Friday, 2 March 2012

At what age should we stop driving our car?

Alan Burridge, age 75, of Woodstock Ontario said, “Driving gave me an incredible feeling of power.” You notice that he spoke in the past tense.

That feeling he had from driving race cars to the family sedan, was a natural part of Burridge’s life until last September 2011, when his licence was suspended by Ontario’s Ministry of Transportation.

Diagnosed in 2011 with early Alzheimer’s disease, Burridge was encouraged by his doctor to take a $550 on-road driving test from a private company (DriveABLE) to see how his mental decline was affecting his driving skills. Burridge failed the test, so he took it a second time, and again he failed.

The final word on his driver’s licence, the plastic licence that can be key to a person’s independence, arrived in a letter from the transportation ministry. The notice of suspension letter said in part;

“Although you may be disappointed, this decision has been reached to ensure both your own safety and that of other road users.”

Dementia affects the brain’s functioning, creating an inability to work out a complicated decision and, as it advances; a lack of awareness that a decision while driving even needs to be made. In a rapidly aging society, driving with dementia may very well become the new officially recognized form of impaired driving.

In the coming years, there will be a surge of senior drivers on Ontario’s roads suffering from dementia, the general term for those with cognitive impairments such as Alzheimer’s. The number of drivers with dementia in Ontario will more than double from about 45,000 today to nearly 100,000 in 2028, according to a Queen’s University study.

In the past 20 years, the number of drivers over 65 doubled in Ontario, from 600,000 to 1,200,000. At the same time, the Alzheimer Society of Canada reports that more than 500,000 Canadians are living with dementia, with one new case being reported every five minutes. Within a generation, that will increase every year by 250,000 new cases —with a new diagnosis every two minutes.

These are frightening statistics. This means that thousands of motorists in Ontario are suffering from some form of dementia. This increases the risk to the motoring public.

Robert Hopkins, who conducted the Queen’s study and is director of pychogeriatric (psychology of older people) research at Providence Care in Kingston, Ontario said in part;

“This is definitely a public-health issue, and the province has not done a lot (about it.) We’re living longer and the number of drivers with dementia is going to increase substantially. It’s going to be a problem.”

Ontario remains one of the safest places to drive, with the lowest road-mortality rate for people of all ages in North America, according to the Ministry of Transport’s latest statistics taken from 2008.

The ministry has a strong focus on drivers with dementia, says spokesperson Bob Nichols. “We continue to actively monitor, evaluate and support research in this very important area to help better determine the magnitude of the cognitively impaired driving problem.”

But the Toronto Star has found a disturbing lack of awareness of the hazards ahead among doctors, government policy-makers and older drivers themselves.

Critics say Ontario’s Ministry of Transport is failing to train family physicians to look for early signs of dementia that might affect driving.

It gave doctors the legal responsibility for reporting medically unsafe drivers, but has never cautioned or punished a physician for failing to report medically unsafe drivers. Nor, critics say, is the ministry focused enough on what researchers call the ‘holy grail’ —a scientific test to help doctors spot at-risk patients without unfairly targeting others.

Many seniors have busy, productive lives, but there is no escaping the reality that the risk of dementia increases with age. It has a direct impact on driving — making those complex decisions, for example, when turning left at a busy intersection with pedestrians crossing and cars racing or even simple decisions such as remaining in one’s lane without inadvertently crossing into part of another lane.

The danger coming up on our roads is a result of two inevitable trends: a massive population of aging baby boomers determined to stay behind the wheel and the creeping onslaught of mental impairment for many motorists as they get older.

“The vast majority of older drivers are safe,” says Dr. Shawn Marshall of the Ottawa Hospital Rehabilitation Centre, who is working on a major research project called Candrive to develop better testing for senior drivers. He warns against “crazy blanket comments that are ageist and unfair. He said, “You don’t want people to be unfairly targeted and you don’t want safe drivers to be taken off the road.”

Because the driving population over 65 has increased so dramatically, the casualty rate for that age group — the number of serious and fatal collisions per 10,000 licensed drivers — in fact decreased by 40 per cent in 2008 compared to the year 1990. But that’s the rate — not the body count.

The problem is that seniors are frailer, so when they get into accidents, the injury and death rate is high. Also, while young people tend to get into single-vehicle accidents — the drunk teenager who hits a tree — seniors tend to cause multiple-vehicle crashes.

“People aged 70 or older have a higher accident rate per kilometre driven than any other age group except young male drivers,” concludes a new study released in February 2012 by Statistics Canada, which added that “seniors are more likely than younger people to be killed when they are involved in a collision.” That is because their bodies are more fragile than those of younger drivers.

The study found that 28 per cent of people over 65 who had been diagnosed with Alzheimer’s disease or some other form of dementia had a driver’s licence, and three-quarters of them had driven in the previous month.

To make matters worse, drugs prescribed to many seniors can be an additional — and largely ignored —road hazard.

Dr. Mark Rapoport, a geriatric psychiatrist at Toronto’s Sunnybrook Health Sciences Centre, led a study that found about 40,000 out of the roughly 210,000 people in Ontario identified as having dementia had active driving licences. Close to 9,000 of them were involved in crashes. I don’t know how many people died as a result of those crashes but one death is too many.

When his team dug deeper into those accidents, they found that drivers on psychotropic medications— antidepressants, antipsychotics or benzodiazepines to deal with anxiety, agitation or sleep problems —had a collision risk 54 per cent higher than when they were not.

This is a triple whammy. These motorists have dementia plus they have a behavioural disturbance and are taking some form of medicine which may interfere with their ability to drive safely. One out of three drivers with dementia in his survey who crashed were in fact taking psychotropic drugs.

The problem is that unlike suspected drunk drivers, for example, seniors involved in accidents are not routinely examined for cognitive impairment. Besides, there is no Breathalyzer-type test — no reliable, quick way to determine the cause of cognitive impairment that might impact driving. That makes it hard to pin down just how many fatal or serious accidents are caused by seniors with cognitive impairment.

That dilemma surfaced dramatically 12 years ago when 84-year-old Pilar Hicks killed Etobicoke’s Beth Kidnie, driving over the mother of three, who was out for an evening walk. Hicks dragged Kidnie under her car until she arrived home. The body became dislodged at the end of Hicks’s driveway, where it lay until discovered by a passerby. The inquest into the tragedy heard that Hicks may have been cognitively impaired at the time of the accident, but authorities couldn’t be sure. But there was no doubt Hicks had dementia by the time the inquest got underway two years later, and she was not required to testify on compassionate grounds.

The inquest had a sharp focus on drivers with dementia, including a recommendation that the transportation ministry find out just how many such drivers were on the roads. The ministry says it followed up on this recommendation by supporting and evaluating several studies, including the Candrive initiative.

Their research showed that close to 7,000 senior drivers were involved in fatal collisions or ones involving injuries in Ontario in 2008, the latest year for which statistics are available. Of those, only 166 were “coded” with a “medical or physical disability” according to the Ministry of Transport.

But the real number could be much higher, since it is the investigating police officers who do the coding at the scene of an accident — and diagnosing dementia is not that easy to determine unless the person making the determination is a psychologist or a psychiatrist.

I would be less than honest however if I didn’t mention that persons who suffer from mild dementia, may still be good drivers because of well-ingrained talents they have acquired after years of driving on the road.

Elderly drivers face many constraints that vehicle modifications can't address. In addition to dealing with issues such as fatigue, vision problems, maneuverability problems, hearing loss, medications, arthritis and other debilitating health problems, elderly drivers must also combat confusion, anxiety, frustration, memory loss, a reduced ability to multitask, diminished concentration and information overload, especially in high-traffic situations. Any one of these factors can significantly impact an individual's ability to make it from point A to point B safely. Combined, they can be deadly. Therefore, it's important to know when, and how, to transition from being a driver to being a passenger, at the same time maintaining one’s self-esteem, sense of independence and, most importantly, freedom.
We’ll never know with any certainty how many drivers over 80 should be getting their licence renewed — or removed. That’s because the official tests the Ontario Ministry of Transport uses to certify drivers over the age of 80 are seriously flawed and may fail to spot seniors with cognitive impairment and signs of dementia.

Ontario drivers over the age of 80 years of age must take a written test and get their eyes checked every two years to renew their licences. More than 121,000 seniors took the test in 2011. The vision test of course will catch failing eyesight, however the multiple-choice test used to test knowledge and basic memory—the all-important driving and brain skills that might deteriorate with age, will be missed. That is because the tests don’t determine a person’s psychomotor speed, information processing, or the ability to handle a crisis or solve other problems that motorists encounter on the road.

“I don’t think it is effective screening for identifying who might be at risk,” says Dr. Shawn Marshall at the Ottawa Hospital Rehabilitation Centre. “For sure we’re missing people,” continues Marshall, a leading expert on senior drivers who is working to develop more accurate and comprehensive tests using hundreds of volunteers who are seniors who are still driving. We’re looking at something that might happen, for who may be the most at risk.”

Inaccurate or incomplete testing for over-80 drivers is just one of many failures in the government’s efforts to identify and help the growing number seniors who may be dangerous to themselves and others on the road, the Toronto Star has found.

That conflicts with what Ministry of Transportation spokesperson Bob Nichols said recently when he said, “Ontario has the one of the most stringent medical reporting programs in Canada,”

While that may be true, the vast majority of the most at-risk drivers are not being spotted, doctors who fail to report face no punishment, and physicians are not being properly trained in the first place to diagnose the impairments that may inflict many of their senior driving patients.

The statistics are like flashing red lights: simply because of our aging population — and the growing prevalence of Alzheimer’s and other types of cognitive impairment. As I said earlier, it is estimated that the number of Ontario drivers with dementia could reach nearly 100,000 in 2028. The potential for fatal accidents by then will be enormous.

If the Ontario system is failing to spot the riskiest drivers by the time they reach 80, it’s having even more problems identifying potentially dangerous senior drivers where it would be most effective — while they are at their doctor’s office. That should be the front line in senior road safety since, more than any other driving age group—seniors tend to have regular visits with their physicians.

Physicians in Ontario are required under the province’s Highway Traffic Act to report any patient who is suffering from a condition that may make it dangerous for the person to operate a motor vehicle. Six other provinces in Canada have similar rules.

That mandatory reporting system in Ontario has been in place since as far back as 1968. And in recent years, there has been a steep rise in reports, from 30,000 in 2006 to 50,000 in 2010, according to figures supplied by the ministry.

But unfortunately, many doctors are not passing on information to the Ministry of Transportation the names of their patients who in their opinion should not be driving vehicles on the road. The reason for this failure is obvious. They know that they will lose their older patients after that. Many doctors are clearly uncomfortable with being put in the awkward position of what they may see as playing police instead of physician.

Physicians are advocates for their patients and they feel torn unless it’s really, really obvious that the patient will not be able to drive. It’s difficult for a doctor to talk about the risk some aged patients are on the road with their patients — and it’s not something their patients will easily discuss either. Further, it is really harder for a doctor to report a patient to the Ministry of Transportation as it can really mess up his or her relationship with the patient. However if they have any doubts about their patient’s ability to continue driving on the road, they should ask themselves the following rhetorical question: “Will I let this person drive somebody I love? If not, then I am going to do what I have to do.”

But even if more doctors wanted to report their patients, they are ill-equipped and poorly trained to do so. Most provinces have mandatory reporting but the tools to identify drivers at risk are not there. It has been on books for many years but without direction, it is not very helpful.”

Last year, the Ontario ministry said it held nine training sessions with doctors to educate them about their mandatory reporting requirements. In 2010, 13 training sessions were held.

In cooperation with Quebec’s College of Physicians, there have been more than 120 workshops for about 4,000 doctors to show them how to spot early signs of dementia.

Even with more training, however, doctors will still face another serious roadblock in trying to spot senior drivers at risk: there is still no reliable and simple test they can perform in their office to measure the levels of cognitive impairment in their patients that might affect their driving unless of course they are psychologists or psychiatrists.

The Ontario legislation does not specify a penalty for failure to report a medically unfit patient, but the general provisions in the Highway Traffic Act call for a fine of up to $500. But that matters little: the ministry told the Toronto Star that no doctors have ever been investigated, much less charged.

“The ministry does not police individual physicians,” says ministry spokesperson Bob Nichols. “The ministry usually becomes aware of scenarios where a doctor did not report when the matter is before the courts.” But by then it may be too late: a fatal or serious crash has already occurred.

“The problem with the evaluation of medical fitness to drive is that nobody in Canada is training physicians to do it,” says Dr. Jamie Dow, the medical adviser on road safety for Quebec’s Société de l’Assurance Automobile, the provincial motor vehicle department. “It’s just taken for granted that because you’re a physician you can judge driving fitness, which is not true,” he says. “Most physicians know absolutely nothing about the effects of a given medical condition on driving.”

Dr. Donald Redelmeier and a team of researchers at the Sunnybrook Health Sciences Centre set out to find just how big that problem was and they discovered that only 3 per cent of medically unfit drivers of all ages were even being reported to the Ministry of Transportation by their doctors.

They combed the historical hospital, police and medical records of 1,600 Toronto drivers involved in ‘life-threatening crashes’ who were admitted for treatment at Sunnybrook — the largest trauma centre in the country for the five years leading up to 2001. They found the overwhelming majority of those seriously injured drivers — mostly suffering from alcohol or drug dependence, but also from cardiac disease or dementia and other neurological disorders were never previously reported to the licensing authorities by their physicians.

According to the ministry, 15.5 per cent of the 2010 reports were for “cognitive/dementia” — almost double the rate from four years earlier. The ministry says close to 80 per cent of the senior drivers who were reported had their licences suspended. Those numbers include drivers over 80 with a possible physical or medical impairment such as failing eyesight or serious cardiac problems.

Still, Ontario’s yearly total of 50,000 drivers reported for some kind of medical impairment represents a tiny fraction of the people on the road — less than .005 per cent of all licensed drivers. That leads many to suspect Ontario’s mandatory reporting system is catching just the tip a much larger unreported iceberg.

Dr. Malcolm Man-Son-Hing, a geriatrician and scientist working with Dr. Marshall at the Ottawa Hospital Research Institute on the five-year project, says they hope it will lead to the first science-based tool to diagnose drivers with dementia. Now at the halfway mark, Candrive is following nearly 1,000 drivers aged 70 and over, using a GPS system that monitors their driving.

“At this point, we are concerned about governments that are prematurely creating policy,” Man-Son-Hing says. “There are huge variations among doctors who report and do not report. It is completely unfair to the patients. We believe there should be a scientific basis for these decisions.”

Until the Candrive study is finished, says Michel Bédard of Lakehead University, a Canada research chair in aging and health, we should not rely on existing on-road tests or in-office tools for doctors.

But Allen Dobbs, who runs an Alberta-based company called DriveABLE (its office near London recommended Burridge lose his licence), says his firm already has solid scientific research and is licensing offices across North America.

DriveABLE administers two tests. The first is a computer touch-screen one involving driving-related questions. The second is the on-road test — the one Alan Burridge failed twice — which examines individuals’ reactions and decisions while they drive.

In Ontario, the ministry requires that companies such as DriveABLE send occupational therapists on the road test — widely considered to offer a better assessment of skills — when drivers are being evaluated.

Dobb’s wife, Bonnie, a professor in the department of family medicine and director of the Medically At-risk Driver Centre at the University of Alberta, developed a checklist for doctors to help them decide their patient’s driving future. Called SIMARD MD, the test is free to doctors on the university’s website.

Bédard has criticized the SIMARD test, saying it is not reliable and sends patients for tests who do not need to go. But Dobbs counters that the tool’s track record is excellent, especially when combined with a road test from her husband’s company.

In the meantime, physicians face stiff push-back from seniors when it comes to giving up that driver’s licence that may have become an essential part of their lives, one many assumed was permanent.

“It’s very rare I have patients who say, ‘Oh you’re right doctor, I don’t think I’d be safe to drive,’ said one doctor. That is because most of us have a very inflated opinion of our abilities.

We certainly cling to that license for as long as we can. Three-quarters of Canadians over 65 remain licensed drivers according, to the most recent Statistics Canada survey, and most continue well into their later years.

More than 200,000 drivers on the road across Canada today are over 85. In Ontario, close to two-thirds of men over 85 are still driving.

Even among the over-90 set, more than one in three Canadian men had driven a vehicle in the previous month.

Many of them might be quite capable drivers, since medical experts stress that health and mental differences vary more among seniors than other age groups.

But here is the dilemma: it is precisely senior drivers who might fail to realize how much of a danger they pose to themselves and others, because the very condition that could make them risky on the road — dementia that robs them of their ability to recognize their own disability.

“Along with cognitive impairment comes loss of insight,” says Stephanie Melvin, deputy superintendent at British Columbia’s Ministry of Transportation. “People aren’t noticing that they’re cutting corners, veering into other lanes, or going the wrong way down the street.”

Years ago, a man in his eighties struck my car while trying to pass me. He didn’t stop like he was supposed to. I decided not to catch up to him because he was speeding. Instead I contacted the police. He denied that he was even on the road we were on but the police saw paint from my car on his bumper. They gave him a choice. Be charged criminally with fail to remain or hand over his licence. He handed over his licence and was told that if he applies for a new one, he will be charged with fail to remain. He didn’t reapply for a new licence. He was obviously a dangerous man to have on the road.

For understandable reasons, people cherish their driver’s licences they may have had since they were teenagers. This is the first generation of seniors who have grown up behind the wheel, and many of them tend to see that licence as a right and not a privilege. It is actually a privilege and not a right.

As medical and safety experts point out, the difference between the alcohol-impaired driver and the medically impaired one is that the drunk driver may be sober the next time he is behind the wheel of his vehicle whereas the mentally disabled person will always be disabled whether or not he is behind the wheel.

There is an element of choice with drunk driving because we can choose to be sober when we get behind the wheel of our vehicle. However, all of us are going to get older and with age, comes the possibility of risk to ourselves, our families, friends and others on the road if we are behind the wheel. We are going to have to face up to the fact that we might not be able to drive safely if our aged brains and bodies are not up to it. Responsible motorists will recognize the risk and voluntarily turn in their driver’s licences. Irresponsible drivers will continue to drive and put us all at risk.

Bad driving imposes risks on other people—even a short journey can put a bad driver in close proximity with others. Turning in one’s own driver’s licence if the driver feels he or she is a risk to others on the road is a responsible balancing of one’s freedom to drive with the safety for others on the road. Fortunately, many conscientious senior drivers police themselves.

Eric Powis, 85, got into a minor accident a year ago while turning left and decided never to drive again. Diagnosed three years ago with early Alzheimer’s disease, the former cop, firefighter and military police officer with the British Army decided the risk of a serious crash was simply too great.

“It became obvious to me that since I had Alzheimer’s and wasn’t going to get better, the best thing I could do was give it up,” he says. “I didn’t want to injure anyone. So I just didn’t bother to renew my license.” That was the action of a very responsible citizen. But for every senior like Powis who recognizes it’s time to give up his licence, how many other potentially dangerous drivers out there are going undiagnosed or unreported by their family doctors and untested by the Ministry of Transportation?

If as a senior you wish to keep driving, here a few tips to keep you and others safe:

Get annual vision and hearing checks

Take senior driving courses and seminars (ex: AARP’s Driver Safety Program)

Visit an occupational therapist who may recommend helpful devices for your vehicle

Invest in a vehicle that best suits your needs

Have emergency supplies in the vehicle at all times

Map out your directions, avoid heavy traffic areas and driving in inclement weather

Use defensive driving techniques

Like all drivers, avoid distractions such as adjusting music players and using cell phones while you are driving

According to the National Safety Council, adult children would rather talk to parents about funeral plans than about taking away car keys. Although many seniors may willingly phase out night driving when they find it impossible to see where they're going, many do not recognize when it's time to give up driving for good. Children and caretakers can help aging parents make the transition as smooth as possible by keeping these important points in mind:

Use compassion. Remember that seniors often associate driving with independence and freedom. Understanding their resistance to relinquishing control over driving can make the transition easier.

Transition gradually. Seniors are more accepting of change that happens slowly. Try making yourself available once a week to drive an aging parent to the doctor, on errands or to recreational activities. It also helps to coordinate other transportation options such as carpooling, community transportation and even alternate methods of obtaining goods and services such as home delivery and internet shopping.

Make financial sense. Owning and operating a vehicle can be expensive, especially for those on a fixed income. Car payments, repair costs, fuel, insurance and registration fees all add up. Giving up the car can make seniors feel more financially secure as much needed income will no longer need to be diverted to auto expenses.

Talk about safety. Some seniors don't realize that they have become unsafe drivers. Riding along with an elderly parent to assess driving skills can become a catalyst for a conversation on driving safety.

Enlist expert help. Many motor vehicle bureaus have elderly assessment services and senior driving courses that can help you and your aging parent understand and cope with changes in driving abilities. Even a parent who passes the standard vision exam during license renewal can be assessed for driving ability if the bureau worker suspects there might be issues that could prevent the individual from meeting minimum driving safety requirements. The individual's doctor can also issue a prescription barring the senior from driving if physical and mental issues could cloud judgment and ability.

Take the keys. If all else fails, it might become necessary to confiscate the keys to a parent's vehicle. This option is imperative if a senior doesn't remember that he or she is not supposed to drive. In such a case, removing the vehicle altogether or disabling it might become the best move.

It works for teenagers when they start their driving careers: a series of graduated steps and restrictions to ease them on to the road safely. Why not use the reverse for seniors — some kind of de-graduated licensing as they approach their final years behind the wheel?

Ontario is one of the few places in Canada and the United States that does not have conditional or restricted licensing for drivers who are medically at risk. But Ministry of Transport spokesperson Bob Nichols told the Toronto Star the province “has not ruled out a conditional licensing regime and we continue to monitor methods used by other North American jurisdictions.” Saskatchewan has one of the most successful and flexible programs designed to keep its roads safe, and its seniors happy.

“We try to balance the privilege to drive with the greater public safety,” says Sandy Crighton, the manager of driver programs for Saskatchewan Government Insurance, the province’s licensing authority. “Losing your license is devastating. We like to give our drivers every opportunity.”

When a driver is reported with a medical condition that might affect driving — by a doctor, a police officer, a family member or the driver himself — a government nurse reviews the file. If the problem is deemed severe enough, the licence could be suspended.

But in most cases the driver undergoes further medical evaluation and a road test. Then, depending how he or she performs, a wide-ranging series of conditions can be imposed to adapt their driving skills to their driving needs.

“We determine where they want to drive,” explains Crighton. “If they live in small town Saskatchewan, they may just want to drive around there and to the farm. A city person might want to drive to the mall and to the doctor’s office.”

Saskatchewan officials then might conduct an even more specialized road test along the specific routes chosen by the senior, and their licence might limit them to that zone. Other restrictions could include driving in daylight hours only and always with another person in the vehicle. The same should apply to drivers in Ontario but the authorities in Ontario seem less convinced.

I am getting fairly close to being eighty. I had a minor accident about thirty years ago when I changed lanes without first looking to see that I could do it safely. But young drivers make that kind of mistake also.

I drive practically every day, sometimes at night and other times on highways both during days and at night. So far, (knock on wood) I am a careful driver. But if I suspect that I am being a risk to others and to my family and also to myself, I will turn in my driver’s licence. However, when I turn eighty and have to take the tests every two years and pass them, I will continue to drive my car.

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