Driving Evaluations for the Skilled Nursing Population, Capstone Project Example

Introduction

Out of all of the challenges that aging poses to the elderly, driving is one of the most important from a public health standpoint. Driving, after all, involves not only the older driver, but also the safety and well-being of others. No other activity is so commonly associated with such a profound public safety concern as a result of older age.

Truisms about old age and driving may be abundant, but there are very real evidences that elderly drivers are a significant demographic with respect to automobile accidents. The literature indicates that the elderly are disproportionately involved in car crashes. The results of one study indicated that drivers 85 and older had 38.8 crashes and 30.7 fatalities for every million miles, compared with 28.6 crashes and 5.6 fatalities for the notoriously unsafe 16-19 age bracket, and 3.7 crashes and 0.9 fatalities for the 45-49 age bracket (Cerelli, 1986, ctd. in Marottoli, Cooney, Wagner, Doucette, & Tinetti, 1994).

In addition to being disproportionately unsafe drivers, the elderly are also disproportionately harmed by traffic accidents, comprising 14% of all vehicle occupant fatalities. In addition to age-related reductions in their ability to drive, the elderly are vulnerable because with age comes frailty, making them more prone to serious injury and death in the event of an automobile accident. And with the problem becoming ever more acute as the Baby Boomer generation ages and retires, the question of how to best assess driving ability is more important than ever.

Fortunately, there are a number of different assessments available. The first type of assessments cover vision. As people age, their eyes change in a number of ways which undermine their effectiveness. The lenses of the eyes become less flexible and more rigid, diminishing their ability to focus on objects close to the person’s face. This undermines the ability of the elderly to focus on things that are closer to them, which is why they so often have trouble with small print. It is also connected to driver safety, as these declines in vision can make it harder for them to read signs or see pedestrians near the vehicle. Assessments of visual ability measure various optical capabilities, allowing specialists to figure out whether or not a given elderly driver should continue to drive. There are also some therapies, like laser photocoagulation and photodynamic therapy, which can stabilize vision but not restore it.

Cognitive assessments focus on measuring cognitive capabilities, such as the ability to pay selective or divided attention. Eye tracking assessments are particularly promising, since they can assess selective attention capabilities in particular. The Useful Field of Vision (UFOV) assessment measures selective and divided attention, as well as spatial resolution, light sensitivity, and contrast sensitivity. The UFOV test is one of the most commonly used and most useful, precisely because it measures so many capabilities.

There are countless stories of the havoc and mayhem sometimes wrought by elderly drivers who discovered, too late, that age-related conditions made them unsafe motorists. In 2003, eighty-six-year-old Russell Weller failed to realize that the Santa Monica street he was about to drive into had been closed to all motor traffic for a farmers market. Hitting the gas instead of the brakes, Mr. Weller plowed headlong into a street given over to pedestrian traffic. His vehicle achieved speeds of 70 mph and he struck fifty people, ten of whom perished (Shulman, Silverman, & Golden, 2009).

Mr. Weller’s story is scarcely exceptional. In 2012, Margaret Tomascik, 89, was already speeding in Wilkes-Barre, Pennsylvania, when she ran a stop sign. Her vehicle struck another motorist, leaped the curb, and then crashed into a nearby construction site, hitting two individuals who were working there. One of the construction workers was severely injured, and the other was very nearly killed (Collis, 2014). In October of 2014, an elderly man driving the wrong way up U.S. 87 in East Bexar County, Texas, caused a head-on collision with another vehicle. The driver of the second vehicle had to be flown by helicopter to University Hospital in order to be treated for life-threatening injuries (Wilson, 2014). A third vehicle was also hit, receiving only minor damage, and the driver of this vehicle was not harmed (Wilson, 2014).

All too often, older drivers get into accidents and cause tragedies after family members and/or neighbors have already noticed a decline but have failed to say anything. In 2006, David Prager of Dallas was concerned when he saw his 90-year-old neighbor, Elizabeth Grimes, back out of her driveway, across her own lawn, and then off the curb (Davis & DeBarros, 2007). Grimes then hit the curb on the other side of the street, mistakenly hit the gas pedal instead of the brake, and took off. Six blocks later, Grimes ran a red light and struck a vehicle being driven by 17-year-old Katie Bolka. Bolka died five days later (Davis & DeBarros, 2006). One can only wonder what would have happened if Grimes’s family and/or neighbors had said something sooner.

The Dimensions of the Problem

Older drivers are disproportionately involved in automobile accidents. One study found that the 85 and up age bracket accounted for 38.8 crashes and 30.7 fatalities per million miles, compared with 28.6 crashes and 5.6 fatalities for the 16-19 age bracket and 3.7 crashes and 0.9 fatalities for the 45-49 age bracket (Cerelli, 1986, ctd. in Marottoli et al., 1994). In a study involving 283 participants with a mean age of 77.8 years, Marottoli et al. (1994) found that 38 of them, 13%, had an adverse driving-related event within the first year of follow-up. Clearly, there are very real and valid concerns to be raised about the safety of older drivers, and the best means of assessing older driver safety.

In the year 2005, some 191,000 elderly people were injured in automobile accidents (Marottoli et al., 1994). While it is true that this figure composes only 7% of all individuals injured in traffic crashes in the course of the year, the elderly were 15% of all traffic fatalities. They also accounted for some 14% of all vehicle occupant fatalities, and some 20% of all pedestrian fatalities. Despite the fact that many elderly adults voluntarily reduce their driving as they age, precisely because of diminishing vision and increased self-perceptions of the risk of accident, from 75 up the crash rates per mile increase quite significantly. From the age of 80 up they increase particularly quickly (Pomidor & Schwartzberg, 2009).

The problem is expected to become all the more acute as the elderly grow in numbers. An estimated 10,000 Baby Boomers are turning 65 every day in the United States; people who are 70 can reasonably expect to live 6-10 years beyond the time when it will be safe for them to drive (Morgan, 2013). Senior citizens are expected to number over 55 million by the year 2020, and 15.5 million of them will be living in areas where public transportation services will be either very poor or completely non-existent (Prah, 2011).Canada has a similar challenge to confront: from 1981 to 2005, seniors grew from 10 to 13 percent of the population. Seniors are expected to reach 23-25% of the population in 2031, and 25-30% in 2056 (Tay, 2011).

Automobile accidents exact staggering costs in lives and damaged property every year. For example, a 2014 study by the National Highway Traffic Administration (NHTSA) calculated that car crashes cause $871 billion worth of economic and societal costs in the United States annually (NHTSA, 2014). The figure covers all dimensions of the incredible damage caused by motor vehicle accidents, from damaged property—the cars themselves and other property—to the impact of deaths, serious injuries, and the like. In 2010, Americans suffered 32,999 fatalities, 3.9 million non-fatal injuries, and 24 million damaged cars. The total costs average about $900.00 per person per year (NHTSA, 2014). To be sure, accidents caused by elderly drivers are a minority percentage of the total problem, as seen. Nonetheless, accidents caused by elderly drivers because of age-related difficulties are a disproportionately larger part of the problem as a whole.

Vision is essential for driving, and vision is affected by the progression of old age in a number of well-known and adverse ways. Broadly speaking, older eyes lose much of their capability to focus, and much of their efficiency and the speed with which they process images (Bieliauskas, 2005). As people age, the lenses of their eyes lose flexibility, becoming more rigid and losing the ability to focus on objects close to the face. The elderly also experience changes in the ciliary muscles that control the eyeballs. Both of these physiological changes lead to presbyopia, a diminishing of the ability to focus on objects nearby. Not surprisingly, a decreased ability to focus on nearby objects is a risk factor for unsafe driving (Gruber, Mosimann, Muri, & Nef, 2013). The lenses of the eyes also yellow, which makes it harder for elderly individuals to differentiate between shades of blue and green. The efficiency with which light is transmitted through the lens also generally drops. For all of these reasons, vision is a capability that bears a great deal of scrutiny in assessments of driver ability (Bieliauskas, 2005).

Cataracts are another optical issue for elderly drivers. Both aging and diseases can cause the lens of the eye, which is normally clear, to undergo opacification, a condition also described as a cataract. With the lens more opaque, light enters the eye in a more scattered fashion, reducing retinal image contrast (Gruber et al., 2013). This problem can be corrected through cataract surgery, which improves visual acuity and contrast sensitivity.

Pupillary miosis is another eye problem that often occurs in old age. With aging, pupil diameters for any given level of illumination show a pronounced tendency to decrease, especially at lower levels of illumination (Gruber et al., 2013). This process has been linked to reduced retinal illumination and decreased ability to adapt the vision to the dark, meaning that elderly drivers tend to be particularly at risk of causing an accident when driving at night. Still other eye conditions that may develop in old age and impair a person’s ability to drive include glaucoma, macular degeneration, and diabetic retinopathy (Gruber et al., 2013).

Both laser photocoagulation and photodynamic therapy have been used successfully to stabilize vision, but neither has resulted in vision gain (Gruber et al., 2013). A variety of medical and surgical treatments are available for glaucoma, and can help the elderly to avoid visual field loss. Diabetic retinopathy can be prevented in some cases, and at least ameliorated and stalled in others, through a combination of laser photocoagulation, vitrectomy, and exercising control of systemic factors. More recently, pharmacological therapies have become a mainstay for treating diabetic retinopathy (Gruber et al., 2013).

Accordingly, one of the more widely-used and useful testing procedures in driver assessments focuses on ascertaining the useful field of view (UFOV). The task itself is a radial localization test, requiring the person to identify the radial direction of a target in their peripheral vision, while also distinguishing between two targets in their central vision. The peripheral target can be moved about in order to ascertain the total field in which the person can rapidly acquire information (Bieliauskas, 2005).

Determining the size of the UFOV necessarily involves assessing several different kinds of visual skills. Not only does UFOV involve light sensitivity, it also involves contrast sensitivity. It also measures spatial resolution, and the ability of the driver to pay selective attention or divided attention. Finally, UFOV also includes the speed of visual input processing (Bieliauskas, 2005). This variegated nature of the UFOV test is its cardinal advantage, and the reason for its widespread use. Because the UFOV test assesses so many different capabilities, it is particularly invaluable for determining whether or not an elderly driver should be allowed on the road. Older drivers with a 40% reduction from the largest possible UFOV size have been found to be 2.1 times more prone to traffic accidents in three-year follow-up periods (Bieliauskas, 2005).

Interestingly, there is evidence that age-related changes in vision that cause impairment may undermine the ability of the elderly to perform successfully on cognitive tests, at least to some degree (Bassi & Hunt, 2010). Blurred near vision caused by these age-related changes can make it somewhat harder for the elderly to complete the tests in a fashion that accurately reflects their true cognitive abilities, causing them to appear to be less safe than they actually are in some important ways (Bassi & Hunt, 2010). Visual acuity issues can at least be addressed in ways that true cognitive declines cannot.

Near-vision acuities below 20/40 may be cause for referral in some states. At 20/50 in particular, some states start to put restrictions on drivers (Bassi & Hunt, 2010). By experimentally creating groups of older and younger adults with near-vision acuities of either 20/50 or 20/100, Bassi and Hunt (2010) could compare their scores on cognitive tests with those of older and younger adults with near-vision acuities of 20/30 or better. What Bassi and Hunt (2010) found was that blurred vision decreased the ability of the seniors, but not the younger adults, to perform well on the cognitive tests, although the results were not found to be significant.

Of course, vision is not the only capability relevant to driving that is also affected in significant and well-known ways by aging (Bieliauskas, 2005). Cognitive abilities must also be taken into account and assessed, particularly the ability to pay attention. Older adults with early-onset dementia may still be able to pass an on-road driving examination, but it is doubtful they will be able to pass tests of cognition and attention (Bieliauskas, 2005; Mitchell, Castleden, & Fanthome, 1995; Hoggarth, Innes, Dalrympe-Alford, & Jones, 2013).

Cognitive declines affect the ability to pay selective attention, that is to say, the ability to focus in on particular stimuli to the exclusion of others. There is some evidence indicating that a particular age-related problem here is the decreasing ability to not pay attention to irrelevant or distracting stimuli (Bieliauskas, 2005). When a person is driving, they must process a great many stimuli, and make very quick assessments about precisely which stimuli to pay attention to, and to what degree. These assessments must be quick because driving is an activity involving high speeds in environments that are often fairly complex, with many different things for a driver to discriminate between (Bieliauskas, 2005).

Attention-based testing is also very important, particularly for distinguishing between elderly adults with and without dementia (Bieliauskas, 2005). Even in the early stages of dementia, older adults show significant declines in the ability to pay attention, especially selective attention. Selective attention is the ability to focus on particular stimuli, noting specific locations, features, or categories of stimuli. Attentional disengagement is a significant feature not only of early-onset dementia but also in normal aging over the age of 75. Elderly individuals in both these categories have a harder time shifting their attention, something that has been implicated in one of the more frequent and common driving errors in the elderly, making left-hand turns (Bieliauskas, 2005).

A particularly promising way to assess the ability to pay selective attention is eye tracking. Eye tracking systems record the position of an individual’s eyes as they watch animation simulating a view of driving (Bieliauskas, 2005). Younger individuals are more capable of maintaining central eye position and not becoming distracted, while older individuals are more readily distracted. These tests have considerable value for ascertaining to what degree a person can shift their selective attention (Bieliauskas, 2005).

In addition to selective attention, the capabilities of orientation, memory, and visuospatial ability are important dimensions to consider with regard to age-related cognitive declines. While many elderly people remain very lucid well into old age, others experience declines in cognitive functioning that may impair their ability to drive (Marottoli et al., 1994). Overall, the elderly perform more poorly than younger adults on measurements of many cognitive skills; nonetheless, there is an argument that cognitive declines in old age seem to be neither universal nor inevitable. As Greenwood and Parasuraman (2012) explained, one long-term study that followed 229 older adults over the course of 14 years found no cognitive decline in 46% of them. Another study found evidence that 68-87% of the variation in cognitive test scores was not related to age.

Rather than being inevitable and universal, cognitive declines appear to be due to a mixture of genetic and environmental factors (Greenwood & Parasuraman, 2012). Despite popular misconceptions, the older brain does not gradually degrade, losing structural integrity and brain cells. In fact, there does not appear to be a particular brain change associated with both healthy aging and cognitive declines. Older brains, in fact, retain a great deal of plasticity, and can function very well into old age (Greenwood & Parasuraman, 2012). All the same, it is of fundamental importance to ascertain whether an elderly adult is experiencing age-related cognitive declines or not.

Many elderly adults do suffer some loss of cognitive functionality over time, and these diminishing cognitive capabilities can make it dangerous for them to be on the road (Greenwood & Parasuraman, 2012). Individuals with cognitive impairments due to conditions such as Alzheimer’s disease, dementia, and others are particularly at risk of getting into accidents and causing tragedies. Driving assessments of the elderly should prioritize identifying these people in order to ensure they are not allowed to endanger themselves and others by driving (Greenwood & Parasuraman, 2012).

Executive function is an important capability that can also be affected by aging, with consequences for the ability of elderly drivers to drive safely. Declines in executive functions have been correlated with a more accident-prone driving history (Daigneault, Joly, & Frigon, 2002). Drivers whose executive functions are compromised are less able to ascertain what they need to do at any given point in time during a driving situation. It becomes more difficult for them to make the kind of split-second decisions that are so often necessary to driving safely and in a responsible manner.

Executive functioning has also been linked to a mediatory role in overall cognitive change (Princiotta, DeVries, & Goldstein, 2013). The abilities most affected by cognitive declines are typically quite complex ones, and executive functioning appears to be especially important in determining whether, and to what degree, these declines will take place. Individuals with high executive functioning late in life are more likely to retain excellent cognitive capabilities, while individuals who suffer executive functioning declines are more likely to also suffer from the loss of a number of complex cognitive abilities.

One particular concern with regard to cognitive impairment in older drivers pertains to early-onset dementia. Drivers with dementia have been found to get into nearly 2.5 time the number of crashes requiring insurance claims as drivers of the same age group who do not have dementia, and such drivers are 10.7 times more likely to get into a crash (Hoggarth, Innes, Dalrymple-Alford, & Jones, 2013). The occasion for concern is the more important in light of the fact that many individuals with early-onset dementia are still able to pass driving assessments on the road. Observations of pass rates range from 35% of drivers with early-onset dementia to 73%, pointing to a clear need for a better way to distinguish between drivers who have early onset dementia and those who do not (Hoggarth et al., 2013).

Hoggarth et al. (2013) tested a combination approach, one that used a mixture of sensory-motor and cognitive tests as well as a medical driving assessment on-road. Out of a sample of 279 elderly people with either Alzheimer’s, mild cognitive impairment (MCI), unspecified cognitive impairment or memory problems, some 155 (55.5%) flunked the medical assessment on-road. Those who flunked were significantly older than those who passed, with mean ages of 80.2 years and 76.2 years, respectively. The sensory-motor and cognitive testing proved more problematic, and the researchers ran into very high levels of both false-positive and false-negative issues (Hoggarth et al., 2013).

Early-onset Alzheimer’s disease has been linked with predictable declines in functionality with regard to driving (Washington University School of Medicine [WUSM], 2003). To a lesser extent, such declines in functionality have been observed with elderly individuals who do not have dementia. A 2003 study found that elderly individuals with dementia decline in their driving abilities faster than those who do not have dementia, although some declines in the other group were also observed. Because one of the features of dementia is a loss of insight, individuals who are demented often fail to realize they are no longer safe on the road, and continue to drive accordingly (WUSM, 2003).

There is support in the literature for the idea that individuals with early-onset Alzheimer’s disease (AD) can still drive for quite some time, so long as their driving activities are subject to evaluation or assessment by an occupational therapy driver evaluator (Brown, Gilman, & Hunt, 2010). However, a key problem with this is that driving is a complex activity involving many different capabilities, and the very earliest symptoms to manifest from Alzheimer’s disease are known to include diminution of recent memory, and the loss of the ability to recognize familiar objects. Accordingly, there is a quite strong case against allowing those with early-onset Alzheimer’s disease to continue to drive, even if their driving is subject to monitoring by an occupational therapy driver evaluator.

In order to evaluate whether or not it is a good idea for those with Alzheimer’s to continue driving, it is important to examine the outcomes of events in which an individual with Alzheimer’s or dementia became lost while they were driving. What Brown et al. (2010) successfully established was that many of these events had deeply negative outcomes. Out of 207 events from 1998-2008 in which an older adult with Alzheimer’s or dementia became lost while driving, 70 were never found, and 32 were found dead (Brown et al., 2010). Of the 116 who were found alive, 35 were found injured. One of the more salient aspects of these findings was that in case after case, the individuals in question became lost during drives to and from places that had long been familiar to them, such as the grocery store, the post office, or the home of a friend or a family member (Brown et al., 2010).

Cognitive testing is a particularly promising avenue for identifying a number of mental and psychological risk factors associated with poor driving in the elderly, particularly risk factors pertaining to Alzheimer’s disease (Mitchell, Castleden, & Fanthome, 1995). Comparisons of the performance of elderly Alzheimer’s patients and elderly people without Alzheimer’s on the Cambridge Cognitive Examination (CAMCOG), the Mini Mental State Examination (MMSE), and the Stroke Drivers Screening Assessment found significant differences between the two groups, differences which point toward a reliable way to assess driving ability in the elderly.  The SDSA in particular has been shown to be reliable, correlating very well with actual metrics of driving performance. The SDSA is composed of four different tests, which collectively evaluate visuospatial perception, concentration, reasoning, road sign recognition, and reaction time (Mitchell et al., 1995).

What Mitchell et al. (1995) found was that all of the Alzheimer’s patients they tested were not able to pass the SDSA. On the other hand, 48% of the control group failed the test, and those who did showed a smaller decline than the Alzheimer’s patients. All the same, the fact that so many of the control group failed the SDSA is significant, and points toward a significant potential hazard. Scores on the MMSE and age of the participants were in turn significant predictors of how well participants did on the SDSA. What this study demonstrates is that in addition to Alzheimer’s patients, many elderly individuals without Alzheimer’s still experience the kinds of cognitive declines that can make driving hazardous.

Marottoli et al. (1994) identified borderline cognitive impairment as a significant risk factor for poor driving; intriguingly, individuals with scores of 23-25 on the Mini-Mental State Examination were most at risk. Even individuals with higher scores on the Mini-Mental State Examination were involved in fewer adverse driving events than those who scored 23-25. This examination covers the cognitive domains of orientation, memory, attention, language, and visuospatial ability. What the authors found was that impaired design copying was the part of the test that was most consistently associated with adverse driving events for the participants. Of the individuals incapable of correctly copying a design consisting of intersecting pentagons, 24% had adverse driving events. Of those who could correctly complete the test, 8% had adverse driving events (Marottoli et al., 1994).

Marottoli et al. (1994) found that another predictor of adverse events was physical activity. In one study, individuals who walked less than one block per day were more likely to have adverse events, irrespective of how often they drove (Marottoli et al., 1994). Physical examination and performance metrics were also significant. The study identified the presence of three or more foot abnormalities as a significant predictor for having adverse events. Impaired ability to flex the left knee was another predictor. Another significant test was the rapid pace walk, with times of over 7 seconds as opposed to seven seconds or less correlated with higher frequencies of adverse events. Out of all of these measures, impaired design copying, less walking, and more foot abnormalities remained statistically significant after being run through binomial relative risk models (844).

Cognitive measurements of executive functioning show distinct differences between elderly drivers with and elderly drivers without a history of accidents (Daigneault, Joly, & Frigon, 2002). In a comparison of elderly male drivers with a history of accidents and elderly male drivers without such a history, Daigneault et al. (2002) found that the more accident-prone drivers scored poorly on four cognitive tests designed to evaluate the executive functions. The Color Trail Test (CTT), for example, measures the ability of the individual to alternate between two colors while following a numerical sequence. This test captures measures of visual acuity and ability to pay selective attention. The Stroop Color Word Test entails reading the name of a color (i.e. RED, YELLOW, BLUE, GREEN), and naming the color of the ink in which that name is written, with the color of the ink not necessarily matching the name of the color. Mental flexibility is an important ability measured by this test (Daigneault et al., 2002).

What Daigneault et al. (2002) discovered was that elderly drivers with a history of accidents performed more poorly on the cognitive tests, despite also reporting safer driving behaviors. While these findings confirm that elderly drivers have a tendency to actively work to drive as safely as they can, unfortunately they also point to certain unpleasant realities regarding cognitive declines in the elderly. Elderly drivers who suffer from cognitive declines can still be accident-prone, even if they go to considerable lengths to be safer on the road. These findings are certainly worth bearing in mind for healthcare professionals as they work with elderly patients on the subject of driving cessation.

Cognitive abilities may even be a better indicator of safe driving ability than other attributes, such as age, physical health, and even vision, at least to some degree. While it is certainly true that these other attributes are very important for the ability to drive successfully, cognitive abilities are so fundamental to the ability to drive well that they may be the cardinal limiting factor with regard to whether or not a driver is safe to be on the road (Ackerman, Edwards, Ross, Ball, & Lunsman, 2008). Ackerman et al. (2008) assessed a sample of elderly participants on a variety of tests, including tests of memory, tests of reasoning, and tests of cognitive speed-of-processing training. They also assessed physical capabilities, including vision, balance, and overall health.

What Ackerman et al. (2008) found indicates a cardinal role for cognitive faculties in determining whether or not an elderly driver is still safe to have a license. Physically speaking, older participants were at greater risk of driving cessation if they had poorer balance, while better physical functioning was correlated with reduced risk of them having to stop driving. Other physical factors were also important. For example, whether or not the participants had had a stroke, congestive heart failure, or heart disease all impacted the likelihood of them having to give up driving. Unsurprisingly, Ackerman et al. (2008) also found a significant role for vision, with participants who had better eyesight less likely to have to give up driving.

However, the cognitive findings were the most significant (Ackerman et al., 2008). The Everyday Problems Test (EPT) was a predictor of whether or not the elderly participants had to give up driving. Specifically, to the degree that the EPT indicated they had problems with instrumental functional performance, the elderly participants were more likely to have had to give up driving. The results obtained by Ackerman et al. (2008) argue strongly for a principal role, or at least a preeminent role, for cognitive processes in assessing senior driver safety and ability.

One proposed approach to actually improving the safety of elderly drivers is pharmacological. The drug piracetam (2-oxy-1-pyrro-lidinone acetamide) is a memory-enhancing and learning-stimulating drug, one that has been claimed to have the ability to improve cognitive function and reverse mild age-related cognitive decline (Riedel, Peters, Van Boxtel, & O’Hanlon, 1998). If true, the drug would be of considerable importance for addressing the problem of elder driver safety.

Riedel et al. (1998) evaluated the performance of 101 elderly drivers between the ages of 60 and 80 who had been identified as poor drivers in a previous screening test. The study participants were then treated with piracetam for 4 weeks, and then evaluated again. The results indicated a very slight improvement in standard deviation of lateral position (SDLP), although this improvement was not statistically significant. The results pointed to the possibility that a longer trial could find statistically significant effects, although driving performance did not improve after the 4 weeks of the test period itself (Riedel et al., 1998).

On the other hand, some drugs have been linked to performance issues with regard to driving. As Meskali, Berthelon, Marie, Denise, and Bocca (2009) explained, all too often the effects of hypnotic drugs have been tested on younger, healthy drivers in the context of a motorway test. The key problem here is that the tests have not been carried out on elder drivers, and they have not been carried out in the more complex environments people in general typically drive in. And yet, there is valid reason to be concerned about hypnotic drugs, particularly benzodiazepines, in the context of driving. There are epidemiological data which indicate that a significant percentage of drivers involved in accidents have been on benzodiazepines at the time. This holds true for drivers in general, not only the elderly: benzodiazepines with long half-lives are apparently the most problematic in this regard (Meskali et al., 2009).

In order to remedy this problem, pharmaceutical companies have taken it upon themselves to develop other kinds of hypnotic drugs, notably the cyclo-pyrrolones and the imidazopyridines (Meskali et al., 2009). Zopiclone and zolpidem are two commonly-used non-benzodiazepine hypnotics, and are quite often prescribed in a number of different European countries. In order to test their effects, Meskali et al. (2009) selected 16 experienced participants of upper-middle to old age, 55-65 years old. The tests themselves were driving simulations based on urban conditions.

Each of the participants was taken through five different driving sessions on different dates; the first of these did not involve taking any drug, creating a control group. The participants were then tested on three different drugs, flunitrazepam, zolpidem, and zopiclone, in successive sessions, as well as a placebo (Meskali et al., 2009). The participants took the drug (or placebo) each night before the experiment.In between sessions, each participant took 14 days to eliminate all traces of the drug from their system (Meskali et al., 2009).

What Meskali et al. (2009) discovered has significant implications for prescribing hypnotic medications to elderly drivers. The results indicated that only zolpidem created a statistically significant increase in the number of crashes in the simulated driving sessions, and the zolpidem-induced increase was only slight (Meskali et al., 2009). The treatments did affect mean speeds at the start of each scenario, with flunitrazepam treatments resulting in higher speeds than the placebo. The zopiclone treatments generally resulted in higher speeds than the placebo, although not in all cases (Meskali et al., 2009). What these findings establish is that some hypnotic drugs have little to no effect on driver safety. This is an important conclusion with regard to establishing the side effects of these drugs when prescribed to older drivers, one that indicates a promising direction for clinical practice.

Driving simulators are another way to assess the ability of elderly drivers to safely operate a motor vehicle. The advantage of this approach is that it tests so many different skills in a format designed to capture some of the actual challenges of driving. There are limitations to this approach, because older drivers quite commonly modify their driving habits in order to be safer drivers to begin with (Bieliauskas, 2005). Nonetheless, such assessments can be useful in assessing the abilities of elder drivers to confront common challenges experienced in driving at any age: animals running out into the streets; vehicles in front of the driver stopping suddenly, or a vehicle suddenly turning onto the street from the right (Bieliauskas, 2005).

One particularly promising method for improving the safety of older drivers is augmented reality (AR) cuing. AR cuing relies on a combination of natural and artificial stimuli, projected as computer graphics onto a transparent plane (Schall et al., 2013). The premise is that this augmentation can help elderly drivers to see important features of the roadway and of their surroundings, and can provide helpful, informative annotations. One concern that has been raised about AR cuing is that this additional information could distract drivers, dividing their attention and reducing accuracy (Schall et al., 2013).

The question of whether AR cuing is effective or harmful in helping elderly drivers to avoid risky behavior was evaluated by Schall et al. (2013). The method of AR cuing under study was SIREN, which provides a four-channel display. The cuing itself consisted of broken yellow lines forming a rhombus shape, used to direct the attention of older drivers to targets, such as signs, that might be difficult for them to spot. The results of the experiment were promising: participants noticed and responded to pedestrians 25% more often. They also responded to warning signs 5% more often (Schall et al., 2013). Despite the aforementioned concerns about AR cuing interfering with drivers’ attention, no evidence of this was discovered in the study. All indications point to AR cuing as a promising means of helping elderly drivers to be more safe on the road (Schall et al., 2013).

Social Responsibility

There is a very valid social responsibility to ensure that elderly drivers are evaluated for potentially hazardous age-related declines in functionality. Fundamentally, evaluating elderly drivers is the most straightforward and obvious means of ensuring that a number of altogether preventable injuries and deaths are indeed prevented (Collis, 2014). Despite the known hazards disproportionately associated with elderly drivers, most American states have failed to address the issue by adopting special regulatory standards governing license renewal for elderly drivers. The state of Tennessee maintains a particularly ill-advised policy, issuing drivers at the age of sixty-five perpetual licenses without expiration dates (Collis, 2014). Compounding this foolish policy, Tennessee will not revoke a driver’s license unless the driver is responsible for a fatal collision. Nationally, Tennessee is ranked sixth-highest for the number of accidents involving drivers over sixty-five years of age (Collis, 2014).

Unlike Tennessee, many states have adopted fairly sensible measures governing license renewal for elderly drivers. A number of states, including Hawaii, New York, South Carolina, and Illinois, require older drivers to pass a vision test. Illinois in particular requires drivers seventy-five and older to undergo testing on the road, and has actually accelerated the license renewal period for drivers over eighty-one. New Mexico requires drivers seventy-five and older to renew their licenses every year. California, Massachusetts, and Texas require older drivers to renew their licenses in person (Collis, 2014).

However, there is also a social responsibility to be very careful in evaluating elderly drivers. While it is undeniably true that there are numerous age-related conditions and developments which make it advisable to have elderly drivers evaluated to ensure their abilities to drive are still sufficient, it is also true that driving is very important for many elderly people. For this reason it is essential to ensure that elderly drivers are not unfairly stripped of their licenses in those cases where they are not actually posing a safety risk to themselves and others (Touhy & Jett, 2014).

The transition from driving to not driving also needs to be handled with care. The elderly often rely on driving to remain independent and functional. If they do not have transportation, many elderly people suffer from physical and social declines. Public transportation is not always available, and even where it is, in urban communities it is often prone to hazards and dangers for elderly passengers (Touhy & Jett, 2014). After giving up driving or being forced to give it up, elderly people often suffer from less social integration, less activity outside of the home, more depression and anxiety, poorer quality of life, and more risk of having to be placed in a nursing home (Touhy & Jett, 2014).

Older drivers are, in many cases, aware of the practical realities of age-related declines in functionality (Touhy & Jett, 2014). Accordingly, they often adopt behavioral strategies designed to mitigate the safety risks. Compared with younger drivers, older drivers frequently drive fewer miles, and drive less often at night, at times of inclement weather, and in congested areas. These tendencies should be taken into account by any healthcare professional working with older patients where the subject of driving is concerned. Healthcare professionals can also recommend these strategies to patients who are beginning to experience age-related declines (Touhy & Jett, 2014).

Awareness on the part of older drivers plays a key role in determining a great deal about whether or not an older person will continue to drive, and if so under what circumstances (Bundy, Clemson, & Kay, 2009). The importance of awareness is in some sense two-fold: awareness helps older drivers pay better attention on the road, and it also helps them to take better stock of their own abilities. An older driver who is aware of their own decline may take steps to mitigate the risks they incur when they do get behind the wheel. An older driver who is not aware, on the other hand, may not adopt compensatory strategies, and may run significantly greater risks as a result. Determining where a given elderly driver fits in relation to these two categories is therefore of very considerable importance. In particular, it can help professionals to ascertain whether or not an elderly driver is safe to continue driving at all, and if so under what circumstances.

Using an instrument called DriveAware, Bundy et al. (2009) measured elderly drivers’ awareness of both their driving performance, and the assessment process itself. The instrument consists of five questions, each designed to capture information about the elderly person’s state of mind with regard to the assessment, their memory, their concerns about their driving, their perceptions and awareness of their driving performance, and their perceptions of how well they performed on a Visual Recognition Slide Test. The study also involved on-road assessments of driving performance, providing a metric of driver safety.

What Bundy et al. (2009) found was that elderly individuals who did well on DriveAware prior to the on-the-road assessment also successfully evaluated their performance after the assessment. This has significant ramifications for assessment. It indicates that elderly drivers who are aware of their performance and how well they are doing on the road are more likely to perceive the need to adopt compensatory strategies if necessary, such as driving more cautiously, avoiding night driving, and avoiding driving in crowded areas. Of course, more aware drivers are also more likely to see when it is time to give up driving.

Recommendations

Nurses and other healthcare providers have an important role to play in carrying out safety assessments on elderly drivers. There are a number of ways in which healthcare professionals can fulfill this important social responsibility. In some cases, taking the opportunity to discuss the particulars of driving can be very helpful. Older drivers may benefit from discussing the routes they take, the time of day at which they drive, the vehicles they use and the options they have when driving these vehicles, particularly with regard to mirrors, adjusting seating, and the like (Kidd, 2001). Healthcare professionals may also be able to help inform community interventions, such as public safe driving sessions, outsider evaluation of a driver’s abilities, more visible street lighting and signage, and making it mandatory to have vision tested for renewal of a license. In addition to street lighting and signage, other aspects of the physical environment can be rendered more safe for elderly drivers. In particular, protected left turns, stop signs that cover all routes of an intersection, and one-way streets can make things much safer for elderly drivers and those who share the road with them (Kidd, 2001).

There are a number of important tests for evaluating driving ability in the elderly, and healthcare professionals should familiarize themselves with these tests. Screening tests such as the Driving Practices Questionnaire and the Driving Habits Questionnaire are particularly important in helping to identify elderly drivers who may pose a safety risk (Kidd, 2001). Other tests are also important. The Mini-Mental State Exam (MMSE) includes a copy design task, in which the test-taker is asked to draw out a design they are presented with. This simple task can provide extremely valuable information about the risk posed by a driver (Kidd, 2001).

The useful field of vision (UFOV) test, discussed previously, is a test that is commonly used in evaluating the driving ability of elderly drivers (Arbesman & Hunt, 2008). Although it has been contested, some evidence has strongly supported the efficacy of this test. Because this test measures visual processing speed, divided attention, and selective attention, it is esteemed as very useful in many circles. As Bieliauskas (2005) explained, the test has been used quite successfully to identify unsafe drivers; because the UFOV test measures so many important dimensions of vision, it has a great deal of potential in clinical settings. Drivers with very limited UFOVs will often be incapable of responding properly to the complexities of the driving situations in which they are likely to find themselves.

Another visual test and training device is the Dynavision, which is designed to train users to optimize how they receive, process, and react to images (Arbesman & Hunt, 2008). The Dynavision has a great deal of potential as an aid to help elder drivers to improve the attention that they pay to driving. The Dynavision system itself consists of a 4- or 5-foot computerized board, which can be mounted on a wall. The Dynavision contains 64 different red square target buttons, all arrayed in five rings nested within each other. Subjects who have tested on it have improved their performance successfully, particularly on measures of divided attention and selective attention. In addition to this, some 60% of participants in one study were able to earn a rating sufficient for them to resume driving safely (Arbesman & Hunt, 2008).

Nurses and other practitioners should also be prepared to evaluate clinical histories for risk factors, and to evaluate driving practices when prescribing medication. Some medications, such as benzodiazepines, TCAs, and antihistamines can potentially reduce driving ability (Kidd, 2001). Despite the fact that over 80% of senior drivers take medications regularly, only about half have spoken with a healthcare professional about the potential for safety issues to arise with regard to driving (PR Newswire, 2012). Healthcare professionals should take an active interest in addressing this topic with elderly patients who take medication and drive, making sure that their patients are aware of possible side-effects and risks. The AAA Foundation has created Roadwise Rx to help older drivers with this problem. The site provides information on typical side effects of both prescription and over-the-counter medications, with the emphasis on side effects that might cause problems for senior drivers (PR Newswire, 2012).

Hip disease is something nurses should be prepared to take note of and connect with driving, because hip disease has the potential to negatively affect driving ability. Healthcare professionals should also be attentive to elderly patients’ driving history, especially crashes and citations. If patients have episodes of getting lost, nurses should make note of this; this is a risk factor for hazardous driving. Observations of family members can also be quite significant; if family members perceive that an elderly driver’s cognitive functioning and/or visuospatial acuity is declining, this is certainly grounds for recommending their driving abilities be formally evaluated (Kidd, 2001).

Perhaps one of the most important duties of healthcare professionals where evaluations of the elderly for driving ability are concerned is discussing plans for driving cessation (Touhy & Jett, 2014). Prior to the time at which an elderly patient has a severe mobility issue that incapacitates them to such a degree that they must stop driving, it would be optimal for their healthcare professionals to candidly but diplomatically broach the topic of driving cessation with the patient and with their family. Broaching the topic is very important for helping the patient and their family to be forthcoming and helpful in identifying any age-related impairments and developments that might make it advisable for the elderly patient to give up driving (Touhy & Jett, 2014).

In addition to the very real and undeniable safety hazards and risks at stake, there is also the fact that elderly patients who voluntarily relinquish their licenses have better outcomes than those who are forced to give them up (Touhy & Jett, 2014). It is therefore a social and professional duty for the healthcare professional to not only broach the topic with their elderly patients, but also encourage the patient, with support from their family, to consider voluntarily giving up driving when the time comes. Toward this end, there are a number of strategies the healthcare professional can follow to help ease the patient toward driving cessation. Rather than an abrupt transition, the move toward driving cessation can be a protracted and gradual one (Touhy & Jett, 2014).

To begin with, the healthcare professional can encourage their patient to avoid driving at times or under conditions in which it is particularly unsafe for them to drive, i.e. the aforementioned conditions of night driving, driving at times when the weather is not favorable, or at times when the traffic is very heavy (Touhy & Jett, 2014). Patients should also be encouraged to avoid roads with which they are not familiar. The patient can also follow other strategies designed to reduce their need for driving. For example, patients who resort to having their groceries delivered to their homes can eliminate a significant amount of their driving needs altogether. Personal services can also be provided in-home, eliminating still more of the need to drive (Touhy & Jett, 2014).

Caregivers can also be tasked with procuring various items for their elderly patients (Touhy & Jett, 2014). In addition, caregivers can serve as copilots in those situations in which it is still advisable or permissible for the patient to drive. They can also help them identify community resources for transportation. In some cases vehicle adaptations may prolong the time in which the elderly person can drive. Along with sensory aids, special training, and special assessment programs, elderly drivers may be able to continue driving for longer than they would have been able to otherwise (Touhy & Jett, 2014).

Given the considerable safety issues raised by elderly drivers who suffer from age- and disease-related declines, there is a clear need for policies and procedures to ensure appropriate testing of elderly drivers. While some individuals are perfectly capable of driving well into old age, it is nonetheless true that many aspects of the aging process compromise the ability of the elderly to perform the complex and often demanding tasks associated with driving. It is therefore essential to ascertain how, precisely, the abilities of the elderly are to be measured, and what criteria are to be used in order to distinguish between safe and unsafe drivers.

The literature confirms that there are a number of predictors for automobile crashes and moving violations (Marottoli et al., 1994). There are essentially four areas of performance and ability which can be assessed to determine whether or not an elderly person is safe to drive: vision, attention, executive function, and more broadly, simulated driving (Bieliauskas, 2005). All of these are important avenues of inquiry for ascertaining the safety of a driver, because all of them measure important capabilities relevant to driving. Significantly, all of them measure capabilities known to decline later in life.

For nurses and other healthcare professionals in particular, evaluating driving ability should start with inquiring into the patient’s driving history. The questions the healthcare professional asks should be designed to capture pertinent information about driving habits and how they have changed (Pomidor & Schwartzberg, 2009). How often does the patient drive? Does the patient avoid driving at night, or on freeways, or under conditions of unpleasant weather? What about adverse events? Has the patient been in any accidents? Were they issued any tickets? If the patient has a caregiver, the caregiver should also be questioned. It is very important to ascertain whether the patient has changed their driving habits or become noticeably less safe (Pomidor & Schwartzberg, 2009).

Of course, physical examinations are also very important. Vision, motor function, and cognition all need to be evaluated carefully (Pomidor & Schwartzberg, 2009). Healthcare professionals can assess motor function through tests of walking ability; tests of the patient’s range of motion, and tests of the patient’s strength. All of these are very useful tests, and they help the healthcare professional to ascertain whether or not the patient poses a risk to themselves or other people on the road. The rapid-pace walking test consists of having the patient walk a 10-foot path, turn all the way around, and then return. The number of seconds is measured, and this metric informs evaluations of motor function ability (Pomidor & Schwartzberg, 2009).

The patient’s range of motion should also be tested. This is accomplished by having them first rotate their necks to the right and the left, an important indicator of how capable they will be of ascertaining their surroundings (Pomidor & Schwartzberg, 2009). Patients should also be evaluated on their ability to make a fist with each hand. Another important test is the steering test: the patient is asked to pretend they are holding a steering wheel in the positions required to make first a wide right turn and then a wide left turn (Pomidor & Schwartzberg, 2009). Motor strength can also be tested for bilateral shoulder adduction, abduction, and flexion. Wrist flexion and extension should also be tested (Pomidor & Schwartzberg, 2009).

The Clock Drawing Test is a common means of cognitive screening, one healthcare professionals should certainly make use of. In the Clock Drawing Test, the patient is instructed to draw the face of a clock. They are asked to draw the clock with the hands at 10 minutes after 11. This task is very simple, but it involves attention, executive skills, and memory, which is why it is such a good metric of cognitive ability (Pomidor & Schwartzberg, 2009). Another important test for cognitive screening is the Trails-Making B Test. In this test patients are asked to draw a line connecting dots to form a path, with each item on this path being alternately a number or a letter, i.e. 1-A-2-B (Pomidor & Schwartzberg, 2009). Taking more than 180 seconds to complete this test is considered abnormal, and merits intervention (Pomidor & Schwartzberg, 2009).

In a great many cases, older drivers may be able to significantly prolong their time on the road by completing special training courses designed to help them drive more safely. The American Association of Retired Persons (AARP) is conducting training seminars throughout the country, with the aim being to teach the elderly how to optimize their driving skills (Morgan, 2013). Seniors who participate in these programs can expect to learn the correct way to grip a steering wheel, something that has changed over the course of their lives as steering wheel designs themselves have changed. Posture, seatbelt position, and the correct placement of the side view mirrors are also important (Morgan, 2013).

One of the most important and unavoidable realities pertaining to elderly drivers is that for many of them, public transportation is not a workable option (Prah, 2011). Even in areas where public transportation is available, it may not be practical, or even safe. The elderly tend to be more physically frail, and many of them have special mobility needs. Some of them have oxygen tanks. For all of these reasons, feasible alternatives to public transportation need to be explored, and healthcare professionals can play a key role in such explorations.

One alternative to public transportation is already being provided by the private sector. The Independent Transportation Network of America (ITN America) is a nationwide organization formed for the express purpose of serving the elderly with regard to their needs for transportation (Prah, 2011). The organization recruits drivers to cover various time slots. Collectively, the drivers on ITN America’s roster allow the organization to give the elderly rides 24 hours a day, seven days a week. Although ITN America’s services are not completely free, they have the distinct advantage of not competing for funds from state or local governments. This is particularly important in a time when such funding is increasingly scarce, with many state and local governments cutting back on spending (Prah, 2011).

The particular brilliance of ITN America is that the organization uses a combination of volunteer and professional drivers. This combination may seem an unusual pairing, but it actually makes a great deal of sense. If the organization were to use only volunteer drivers, it would be unable to keep up with demand; if it were to use only professional, paid drivers, its services would be out of reach for many of the elderly (Prah, 2011). What this organization demonstrates, among other things, is that it is not necessary to rely on governmental support to affect a meaningful solution to an important and complex societal problem. Given the unreliability or outright lack of funding in many instances, the existence of ITN America and the significance of its work is indeed fortuitous, pointing to an efficacious solution to the issue of transportation for those elderly individuals no longer safe to drive.

Conclusion

Assessing the capabilities of older drivers is of fundamental importance for ensuring their own safety and that of others. Tests of vision, cognitive abilities, attention, and executive functioning are all of considerable importance for assessing the ability of an elderly individual to continue to drive safely. There is a very real social responsibility to ensure that elderly drivers who have become a risk are identified and parted from their keys. All too many tragedies have occurred because someone failed to say something or do something until it was too late. On the other side of the coin, healthcare professionals have an obligation to their patients: they need to tell them the truth and help them to understand the very real need to do what needs to be done. While scarcely easy, this is a vital and necessary function for healthcare professionals to serve, one of considerable importance for the wellbeing of the public.

Ultimately, many elderly drivers are not capable of remaining safely on the road. However, driving is a very important skill for many older adults to have, since it is fundamental to mobility and a sense of independence. The challenge confronting professionals is not only to differentiate safe and unsafe drivers, but also to help older patients make the transition to giving up their driving when the time comes. The problem is in many ways a complex one, since elderly individuals who stop driving often face significant challenges in finding alternatives with regard to transportation. It can also be difficult to convince an older person that they need to give up driving for the safety both of others and themselves. With careful planning and an evaluation of the options, healthcare professionals can broach the topic with elderly patients in a way that is diplomatic, tactful, and helps them to accept the need to give up the road.

References

Ackerman, M. L., Edwards, J. D., Ross, L. A., Ball, K. K., & Lunsman, M. (2008). Examination of cognitive and instrumental functional performance as indicators for driving cessation risk across 3 years. The Gerontologist, 48(6), pp. 802-810.

Arbesman, M., & Hunt, L. A. (2008). Evidence-based and occupational perspective of effective interventions for older clients that remediate or support improved driving performance. American Journal of Occupational Therapy, 62(2), p. 136.

Bieliauskas, L. A. (2005). Neuropsychological assessment of geriatric driving competence. Brain Injury, 19(3), pp. 221-226.

Brown, A. E., Gilman, I. P., & Hunt, L. A. (2010). Drivers with dementia and outcomes of becoming lost while driving. American Journal of Occupational Therapy, 64(2), p. 225.

Bundy, A. C., Clemson, L., & Kay, L. G. (2009). Awareness of driving ability in senior drivers with neurological conditions. American Journal of Occupational Therapy Association, 63(2), p. 146.

Collis, H. M. (). Why Ms. Daisy was not allowed to drive herself: An examination of the need for federally mandated license renewal procedures for elderly drivers. Transportation Law Journal, 41(45), pp. 45-66.

Daigneault, G., Joly, P., & Frigon, J.-Y. (2002). Executive functions in the evaluation of accident risk of older drivers. Journal of Clinical and Experimental Neuropsychology, 24(2), pp. 221-238.

Davis, R., & DeBarros, A. (2007, May 02). Older, dangerous drivers a growing problem. USA Today. Retrieved from http://usatoday30.usatoday.com/news/nation/2007-05-02-older-drivers-usat1a_N.htm

Greenwood, P. M., & Parasuraman, R. (2012). Nurturing the older brain and mind.Cambridge, MA: Massachusetts Institute of Technology.

Gruber, N., Mosimann, U. P., Muri, R. M., & Nef, T. (2013). Vision and night driving abilities of elderly drivers. Traffic Injury Prevention, 14, pp. 477-485.

Hoggarth, P. A., Innes, C. R. H., Dalrymple-Alford, J. C., & Jones, R. D. (2013). Predicting on-road assessment pass and fail outcome in older drivers with cognitive impairment using a battery of computerized sensory-motor and cognitive tests. Journal of the American Geriatric Society, 61(12), pp. 2192-2198.

Hunt, L. A., & Bassi, C. J. (2010). Near-vision acuity levels and performance on neuropsychological assessments used in occupational therapy. American Journal of Occupational Therapy, 64, pp. 105-113.

Kidd, P. S. (2001). Injury prevention in the elderly. In M. Foreman et al. (Eds.), Critical care nursing of the elderly (2^nd ed.) (pp. 107-132). New York: Springer.

Marottoli, R. A., Cooney, L. M., Wagner, R., Doucette, J., & Tinetti, M. E. (1994). Predictors of automobile crashes and moving violations among elderly drivers. Annals of Internal Medicine, 121(11), pp. 842-846.

Meskali, M., Berthelon, C., Marie, S., Denise, P. & Bocca, M.-L. (2009). Residual effects of hypnotic drugs in aging drivers submitted to simulated accident scenarios: An exploratory study. Psychopharmacology, 207, pp. 461-467. DOI: 10.1007/s00213-009-1677-2

Mitchell, R. K., Castleden, C. M., & Fanthome, Y. C. (1995). Driving, Alzheimer’s disease and ageing: A potential cognitive screening device for all elderly drivers. International Journal of Geriatric Psychiatry, 10, pp. 865-869.

Morgan, P. (2013, October 20). Aging drivers work to keep their keys. Tampa Bay Times. Retrieved from http://www.tampabay.com/

National Highway Traffic Safety Administration. (2014, May 28). New NHTSA study shows motor vehicle crashes have $871 billion economic and societal impact on U.S. citizens. NHTSA. Retrieved from http://www.nhtsa.gov/About+NHTSA/Press+Releases/2014/NHTSA-study-shows-vehicle-crashes-have-$871-billion-impact-on-U.S.-economy,-society

Pomidor, A. K., & Schwartzberg, J. (2009). Driving and the older adult. In C. Arenson et al. (Eds.), Reichel’s care of the elderly (6^th ed.) (pp. 517-529). New York: Cambridge University Press.

PR Newswire. (2012). Safe driving ‘prescription’ for senior drivers. PR Newswire. Retrieved from http://www.prnewswire.com/

Prah, P. M. (2011, August 4). Driving services help senior mobility without spending public money. McClatchy-Tribune Information Services. Retrieved from http://www.mcclatchy.com/

Princiotta, D., DeVries, M., & Goldstein, S. (2014). Executive functioning as a mediator of age-related cognitive decline in adults. In S. Goldstein & J. A. Naglieri, Handbook of executive functioning (pp. 143-158). New York: Springer.

Riedel, W. J., Peters, M. L., Van Boxtel, M., & O’Hanlon, J. F. (1998). The influence of Piracetam on actual driving behaviour of elderly subjects. Human Psychopharmacology, 13, pp. S108-S114

Schall, M. C., et al. (2013). Augmented reality cues and elderly driver hazard perception. Human factors, 55(3), pp. 643-658.

Shulman, N., Silverman, M., & Golden, A. G. (2009). The real truth about aging: A survival guide for older adults and caregivers. New York: Prometheus Books.

Swanson, A. (2005, March 07). Analysis: Aging drivers growing problem. UPI Perspectives. Retrieved from http://www.upi.com/

Tay, R. (2011). Ageing driver licensing requirements and traffic safety. Ageing and Society, 04, pp. 655-672.

Touhy, T. A., & Jett, K. F. (2014). Gerontological nursing & healthy aging (4^th ed.). St. Louis, MO: Elsevier.

Washington University School of Medicine. (2003, October 3). Driving performance declines with dementia and age. Science Daily. Retrieved from http://www.sciencedaily.com/

Wilson, M. D. (2014, October 27). Elderly man driving wrong way causes major crash east of San Antonio. My San Antonio. Retrieved from http://www.mysanantonio.com/news/local/article/Major-crash-in-East-Bexar-County-on-5850478.php