Safety and the Older Driver (May 2021)

MICHAEL BUCKLEY: Hello, I’m Michael Buckley with the BrightFocus Foundation. Welcome to today’s BrightFocus Chat, “Safety and the Older Driver.” If today is your first time joining us, welcome. I’ll tell you briefly about who we are and what we’ll do today. BrightFocus is funding some of the top scientists in the world—these are researchers that are trying to find cures for macular degeneration, glaucoma, and Alzheimer’s. We try to share the news, the latest research findings, and best practices with families that are impacted by these diseases. We have plenty of materials on our website, BrightFocus.org, and today’s BrightFocus Chat is another way of sharing this information. Because we fund research in both mind and sight, we really thought that safety in the older driver would be a great topic for today because it’s something that impacts millions of American families. It’s at the intersection of vision health and your brain health or your cognitive health, so we thought it would be a great opportunity. Today we’re really fortunate to have one of the nation’s leading authorities on driving for older Americans. Her name is Elin Schold Davis. She directs the Older Driver Initiative at the American Occupational Therapy Association. She’s spoken all across the country on this topic. You see her a lot in media/articles on the topic, so we’re just really fortunate to have you with us, Elin, so welcome.

ELIN SCHOLD DAVIS: Well, thank you. Thank you so much for including me in your Chat series, and I’m thrilled to talk about a topic that’s near and dear to my heart.

MICHAEL BUCKLEY: For our listeners, one out of every five drivers in America is over 65. Does this make … and as our nation’s population ages, this becomes an even more important topic. So, Elin, with, again, 20 percent of the drivers in America are over 65. Before we get into some of the issues and challenges there, just the big picture: Is our country getting better at making cars and making roads that are safer?

MS. ELIN SCHOLD DAVIS: There’s a big question to start out with. Absolutely, and I like to … when we talk about … when we lead with the idea that we’re an aging society, one of the first lines I always want to start with is: That’s an opportunity, it’s not a problem. We’re really lucky to be having the medical care, the people being healthier, having access to really managing their self-care and their interest in being mobile in their community. It’s a wonderful thing. So, when we look at aging, what we have to do is, I think, shift the focus as we look at resilient survivors—people that are very experienced with driving—and try to do what we can to help people drive into their older years, recognizing that some things do change, and you’re absolutely right. We are universally looking at this from many angles: from the person, which I think we’ll focus on a bit more today, but also we’ll talk a bit about how cars have changed to accommodate the broadening of skill sets of drivers and the broadening of skill sets of drivers navigating on the roads. And the road infrastructure has been changing to accommodate this, using concepts like universal design, and we can talk about that as we go through this Chat.

MICHAEL BUCKLEY: We talked about the resilience and positive proactive adaptation to some of the challenges that come with age. What are some of the challenges that make driving harder for some older Americans?

ELIN SCHOLD DAVIS: Well, one thing I like to do when I think of challenges and aging is distinguish aging from medical conditions. Medical conditions, like glaucoma, are not normal aging, if you will. They’re common in aging, and more people as we age acquire some of these medical diagnoses, but let’s just not confuse them with the concept of aging—aging with medically related changes that are really unexpected. They’re not what you planned for. You could have been going to exercise class. You could have been doing everything—I use air quotes—“right,” and you still can be acquiring some medical diseases and medical changes. So, I think the idea of aging with medical conditions is a different kind of demand. It’s a new kind of demand for people to recognize, learn about it, empower themselves to be able to adapt to these changes, and understand that it’s not something you maybe wanted; it is not maybe something you deserved. However, it does not have to be a show stopper, and it’s something you can really do a lot about when we embrace understanding those changes.

MICHAEL BUCKLEY: My understanding of the issue is, it’s both a vision acuity issue but also sometimes cognitive health. Are those two intertwined, or are those separate challenges to the brain health and eye health?

ELIN SCHOLD DAVIS: Oh, boy. I think they’re all different. They’re all different mechanisms, although there is some literature that supports that when our vision is compromised, when we see less, it can look sometimes like a cognitive decline, and, really, it’s because we didn’t get the information. So, there really is, I would say, some support of really doing everything you can to optimize your vision with the eye doctor visits, the health of your eye, doing everything you can to comply with the medical care that’s possible, because the more we get sensory information in from our eyes, from our feelings, from our bodies, the more we are … that supports our cognitive alertness, so to speak, within how we manage. Cognitive changes as a diagnosis, like we might jump to dementia, is another … that’s just another category of medical conditions that some people are faced with.

MICHAEL BUCKLEY: Yes, and I appreciate that. I know I’ve heard you speak a little bit today and in the past about trying to take charge, trying to be proactive so this doesn’t have to be a … I think a lot of us, when we think about older driving, we think about something negative. We think about something that’s unexpected and unfortunate and unpleasant, but I’ve heard you talk about how to get ahead of this. How would you … could you elaborate on that?

ELIN SCHOLD DAVIS: Yeah, and I work in rehab, so, of course, my professional perspective—my background—is trying to help people be informed and figure out what they can do about it. But, you know, the first step is difficult because the idea of understanding what’s going to happen to us or understanding the possible conditions associated with something can be overwhelming and depressing, and what I try to do—and I do get accused of being a Pollyanna sometimes—but I think there is some empowerment in knowledge. I think we can … I used to sometimes talk to clients I worked with saying, “Beat it with brains,” you know? If you can work on understanding the physiological changes that you don’t have control over and then figure out how you can balance those changes with some adaptation or compensation of things that you can do, even though it takes a bit of understanding that we’re doing this because … again, we didn’t ask for it, but if we start taking the challenge on, “If I’m going to learn how to best do what I need to do,” that is really positive.

And when I think of … especially the aging community, I think of them as experts at change. I think that we need to recognize that people, as they age, every decade you get better at change. Every decade, something’s different. We’ve been acquiring changes. We’ve been adapting to things for a very long time, so I think if we can try to frame some of these adaptations to these vision changes to tap into the resiliency and the experience of adapting to change, it’s much more positive. And if I can just add to that, I worry sometimes that if we acknowledge changes, sometimes others in our life or our community can jump to conclusions. They can … if you say, “I’m worried that it’s not as easy to see the stop signs,” I think we may be afraid to mention that because we may be afraid others are jumping to conclusions like, “Well, then, you shouldn’t drive.” That’s a big leap, and I think we have to welcome these conversations to be recognizing these changes first with figuring out what to do about them before we jump to next-step conclusions.

MICHAEL BUCKLEY: That’s great, and I appreciate that point a lot. Elin, we just got a question from a listener from Utah that really gets to the point that you just mentioned about when you either announce something about yourself or somebody observes something about you, what are some of the things to look for, either in your own driving or in another person’s driving that might be cause for concern?

ELIN SCHOLD DAVIS: You know, that’s a very … almost, I would say, a loaded question for this format because I think there are a number of things we can look for. I think we look for them every day, whether we’re watching our kids as drivers or we’re driving ourselves. And then we have to distinguish bad habits from things that indicate loss of skill and ability that leads toward decisions about not driving. There are a number of publications out there that have lists of things called warning signs, and they’re helpful. I think if you go to the Hartford Center for Mature Market Excellence, our AOTA website, AAA, AARP, many groups have been developing warning signs—risks—because people ask for this, and it is a good place, but it’s a starter.

And I think it’s really important that warning signs are thought about in clusters. There are some bad-habit clusters, and there are some warning signs that are more significant, and I will point out a couple of them that I think are worth taking … really allowing yourself to take seriously. When people get lost getting home to a familiar place, it’s a warning sign that should be thought about seriously. It’s a piece of a puzzle. No one thing should act on its own, but getting lost going to a familiar place, we can excuse it away sometimes, but it’s a warning sign that’s serious. Also, if you notice a loved one who needs so much time to make a decision, such as stopping on the highway to decide if they’ll exit or not or coming really close to stopping, really needing so much more time than the driving environment demands, those are warning signs that should be looked at very seriously. But I think we have to think about warning signs as giving us a cluster of examples and a way to start a conversation and not jump to preemptive conclusions.

MICHAEL BUCKLEY: That’s a great point. And for Elin, today’s audience is generally people who have been impacted by age-related macular degeneration, which for a lot of people the vision change progresses very slowly, and I so think you made really good points about how, if the vision is changing gradually, what people should be mindful of. This leads to, I think, what’s just a really hard conversation in so many households across the country in how to talk about this, either whether you the driver bring it up or a family or a friend. I mean, do you have some tips to navigate what, to me, would seem like a very challenging conversation?

ELIN SCHOLD DAVIS: Well, if I can put my Pollyanna hat back on for a moment and ask the forgiveness of the listeners, I wish we could move this into an important conversation, but somehow get away from feeling like it’s a persecution conversation, you know what I mean? It’s really tough, but some of these changes are real, and I think the hard part is that driving historically … you know, we used to tease in the line of work that I’m in. Let me give you a little historical thought. We used to talk about that men wanted to drive to their funerals. My father, born in 1925, when he got his license for 25 cents, it was a license for life, you know? He did not … he didn’t see a driver’s license as something that was pegged to his skill set. Now, he was also a small plane pilot, and he knew that he had to keep up his medical, but we don’t have that sense, or we didn’t have that sense about driving, but there’s really a skill set that you need to keep driving.

And I think that what we have to do is somehow figure out a way of families to talk about if the skill set or skills are strong enough that the risk of driving is the best choice for you to stay active and stay healthy in your community as long as you can, or is the skill set changing where we really need to start thinking about ways to be preserving your mobility and your involvement in your community, but helping driving not be the only connector? And I think, for some people, the emotion is tied to: They know no other way. They feel like if they lose that, they’re being cut off. And there are reports that are very … that we find very disturbing in our research community that people are stranded without options when they lose the one familiar way to get around. So, I think if this discussion can start to evolve as, “One is planning smart,” instead of, “Who’s going to be the mean, evil one to take away?” I think we can get ahead of it a little bit.

MICHAEL BUCKLEY: That’s a great point. To that point of trying to have it be an actual conversation, are there ways that a family can make a commitment or make some sort of plan that everybody involved has the cliched “skin in the game” on, so it isn’t just that yanking the keys away? Are there some commitments that families can make together on this?

ELIN SCHOLD DAVIS: You know, I think that’s an excellent question, and one I hope people … especially people that have a condition that is progressive, even though it’s slow, and so, that’s great. The advantage is it’s slow, but … we know that something needs to be done. I think the idea of a family having a meeting or meetings … there are contracts. We even have one on the AOTA website. The one I like about the one we’ve posted on our website with AAA is that it’s a “contract,” if you will—and I use air quotes if you could see me. It’s saying … the family’s saying—if I can say Mom or Dad as an example—“I promise to do everything I can to support you in staying the road as long as you can. We’ll get the eye appointments. We will do the research, look into what’s out there.” and the person with the condition is saying, “I promise to you that I will prepare myself to hear what you have to say when you think it’s time for me to reduce or stop,” and you’re making that commitment early on. You’re making it with your full cognitive capacity, if you will, and if you’re so unlucky to have both a vision issue and a cognitive issue—both a dementia and we call it comorbidities—the loved ones know what your wishes were, and you made it explicit and clear. It’s not unlike wills. We talk about people should be planning for their transportation like they’re planning for their money and they’re planning for their housing.

MICHAEL BUCKLEY: That’s a good point.

ELIN SCHOLD DAVIS: They’re looking ahead, and they’re really thinking about it. And they’re getting their family on board as their advocates. Absolutely, family should be their advocates. In occupational therapy, we are your advocates. We’re there to keep you on the road as long as safely possible, but we also have your back that if it’s really dangerous and unwise, we’re going to tell you, because telling you is caring. Telling you is compassion. Being willing to tell people what they want to hear and sometimes what they don’t want to hear but based on the best facts we can come up with is compassion, and that underlines the whole concept of prevention.

MICHAEL BUCKLEY: I agree. That’s a great point. And sort of a broad-brush question, I know that there’s a range of products and services, whether it’s offered by for-profit companies or other groups; this is a big picture. What should someone be thinking or looking for when they look to … if they start to investigate different products or services that might help somebody continue to drive?

ELIN SCHOLD DAVIS: Well, I think one thing you have to distinguish is knowledge—knowledge as a driver, habits of the driver—from medically related changes or disease-related risk. So, number one, shore up your knowledge, and take a refresher course—taking a course by AAA or AARP that might be offered by your driver’s safety council or maybe even taking a lesson, so to speak, with the driving instructor to make sure you really know how to navigate those roundabouts or you know how to use these … there’s a lot of … I understand in the follow-up there’s a comment with a next question about the infrastructure and the way our roads are designed, but understanding how those roads are designed is part of your prevention package. But don’t mix that up with somebody who is helping you understand applying a vision-related or medically related change to your driving skill; that’s different.

So, we’ve got knowledge and habits, and we want to get rid of any of those bad habits if we can because that’s going to … that’s a risk-reduction effort. But then, we also need to look specifically at: How do you manage? Do you feel loss, the changes with macular degeneration? And that’s where the skills of an OT or a driving specialist may make sense, just as if you went to exercise. You may follow a video and learn how to do an exercise, or you may go to a physical therapist to figure out how to do your exercise when you’ve got arthritis. They are both perfectly legitimate services out there, but pick which one fits for you and what your needs are.

MICHAEL BUCKLEY: T I think that sets up well a question we just got from Michigan, which obviously is a very important state in this conversation. The caller is wondering if you could comment on other particular features that are currently in some newer-model cars that you think are very helpful. And even looking down the road, what do you think of self-driving cars? So, what should somebody look for in a car right now? And then just thinking ahead, do you think there’s a future for self-driving cars?

ELIN SCHOLD DAVIS: Well, there’s absolutely a future for self-driving cars, but it’s not tomorrow. Although, when we look at the vision community, these self-driving shuttles or transportation vehicles is something that’s going to be, I think, sooner on the horizon, and managing getting on and off the shuttle or managing getting where you need to go using an unescorted mode of public transportation; that’s going to be an earlier question, but it absolutely rests in the future, and I think we need to be part of the advocacy group paying attention to the development of these features and making sure our needs are mentioned.

But getting back to the individual car, there’s a tremendous explosion in the features in a vehicle, both to … and I would distinguish both to help us navigate or use a car—how to see the controls, how to manage the operation of the vehicle—and also how to survive a crash—the survivability idea of a crash—and that’s where you look at the safety features that are in vehicles. And we have a program called CARFIT, if you’ve ever heard of it, car-fit.org, that’s an education program between AAA, AARP, and AOTA. What we do here is we look at how people understand how the safety features are designed to work and make sure they take advantage of them. I often use the analogy that cars … if you think of a race car, if you hopped in a race car as a short woman and the driver was a 6-foot-4 male, it’s possible that all of those fabulous safety features wouldn’t do you one bit of good if you didn’t tighten them up and get them down to your size. And so, the idea … and our vehicles are not one size … our vehicles are one size fits all; we have to adjust to make them fit us. We don’t buy a car for a 5-foot 4-inch person. We buy a car that fits a wide range of people, so we need to learn how to adjust those, and we also have all these other navigation features within our vehicle.

My other analogy I like to use—I can find a car; it’s more like buying a new iPhone. It used to be you normally got a phone in your house, you just picked it up and you answered, and you dialed the dialed the dials. Now you get a phone that’s got all these different features, and how do they work? You know, our cars are more like that now, and so, it really takes some time to learn them. I feel like I’m going on and on because I could go on in this topic.

MICHAEL BUCKLEY:  I want to talk for a moment about the role of the eye doctor, because, to me, this a really interesting … it’s sort of a little complicated situation now. My understanding is, in a number of states, the eye doctor has to tell the state motor vehicle agency if a person has had significant deterioration in their vision, but yet I also don’t want people to feel like they shouldn’t go to an eye doctor because they’d lose their license, so is my premise correct? And if so, how does somebody … what’s a positive role for the eye doctor in this?

ELIN SCHOLD DAVIS: That’s a loaded question, because I think the proper response is most states have vision requirements—have minimum vision requirements—for acuity. Some have it for peripheral fields. That’s a leap to say that the eye doctor—although they measure these things sometimes in their appointments, depending on where you’re at and the type of visit you’re having—they are not necessarily in the role or have wanted to be in the role of starting this conversation about your driving, and I know this is a national podcast, but I’m just going to take a little bit of a risk here and say they’re conflicted. I think, as a general group, they’re conflicted. They want you, as consumers, to get your eye health checked. They want you to come in. They don’t want you to link them with your driver license. On the other hand, if you really want to practice prevention and you really want to understand if your eye changes are going to affect driving, you need to hear this from them. My advice in this podcast is: Ask your doctor to talk to you about your vision and your state vision licensing requirements—and you may need to bring a copy of them in, because most doctors are likely not aware of them—because it’s kind of like they don’t want to go there. But if you ask, they can talk to you about it, and that is not a leap saying they’re making a licensing decision.

And let me distinguish: Doctors do medical things. They diagnose. They measure. They give us the … they will tell us what our acuity is as a number. It is the state driver-licensing agency that decides what that number means. The state licensing agency issues your license. The state licensing division removes licenses; doctors don’t. Doctors come up with the data, and there’s a fuzzy lane between this whole concept of reporting. But what I could say—again, I’ll put my Pollyanna hat on here, I admit it—if we as consumers embrace the fact that we want to know if we’re no longer safe for ourselves or others, we want to know the data, and then we can help to decide, making this decision, if we don’t need our state licensing requirements, what are we going to do with that information? And I don’t think we always have to make it somebody else’s responsibility to tell us what to do. I think we can be better at managing what to do with the data. Invite your doctor to talk to you about it. Invite them to bring it up. Tell them you … tell them you want to know what the information is, and help bring the vision to the ophthalmology/optometry community into helping us with some of these … some of this analysis of these data.

MICHAEL BUCKLEY: I appreciate the nuanced approach there, and you’re right, I think these should be positive roles that these professionals can play. People who aren’t as versed in these issues as you are will talk about driving in a very binary way: Either you drive, or you don’t drive. I was wondering if you would comment on: Are there ways to transition or split the difference in terms of reducing how or when or where you drive, or are there transitions, and how should someone navigate that?

ELIN SCHOLD DAVIS: I think that’s a great question, and I can tell you, I think everybody—no matter they’re age or their medical diagnoses—should become more transportation savvy. We should have more than one egg in our basket, so to speak. We could … we could break a leg tomorrow and need to use another mode of transportation. I think the more that you learn what your other options are in your community and actually use them … when I first started traveling to D.C., I was nervous on the Metro. Now I can read a book, and I don’t even think about it when I’m taking the subway to my destination. There is something about practice, and I would encourage people to not be car-dependent; that is something we do to ourselves. If taking away the car has been our only lifeline, we’ve put ourselves, to some degree, in that condition, whether you’re looking at housing and you want to make sure: Does this house I’m moving to really have access to other modes of transportation? Whether we’re looking at we might be afraid of using the bus, how could we practice? How could we ride with family members? How could your group of friends meet for lunch using a bus, you know, every so often? So that this option becomes your tool, so that as you experience changes … and many times for people, changes don’t happen overnight, and you may have good days and bad days, but you feel like you can use other options. Have you tried using Uber? Have you used a cab lately? Have you thought about having more arrows in your quiver, as they say, so that you are again in charge of being transportation-independent?

MICHAEL BUCKLEY: Those are great points, and I would think that that would help some of the mental health adjustments to still maintain—particularly as we are hopefully heading out of the pandemic—these opportunities to have that, and that’s something that we see a lot with the research that BrightFocus funds about the importance of social and intellectual and cognitive stimuli that comes from getting out. Those are great points.

ELIN SCHOLD DAVIS: Can I comment just quickly on cost?

MICHAEL BUCKLEY: Sure.

ELIN SCHOLD DAVIS: Because I think a lot of times, again, we do what we’re used to. We’ve had a car, and we’ve paid for renting a garage, slot, whatever, for our vehicle, and we don’t necessarily translate that into: How many rides would it pay for? And I think one of the things that I would love to see when we talk about transitioning is understanding spontaneous rides might be more expensive. If I want to run out and get an ice cream cone and call a cab, yeah, it might cost me 20 bucks, but I want to go get an ice cream cone on Sunday. I don’t need to use that every time. I might have my friend take me to the store at other times that works for her. So, think about your transportation independence, your spontaneity, and try to be careful not to make it all based on … just because $20 may seem like a lot for a cab ride, actually, paying $50 a month for keeping your car in the garage and not using it is expensive, too. So, it’s just thinking about cashing out what you’re spending on insurance in your car and thinking about really supporting your desire to stay active in the community, whether you’re a driver or not so much a driver or maybe not a driver.

MICHAEL BUCKLEY:  I think it gives us a really under-appreciated perspective of: Cars cost a lot of money, even more than you think, and then to put a price tag on independence. That’s great. Elin, as we conclude this conversation, I found it just really interesting, and I appreciate you being both positive and nuanced, because I think you’re right. This topic can be painted very black and white. This topic can be painted as all about loss and negativity. I was wondering, as we conclude, do you have concluding final comments or suggestions to our audience today?

ELIN SCHOLD DAVIS: I just really appreciate the opportunity to talk about the things that we do. I really think prevention—prevention of crash, prevention of injury—is really what we’re talking about, and the reality is prevention means you do something before the bad happens, so really owning the idea of understanding what condition you might be dealing with, making sure you ask for as much information as you can from the care providers that you’re going to. A lot of people are afraid, I don’t know. They worry to bring up the topic of driving because they don’t want to be negative. Tell them you want to know. You want to be informed. You want to be a good steward of your transportation. You want to drive as long as you can, you want to access every support that there is—and there are supports—but you also want to start thinking ahead so that you’re in charge of making your own decisions and thinking as best you can and thinking about your options. So, I just encourage you to access your providers—your doctors, your eye doctors, your occupational therapists, the various providers that might be in your community—to help you to be as informed as you can be so you can make the best decision for your own situation.

MICHAEL BUCKLEY: That is great advice for today’s topic and great advice for many other parts of life. Elin, on behalf of BrightFocus and all of today’s listeners, I just really want to thank you for doing just a great job today. It really shed a lot of light onto this topic, so thank you very much for being with us today.

ELIN SCHOLD DAVIS: And thanks so much for your listeners for embracing this topic. I really appreciate the opportunity. Have a great day.

MICHAEL BUCKLEY: Thank you. On behalf of BrightFocus, thank you very much for joining us. Goodbye.