and improved signage and information systems, user-friendly public transport net- works, transportation alternatives, well-designed land use and housing choices, cost-effective delivery of private and public services, and coordination in the delivery of human and social services. Safety of Older Persons in Traffic (Hakamies-Blomqvist) • Shift the research emphasis from why older drivers are at higher crash risk to which older drivers are at higher crash risk • Examine quality of exposure versus quantity of exposure. • Increase the sample size of the very old (80 and above), particularly in travel surveys, to enable researchers to disaggregate risk by variables such as health conditions and quality rather than quantity of exposure. • Identify the health variables that correlate with accident rates. Adaptive Strategies of Older Drivers (Smiley) • Conduct field tests with ITS technology on drivers prepared to use it. • Identify the causes of driving self-restriction and cessation to determine whether changes are due to lifestyle or functional ability, and examine the implications for mobility. 37

• Identify groups to assist with training and education. • Extend research beyond visual acuity to other vision measures. • Develop and evaluate the effectiveness and cost–benefit relationships of screening tests in various settings, such as departments of motor vehicles, malls, and physicians’ offices. • Conduct research to develop specific advice on the best methods for reducing risk. • Study the role and effectiveness of coping strategies to determine what influences their effectiveness, for whom they work, and how to encourage peo- ple to use them. • Investigate the decision-making processes that result in driver adaptation. • Since changes in operational choices are difficult to bring about and are likely to require expensive one-on-one retraining, focus research on strategic and tactical, rather than operational, choices. • Create effective strategies for providing strategic advice to older persons on the use of seat belts and reducing driving at night, in poor weather, and after drinking alcohol. Include advice on when drivers should restrict their own driv- ing in various ways and when drivers should give up their licenses entirely. • Create additional strategies for offering tactical advice on subjects such as appropriate positioning in intersections for a better view of oncoming traffic when turning left, entering into traffic more quickly once the turn is initiated, and directing attention more consciously to the driving task as opposed to con- versing with passengers while negotiating intersections. • Make older drivers aware of specific limitations that develop with age, such as poorer ability to estimate the speed of approaching traffic. • Develop educational material on older drivers for family members alerting them to appropriate adaptations and to the fact that older drivers do adapt where intervention is required. Driver Capabilities (Owsley) • Clarify the distinction between disease-oriented impairment and cognitive functional impairment due to the normal aging process. • Evaluate and demonstrate the effectiveness and cost–benefit of safety interventions. • Evaluate the effectiveness of coping strategies in terms of how they work, their effectiveness, and strategies for encouraging people to use them. • Continue in-service medical education for professionals in driver assess- ment, rehabilitation, and referral options. • Deploy multidisciplinary teams for assessment, remediation, and counsel- ing. SAFE MOBILITY FOR OLDER AMERICANS 38

• Conduct further research into the relationship between crash risk and visu- al contrast-sensitivity, especially due to cataract. • Determine which screening tests or combinations of tests are the best pre- dictors of crash risk. • Extend research beyond visual acuity into higher-order visual-processing skills in screening at-risk older drivers. • Investigate and document the progression of cognitive impairment and determine the stage at which it becomes a threat to safe driving. • Determine whether physical difficulties in everyday-life activities serve as markers for physical difficulties in operating a vehicle safely. • Investigate minimum levels of physical function necessary for safe driving and the extent to which compensatory behaviors such as driving more slowly and avoiding heavy-traffic areas minimize crash risk among older persons. • Rigorously evaluate and document the effectiveness of interventions for reducing crash risk by overcoming functional impairments such as treatment of eye conditions, training in specific cognitive skills related to driving, physical training, exercise regimens, and driver education programs. Age-Related Disease, Mobility, and Driving (O’Neill and Dobbs) • Conduct research on the relationship between disease and driving and other forms of mobility. • Use dementia as a paradigm for cognitive conditions. • Develop literature on fitness to drive that emphasizes enabling strategies as well as barriers to driving. • Provide education in assessing fitness to drive for specialists dealing with older people and those with disabilities. • Develop specialist centers allied to departments of geriatric medicine and psychiatry to catalogue the development of the skill base required for safe mobility. • Lobby health care insurers to provide coverage for interdisciplinary driver assessment and conduct research that establishes the validity and effectiveness of the process. • Link medical sections of departments of motor vehicles with both public health and medical specialists dealing with older people. • Enlist the support of area agencies on aging to promote a positive agenda and ensure that local guidelines are both evidence based and enabling where possible. • Ensure access to adequate, affordable, and acceptable alternative trans- portation. SUMMARY OF RESEARCH RECOMMENDATIONS FROM TECHNICAL PAPERS 39

Driver Programs (Staplin and Hunt) • Explore financing arrangements, including the role of insurance compa- nies, for assessment and rehabilitation programs. • Develop effective tools for heightening awareness of driver education solu- tions. • Increase the number and availability of driver safety interventions. • Encourage the participation of occupational therapists in medical advisory boards. • Provide incentives to increase the number of certified driving rehabilita- tion specialists. • Design older-driver assessments to identify the best methods for keeping individuals mobile and participating in activities. • Evaluate interventions as they are developed to ensure effectiveness and cost–benefit. • Create multidisciplinary teams to assess, remediate, counsel, and train older drivers. • Modify licensing programs to reflect an emphasis on functional assess- ments. • Utilize medical advisory boards to assess, remediate, and extend driving time under restricted or limited driving. • Heighten public awareness by developing and disseminating information on effective driver education tools. • Expand the number of programs that provide interventions to increase driver safety. • Catalogue the laws and capture the actual practices concerning physician reporting of impaired drivers in the states. Mobility Options for Seniors (Suen and Sen) • Conduct a demonstration trial focusing on families in the continuum of mobility services provided to older persons. • Test the effectiveness of street crossings with people detectors to extend the pedestrian phase of street crossing for slow walkers. • Quantify the importance of mobility to well-being. • Investigate and document the reasons for low transit use among seniors. • Examine census data and forecasts on future geographic distributions of older persons to predict future problem areas. • Study the compatibility of powered wheelchairs with respect to pedestri- ans and other road users. Develop an effective strategy for protecting these road users from traffic. • Define travel options for seniors on the basis of functional ability. SAFE MOBILITY FOR OLDER AMERICANS 40

• Critically examine travel needs and abilities from older persons’ perspec- tives. • Evaluate the effectiveness of travel training and mobility managers. • Document the liability issues related to volunteer drivers and identify strategies for overcoming legal barriers. • Encourage local and state governments to provide transit, paratransit, and taxi services; include public education campaigns to inform seniors of service availability, eligibility, and cost; include vehicles that cater to older persons with features such as low-floor buses and wheelchair ramps; and establish rea- sons why seniors do not use transit where it is available and the steps needed to overcome these barriers. • Codify research on mobility and mobility options into guidelines to assist state and local planners in developing, implementing, and managing services. Document and disseminate best practices. • Conduct research to establish the level of mobility required for convenient independent living. • Define the term “well-being” and quantify the importance of driving for well-being. • Examine geographic information on older persons to project future growth areas and the accompanying mobility needs. • Identify and document sustainable transit solutions for older persons. • Provide sensitivity training on the needs of older road users for manage- ment, operations, and frontline staff in transportation services. • Investigate the role of mobility managers and the one-stop shopping approach to driving and alternative mobility options. • Encourage older drivers to plan for transportation needs at the time they plan for retirement. Surviving Without Driving: Policy Options for Safe and Sustainable Senior Mobility (Freund) • Encourage a variety of transportation to meet the needs of older persons. • Continue funding with public resources and develop incentives to attract personal and charitable private resources. • Increase reliance on volunteers as an integral part of the transportation service. • Analyze and respond to consumer preference in developing transportation alternatives. • Incorporate modern independent lifestyles into marketing programs to adjust for resource or logistical trade-offs in service characteristics and pay- ment choices. SUMMARY OF RESEARCH RECOMMENDATIONS FROM TECHNICAL PAPERS 41

Highway Research to Enhance Safety and Mobility of Older Road Users (Schieber) • Develop performance-based requirements for highway sign legibility and use these parameters to establish and validate minimum retroreflectivity requirements. Document cost–benefit analyses and trade-off studies used to jus- tify any specifications that fail to meet the performance-based requirements of the design older driver fully. • Develop performance-based requirements for roadway delineation and use these parameters to establish and validate minimum retroreflectivity require- ments for roadway markings. • Carefully evaluate the conceptual and methodological basis of gap accept- ance models for highway geometric design relative to the characteristics of the 85th percentile 75-year-old design driver. • Model and evaluate the performance of older drivers while making left turns to determine how vehicular control and focus of attention, “functional risk factors,” may influence their overinvolvement in left-turn crashes. • Conduct studies that use state-of-the-art eye-tracking techniques to ascer- tain and model how older and younger drivers scan their visual environment. Determine what visual information drivers use and when they need it. • Conduct research to ascertain how geometric design, traffic control devices, and ITS can be modified or used to accommodate merging into high- speed or high-density highway traffic situations. • Evaluate the impact of small target visibility models of highway lighting design on performance, comfort, and fatigue among older drivers. • Investigate the extent to which driver fatigue may disproportionately influ- ence performance in the older population. • Evaluate the performance of proposed traffic-calming techniques and their workload demands on older drivers and pedestrians, and incorporate the find- ings into the development of regulations and guidelines. • Develop a system-level approach to the design, placement, and mainte- nance of highway signs. • Model and evaluate the reluctance of older drivers to execute right-turn- on-red operations in urban areas. • Evaluate the impact of various levels of street lighting on the current mobility of older drivers. Conduct cost–benefit analyses to determine whether larger investments in highway lighting infrastructure are needed to accommo- date nighttime visibility problems. • Further study and quantify the role of durable fluorescent colors in improving the conspicuity and legibility of highway signs among older drivers. SAFE MOBILITY FOR OLDER AMERICANS 42

Safety of Older Pedestrians (Oxley, Fildes, and Dewar) • Conduct a more detailed investigation of crash involvement patterns. • Examine older-pedestrian performance in complex settings and the role of inappropriate behavior in older-pedestrian crashes. • Evaluate the effectiveness of speed reduction and median strips for older pedestrians. • Examine the suitability of road and highway design for older pedestrians and mount a greater effort to provide a safe traffic environment for older pedes- trians, especially in high-density pedestrian areas. • Create adequate crossing time guidelines for older pedestrians and pro- mote better maintenance of sidewalks and street lighting. • Assess the mobility needs and patterns of older pedestrians. • Develop safer access for older people at tram and bus stops. • Develop alternative mobility options for older pedestrians. Land Use and Travel Patterns Among the Elderly (Giuliano) • Create scenarios of “driver-friendly” as well as pedestrian- and transit- friendly urban design alternatives: streets widths that protect pedestrians, more and better signage and traffic control, easily negotiated parking facilities, and so forth. • Supplement current research and knowledge on the relationship between land use planning and senior mobility. Investigate how older persons adapt to declining driving skills in low-accessibility areas, whether those who reside in such areas are significantly more mobility disadvantaged than those who live in neighborhoods with higher accessibility, how much consideration is given to future mobility needs when they move, how sensitive the developers of senior communities are to mobility and accessibility, and what cities are doing to encourage location of senior communities in appropriate places. • Conduct longitudinal case studies of residents in different neighborhoods to trace shifts in travel behavior over time and how these vary across neighbor- hood/community types. • Conduct cross-sectional studies of senior community residents in various locations to determine how different levels of accessibility affect travel patterns and car use. • Study urban planning practice related to senior housing development and mixed-use development to examine who locates in such developments and why. Reducing Injuries and Fatalities to Older Drivers: Vehicle Concepts (Pike) • Quantify and compare the changes, as well as the variation, that occur within older-person age groups. SUMMARY OF RESEARCH RECOMMENDATIONS FROM TECHNICAL PAPERS 43

• Identify vehicle and highway features that address at-risk road users. • Formulate intervention strategies, including driver testing, training, educa- tion, and licensing. • Investigate the potential of adaptation techniques for safety features and concepts to address the special needs of older drivers and occupants. • Identify adaptation techniques and concepts that older road users will accept. • Determine whether current test procedures, devices, and criteria can be scaled to reflect the older population or whether unique features are needed. • Determine which aspects of aging are associated with fatal and injury- producing crashes. • Determine the need for additional driver training on the proper use of new technologies. • Develop intersections that utilize electronic interaction between vehicles and roadways to reduce crashes. • Quantify driving-related changes that occur with aging and identify vehicle–highway modifications to address these changes. • Improve testing devices and criteria for evaluating occupant protection devices for older drivers and passengers. • Explore the usefulness of a different owner manual format for older vehi- cle users. Automotive Adaptive Equipment and Vehicle Modifications (Koppa) • Develop assistive devices for easing the effort of fastening safety belts for those with movement and dexterity limitations. In-Vehicle Intelligent Transportation Systems: Safety and Mobility of Older Drivers (Caird) • Account for older-driver capabilities in the design, modification, and eval- uation of ITS technologies. • Develop guidelines that can assist designers in achieving legibility, com- prehension, minimal attention, ease of use, and so forth for older drivers, and give illustrative case examples. • Develop training for older drivers in the use of ITS devices and systems. • Conduct long-term measurement of driver use and performance with an ITS-related system focusing on the principle of convergent empirical evidence from objective and subjective sources. • In evaluating ITS devices, consider individuals who may have difficulty using in-vehicle displays (older drivers), the fit of a presentation modality to drivers’ sensory capabilities (auditory, visual, and multimodal), limiting tasks SAFE MOBILITY FOR OLDER AMERICANS 44

that divide attention (braking and object recognition), optimizing the form that display images take (size, color, location, etc.), and determining whether the systems can be safely operated in a wide range of traffic contexts (emergen- cies). • Evaluate appropriate as well as inappropriate behavioral adaptation in the use of ITS applications (e.g., whether drivers adopt higher speeds at night because they can see further ahead by using ITS applications). • Analyze and apply basic empirical knowledge of driver behavior and adaptive strategies to the development of ITS technologies. • Evaluate the extent to which ITS technologies offset declines in safety and mobility due to aging processes. Impact of Public Information on Safe Transportation of Older People (Milton) • As older persons experience the initial problems of aging that begin to affect driving and trigger self-compensation, provide information that acknowl- edges that gradual physical and mental changes are normal and that continuing adjustment of driving behavior often can extend safe driving for many years. Endorse acceptance of the need for change as the key to safe operation. • As older persons experience additional symptoms of aging that may make driving unsafe, provide information about available evaluation and rehabilita- tion opportunities and vehicular adaptive devices. • Develop an active presence and involvement of “early warning” networks, including family, friends, police, doctors, and the health care community. Educate all segments in awareness of aging symptoms that may require inter- vention. • Identify and document incentives and messages that trigger the interest and action of families and friends to help an older person make wise choices about driving. • Conduct research to determine motivation strategies that encourage physi- cians to address patient driving capabilities, and identify their information needs to supplement their recommendations about driving. Determine the effec- tiveness of information concerning rehabilitation and evaluation services in terms of encouraging doctors to incorporate these services more frequently into their treatment regimens. • Determine what incentives and training will encourage the broader health care network to assess driving capabilities as a regular facet of examinations and to identify what kinds of information they would find useful in assisting patients. SUMMARY OF RESEARCH RECOMMENDATIONS FROM TECHNICAL PAPERS 45

• Provide information that helps older drivers shift to another form of trans- portation (including a change in lifestyle) as they become incapable of safe driving. • Develop materials that present the transition in constructive terms, and motivate the support network to facilitate change. • Create materials that identify assistance available to older persons who are no longer driving. • Describe transportation options and motivate participation of the support network to help older persons negotiate and become comfortable with the idea of alternatives. • Address remedial opportunities for those whose recuperation may eventu- ally allow resumption of driving. • Conduct focus groups of men determined to remain drivers at any cost to learn what motivations might alter their perspective. • Stratify research demographically to ensure that all socioeconomic groups are represented and can be disaggregated. Transportation Policy for an Aging Society: Keeping Older Americans on the Move (Cobb and Coughlin) Agenda Setting and Education • Educate state policy makers about aging. • Promote alternative transportation as a mode, not solely as a social policy tool. • Reinvent licensing bureaus as mobility resource centers. • Earmark funding/fees to build organizational capacity. • Encourage automakers to provide education in new technologies. • Implement the highway design guidelines recommended by the Federal Highway Administration. Technological Innovation • Invest in research and development for new automobile technologies to address unique safety and operational issues associated with older drivers and passengers (e.g., driver workload, safety of older women, and passenger ingress/egress). • Define a cost-effective test regime to sample all drivers for fitness. • Demonstrate and evaluate the White House National Science and Technology Council’s 1997 recommendations to develop a regional mobility management system to provide a basis for the next-generation paratransit sys- tem for all ages. SAFE MOBILITY FOR OLDER AMERICANS 46

Market Leverage and Stimulation • Promote industry research and development and the affordability of new technologies through federal tax incentives. • Urge the insurance industry to provide technology discounts for use of “safety technologies.” • Amend state liability statutes to extend protection to volunteer driver net- works and educate volunteers about these protections. • Conduct research assessing the efficacy and market potential of transit-ori- ented development and “livable communities” for middle-aged and young-old persons seeking new homes to age in place. • Encourage individuals to plan and save for their future mobility needs, thereby creating new markets for both private and public services. SUMMARY OF RESEARCH RECOMMENDATIONS FROM TECHNICAL PAPERS 47