Lisa J. Molnar, David W. Eby, Renée M. St. Louis, Amy L. Neumeyer University of Michigan Transportation Research Institute Lisa J. Molnar, David W. Eby, Renée M. St. Louis, Amy L. Neumeyer University of Michigan Transportation Research Institute 2901 Baxter Road Ann Arbor, MI 48109-2150 Phone: 734-763-2466 Fax: 734-936-1076 www.umtri.umich.edu DECEMBER 2007 This publication was prepared with support from AARP. The opinions, findings, and conclusions expressed in this publication are those of the authors and not necessarily those of AARP. ACKNOWLEDGMENTS Several individuals contributed to the completion of this project. We thank Audrey Straight, formerly of AARP, for initiating this project and Frank Carroll of AARP for seeing it through. Bruce Chin, Vazir Fatehi, Albert Gorlin, Betty Hammond, Lidia Kostyniuk, Dorothy Mack, Nancy and Philip Margolis, Jordan Molnar, Christine Norman, Bohdan Paszkowskyj, Frankie and Willis Patterson, Shirley Sims, and Errol and Pat Soskolne appear in the photographs. We acknowledge University Living of Ann Arbor and the University of Michigan Geriatric Center’s Turner Senior Resource Center for their assistance with the photography sessions. Photographs by Gregory and Lidia Kostyniuk TABLE OF CONTENTS Table of Contents Introduction 1 Driver Screening and Assessment 6 Education and Training 27 Vehicle Design and Advanced Technology 43 Roadway Design 48 Transitioning from Driving to Other Transportation Options 55 Transportation Coordination 64 Alternative Transportation Options 72 Web Resources 94 Endnotes 96 Bibliography 99 {i} INTRODUCTION Introduction I n 2003, we published Promising Approaches options. We recognize that no single area holds the for Enhancing Elderly Mobility,1 a guide high- key to achieving the safety and mobility goals for lighting programs and practices in a number older adults. A sustained and broad-based effort on of areas considered to hold promise for multiple fronts, involving collaboration among a enhancing the safety and mobility of older adults. diverse group of professionals, is needed. We hope Development of the guide was based on exten- that this guide will serve as a useful resource for sive review of the literature and discussions with anyone involved in working to meet this worthwhile experts in aging-related fields, and was intended as challenge. a resource for community professionals interested Why older adult safety in developing programs to enhance older adult and mobility continue to mobility. We noted that while each community would have to tailor its efforts to fit its own unique be important issues character and that of its older adult population, There has been tremendous growth in the older much could be gained from learning about existing adult population in the United States and elsewhere programs and practices. in the past few decades, and this trend is expected to Since publication of the guide, a number of new continue. By 2030, one out of every five Americans initiatives in the areas of older adult safety and will be over the age of 65, resulting in an older mobility have been launched at the federal, state, adult population of more than 70 million people. and local levels. In addition, there is widespread Although many people drive less as they get older, agreement that safety and mobility go hand in older adult drivers are more likely to be involved hand. Thus, two complementary but interdepen- in a crash for every mile they drive than any other dent goals have emerged with respect to older adult age group except the youngest drivers. While there drivers: to help those who are able to drive safely is growing evidence that the older driver crash rate continue to do so; and to identify and provide com- per mile driven may be biased upward due to the munity mobility support to those who are no longer tendency of older drivers to drive shorter distances, able to drive. The purpose of this guide, Promising older drivers are clearly at increased risk of death Approaches for Promoting Lifelong Community and serious injury, given a motor vehicle crash, Mobility, is to update and expand upon our earlier due to age-related frailty. Thus, in explaining older work, particularly with regard to the transition from driving to non-driving and the need for alternative transportation options for older adults who are no longer able to or choose not to drive. The promising approaches in this guide are pre- sented within the context of several areas that hold promise for promoting lifelong community mobility, including driver screening and assessment, driver education and training, roadway design, vehicle design and advanced technology, transitioning from driving to other transportation options, transporta- tion coordination, and alternative transportation {1} PROMISING APPROACHES TO PROMOTING LIFELONG COMMUNITY MOBILITY drivers’ heightened casualty involvement per dis- areas that compromise their ability to drive safely. tance traveled, research suggests that physical frailty The visual declines most likely to affect safe driving is a key factor for almost all older adults, a high include reduced static and dynamic acuity, contrast level of urban driving is a key factor for many older sensitivity, sensitivity to changes in angular size and adults, and reduced fitness to drive is a key factor for motion, pattern perception, visual attention, and some older adults.2 visual search capability, as well as increased vulnera- bility to glare. Cognitive declines most likely to affect Most Americans consider driving to be essential safe driving include a slowing of information pro- to their independence and quality of life. Probably cessing leading to less efficient working memory, as in no other country is mobility so closely linked to well as declines in selective attention, divided atten- the personal automobile, and this is just as true for tion, and attention switching. Psycho motor changes older drivers as for young people starting out their with adverse affects on driving include reduced limb driving careers. In part, this is due to the values and strength, flexibility, sensitivity, range of motion, and traditions that have shaped our country, and in part, head and neck mobility. Older adults are also more to the absence of acceptable alternatives. Driving likely than younger people to suffer from certain provides an opportunity for people to stay engaged medical conditions that impair functionlike stroke civically and socially, and to participate in activities and dementia. that enhance their well-being. Loss of driving privi- leges can lead to increased social isolation by pre- Many older adults are able to compensate for venting regular contact with friends and family, and declining abilities and continue to drive safely. For has been associated not only with a loss of indepen- example, they may stop driving at night, reduce dence, mobility, and freedom but also with feelings their driving in unfamiliar areas, rely on a passenger of diminished self-worth, reductions in self-esteem, to navigate or read road signs, or use less traveled loss of identity, and depression. As older adult drivers have come under increased scrutiny, it has become apparent that it is not age, per se, that leads to problems with driving. Rather, it is declines in driving-related abilities that often accompany aging or arise from medical conditions or the medications used to treat them that make driving more dangerous. Although these medical conditions can occur at any age, they are more likely to occur as one becomes older. At the same time, there are significant individual differences in the rate of decline and what functions are affected— each individual is unique. Thus, there is widespread agreement that traffic safety efforts should focus on helping older drivers maintain safe driving as long as they are able to do so, rather than on restricting all older drivers simply because of their age. We know that driving is a complex task that requires visual, cognitive, and psycho motor abilities. As people age, they may experience declines in these {2} INTRODUCTION roads. For those who continue to drive, declines in ways, safer easier-to-use automobiles, improved abilities can have very real implications for driving. systems for assessing competency of older drivers Older drivers are more likely than younger drivers and pedestrians, better easier-to-use public trans- to be involved in crashes at intersections, espe- portation services, targeted state/local safe mobility cially when making left turns across traffic, and on action plans, better public information, and basic limited access highways when merging, exiting, and social policy research. and changing lanes. Common areas of difficulty for The American Association of State Highway and older drivers include yielding to oncoming traffic, Transportation Officers (AASHTO), with sup- responding to road signs or signals, searching and port from the National Highway Traffic Safety scanning the road environment, staying in the lane, Administration (NHTSA), Federal Highway positioning the car for turning, maintaining regular Administration (FHWA), and Transportation speeds or keeping up with the traffic flow, passing Research Board (TRB), published its strategic plan other cars, and stopping. in 1997, which included older adult drivers as one The research on older drivers makes it clear that of 22 emphasis areas for reducing roadway fatali- the issue of older adult mobility requires our atten- ties.6 As part of a series of guides to assist states in tion. What is less clear is how communities can best implementing the plan, the TRB report, A Guide for respond and take effective action to enhance older Reducing Collisions Involving Older Drivers (NCHRP adult mobility. How can communities decide what Report 500),7 laid out a comprehensive approach programs and practices will work for them? What are to reducing older driver crashes and injuries that the necessary steps for planning successful efforts included five broad objectives and 19 strategies. and carrying them out? What are the barriers com- The objectives were to plan for an aging population, munities might encounter and how can they be improve the roadway and driving environment to overcome? better accommodate older drivers’ special needs, identify older drivers at increased risk of crashing Planning for older adult and intervene, improve older adults’ driving com- safety and mobility petency, and reduce the risk of injury and death to A broad array of planning efforts has been under- older drivers and passengers involved in crashes. taken at the federal and state levels over the past More recently, TRB highlighted older driver initia- several years to help communities plan for their tives being undertaken by the federal, state, and older adult population’s mobility needs.3 At the heart local government, as well as national nongovern- of these efforts is the recognition that older adult mental organizations, professional organizations, mobility is a complex issue that requires a multi- and other private-sector organizations in the report faceted and comprehensive approach. In 1997, the Improving the Safety of Older Road Users: A Synthesis U.S. Department of Transportation (DOT) identified of Highway Practice (NCHRP Synthesis 348).8 The three policy objectives—safety, individual personal report represents a “snapshot” of programs and mobility, and facilitating the eventual transition to policies in place across the country to improve mobility alternatives—as part of its vision for the the safety and mobility of older road users, and U.S. transportation system.4 This vision was fur- focuses on five broad areas including planning for ther outlined in the 2003 report, Safe Mobility for a older road users, roadway engineering and traffic Maturing Society: Challenges and Opportunities,5 operations, driver licensing, public information which identified strategies for improving the safety and education, and enforcement and adjudication. and mobility of older adults in seven key areas The report is a valuable resource for information on including safer easier-to-use roadways and walk- promising programs and practices, as well as the {3} PROMISING APPROACHES TO PROMOTING LIFELONG COMMUNITY MOBILITY broad array of planning efforts occurring across the needs of an aging population and the need for U.S. The report identifies six states with compre- resources to assist in this challenge. hensive plans for improving older road user safety Organization of this guide and and mobility including California, Florida, Iowa, how to get the most from it Maryland, Michigan, and Oregon. An overview of state and local planning initiatives for these six and This updated guide identifies several areas in which other states, including links to a number of older promising approaches for promoting lifelong com- adult driver planning documents, is also provided. munity mobility have been developed in the U.S. and elsewhere. These areas include driver screening and assessment, driver education and training, roadway design, vehicle design and advanced tech- nology, transitioning from driving to other trans- portation options, transportation coordination, and alternative transportation options. For each area, the guide contains: • An introductory section that provides general background information on the area and dis- cusses how it contributes to promoting lifelong community mobility; • A discussion of how the area can best promote lifelong community mobility, including impor- tant components of a promising approach; • Descriptions of current programs and other initiatives in the area that appear to be especially AARP has increasingly become involved in trans- promising; and portation and mobility issues in recognition that most strategies to promote older adults’ health and • A full listing of promising programs and other well-being and their ability to remain living with initiatives in the area, in alphabetical order, and dignity in their homes and communities depend on summary information about each. transportation. AARP has sponsored a number of Choosing promising programs and other initiatives older adult mobility forums around the country to for promoting lifelong community mobility can be a explore these issues, bringing together professionals challenging task—this is especially true when many from health, gerontology, and transportation, as well of the programs and initiatives have not been for- as older adult consumers and advocates. A recent mally evaluated. In cases where we lacked objective forum conducted in Florida resulted in recom- information about program effectiveness, we used mendations in four areas—emergency evacuation our best judgment to identify promising programs preparedness, community planning for older adults, and initiatives. To the extent possible, we based safe driving for older adults, and transportation these judgments on whether the programs and options.9 Using an electronic voting process, partici- initiatives incorporated the components we con- pants identified several action ideas for each area. sider important to promoting lifelong community The efforts of AARP and the other organizations and mobility. We highlighted some programs and initia- agencies highlighted here underscore the growing tives that we felt stood out, particularly in terms importance of meeting the safety and mobility of their scientific basis, comprehensiveness, or {4} INTRODUCTION We also made the decision to include all programs directed at older adults with dementia in the transitioning section given that even though many individuals with early stage dementia are still able to drive, eventually, as the disease progresses, all indi- viduals with this diagnosis will have to stop driving. Updating the original guide involved several steps. First, we contacted representatives from each of the programs or practices highlighted in the original guide to make sure that the programs/practices were still in place and that information was accu- rate. Several programs were dropped because they were no longer being funded or in use. Second, we timeliness. The promising programs and initiatives developed a list of close to 100 new programs or included in this guide are in various stages of devel- initiatives based on the literature review and discus- opment. Some are, in fact, still considered experi- sions with experts in the field. Of particular interest mental but represent innovative approaches that were programs and other initiatives in the areas of have considerable potential for enhancing mobility. transitioning from driving to other transportation The list has changed from our original guide and options and alternative transportation programs. will continue to change with new developments in Third, we reorganized the guide to better reflect cur- aging-related research or as more programs undergo rent thinking in the areas of safety and mobility. The formal evaluation. Thus it represents a snapshot of seven areas in the guide, while presented separately efforts that we are aware of, based largely on infor- for ease of the reader, are clearly interdependent mation from published materials and discussions and mutually supporting, and should be viewed with experts in aging and transportation. collectively as part of a comprehensive approach to A second challenge in producing this guide had to enhancing older adult mobility. do with determining which section to assign each promising program or other initiative. In many cases, programs or initiatives cut across two or more sections—yet to avoid duplication, each program or initiative appears in only one section. Again, we used our best judgment to choose the section to which the program or initiative seemed to be most closely tied. We recommend that as readers review the program/initiative summaries, they keep in mind that the programs/initiatives may be appli- cable to sections other than just the one in which they appear. This is particularly true for programs and initiatives in the education and training section and the transitioning from driving to other trans- portation options section. These sections overlap with one another and both contain programs that may have screening and assessment components. {5} PROMISING APPROACHES TO PROMOTING LIFELONG COMMUNITY MOBILITY Driver Screening and Assessment M aking informed decisions about vision tests, or other testing or certification (e.g., driving fitness requires meaningful written and road tests, certification of fitness). Even information about the changes in with these provisions, however, it may be several driving-related abilities drivers may years before older drivers have to actually appear experience and how these changes affect driving. at a licensing agency to renew their license. Thus, Although many of these changes result from medical licensing agencies also rely on review of driver his- conditions that become more prevalent as we age, tory records and referrals from health professionals the effects of these conditions vary from individual (e.g., physicians, occupational and physical thera- to individual, and are complicated by the medica- pists, social workers, vision specialists), law enforce- tions used to treat them. Thus, screening and assess- ment officers, courts, and families and friends of ment has increasingly focused on the functional older drivers, to alert them to situations in which declines that can affect driving rather than on the an individual’s driving fitness may be in question. medical conditions that lead to these declines. However, few states require physician or other professional reporting of unfit drivers to licensing Screening and assessment can occur in a variety agencies, although many encourage or at least do of settings and at various levels of complexity. not forbid it. Close to half the states provide some Screening signifies the first step in identifying at-risk type of protection from liability for physicians, while drivers and is intended to identify more obvious a fewer number offer legal protection or anonymity. functional impairments. Screening may prompt and/or inform more in-depth assessment but it should not be used by itself to determine driving fitness. In-depth assessment to determine the level and cause for an observed impairment is needed to support decisions about whether someone should continue driving and under what conditions. Collectively, screening and assessment contribute to a comprehensive, multifaceted approach for identi- fying older drivers who may be at risk. Licensing agencies Licensing agencies have a unique opportunity to screen for fitness to drive because older drivers, like everyone else in the driving population, must go through a license renewal process. Driver’s license renewal policies in the U.S. vary from state to state in terms of the length of the renewal cycle, require- ments for accelerated renewal for older drivers, and other renewal provisions (see Table 1). Fourteen states require accelerated renewal for older drivers, and 17 states have other special renewal provisions including requirements for in-person renewal, {6}