Driver screening for older adults.

W HEN reflecting on the oftasked question “Should older drivers have to prove they can drive?” one finds that no facile answer come comes to mind. Several key issues need to be considered before one can propose a satisfactory response. To begin, if by“prove”wemeanpass tests above and beyond what are customary for other drivers, then important questions arise: Are older drivers (65 years or older) different in some way other than age? Are they less safe drivers than younger drivers? By some measures, seniors are safe drivers. More than 70% wear seat belts, the highest percentage of any driving category. They respect the speed limit more than drivers in other age groups, seldom take risks behind the wheel, and receive the fewest moving violations of any drivers. On the other hand, although seniors do not drive as often as their younger counterparts, they account for a disproportionate number of crashes on the nation’s roads. Whereas for drivers younger than 65 years, the crash death rate has dropped 3% since 1995, the death rate for drivers older than 65 years has risen 15% in the same period, while their population has increased by only 1%. Currently, the elderly make up about 13% of the US population, but they account for over 18% of highway fatalities. In addition, they are the ones dying at the highest rate in these collisions. Seniors account for nearly one third of all deaths occurring at intersection crashes, and half of those elders die attempting left turns. Furthermore, because of their generally more cautious and slower driving, the elderly are involved in a disproportionate number of rear-end collisions. Projections by the National Highway Safety Administration suggest that these trends are likely to accelerate in the coming decade specifically because today’s seniors are driving considerably more than past generations of elders. We also need to ask “Do all elderly drivers contribute equally to their increased risk for crashes, or is it only some portion of this population that carries the main risk?” The elderly are characteristically considered a very heterogeneous group in many regards, including with respect to health. However, most communities include seniors whose ages range from the conventional cutoff of 65 years to 100 years or older. We call them all seniors, but there are likely to be great differences among them in many respects. Even among persons of the same age, great variability exists in numerous attributes. One of the most significant of these is state of health. Health deteriorates exponentially after middle age over a period of 1 to 3 decades. For some, the rate of decline in health will be fairly rapid, for others it will be slower, with disabilities making only a very late appearance. This variability is extremely relevant to assessing driving skills. It is well established that a number of medical conditions such as visual impairments, dementia, stroke, severe arthritis, and others pose serious obstacles to safe driving. The likelihood of acquiring these conditions increases exponentially with age. However, even among the very old, some individuals live without seriously debilitating medical conditions and are as capable of driving safely as they were in younger years. Given their vast driving experience on the whole, the only plausible reasons why seniors might become unsafe drivers would be either because of a dramatically changing driving environment or a diminishment in their own faculties needed for driving. While a combination of both types of changes is possible, the greatest impact on safe driving is likely to come from the lessening of key faculties by specific diseases affecting key organs. Age per se, therefore, is not the critical factor in losing one’s safe driver capabilities. Rather, it is the loss of health through the occurrence of diseases that are increasingly common (but not totally inescapable) with advancing age. These diseases impair the physical and mental faculties requisite for safe driving. Thus, we should not be particularly concerned with the healthier elderly who probably have a long record of safe driving. Rather, we should worry more about those elderly who were perhaps once safe drivers but who now may be losing their health in ways that specifically affect their drivFrom the Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles School of Medicine, Los Angeles, and the Veterans Affairs Greater Los Angeles Healthcare System, Sepulveda, Calif. The author has no relevant financial interest in this article. L. Jaime Fitten, MD