Assessment of Older People's Health and Social Care Needs and ...

The calculation of risk is highly complex: ironically, some of the protective measures undertaken byolder people (Iow mileage and low speeds) may conspire to present a spuriously high risk per miledriven". Also older people are more frail and crashes involving the elderly are also more likely to befatal, by a factor of 3.5 in two-car accidents". Janke has suggested a reasonable interpretation ofthese apparently contradictory findings". A group's average crash rate per year may be considered asan indicator of the degree of risk posed to society by that group, whereas average accident rate permile indicates the degree of risk posed to individual drivers in the group when they drive, as well astheir passengers. The increased risk to individual drivers is most likely due to age-related illnesses,particularly neurodegenerative and vascular diseases"·"·38rather than to age per se.Two opposing Viewpoints have been taken on the likely impact of increasing numbers of older driverson crash trends. The most alarmist viewpoint is that the number of elderly traffic fatalities will morethan triple by the year 2030, based on current rates. If this expected increase occurs, the number ofelderly traffic fatalities in 2030 would be 35 percent greater than the total number of alcohol-relatedtraffic fatalities in 1995 39 • A more optimistic approach is a reiteration of Smeed's law, wherebyincreasing numbers of new drivers in a population display a diminishing number of accidents overtime'·.A third problem is that healthcare proViders are placed in an awkward situation in several states inthe US, provinces in Canada and a minority of countries in Europe. In these jurisdictions it ismandatory to report drivers with certain illnesses to driver licencing authorities'"'''. In the absence ofevidence-based guidelines and pathways of remediation after reporting, this process does notrepresent a health gain for our patients, and may even represent a loss of independence. Thatdoctors have a difficulty with this type of legislation is typified by the effect of the introduction ofcompulsory reporting of drivers with dementia to the California Department of Motor Vehicles. In theyears following the introduction of the legislation, there was no increase in the numbers reported.Although some of this under-reporting may stem from ignorance, it is also likely that doctors areunWilling to commit their patients to judgement by a system which is not eVidence-based and seemspre-occupied with keeping patients off the road.The medical literature on medical fitness to drive is relatively recent. It reflects societal bias and twomajor themes are obvious. These are i) a relative unawareness among doctors and the rehabilitationdisciplines of the functional and medical importance of fitness to drive and ii) an over-emphasis onselecting those who should not drive rather than on enabling older drivers. Doctors are unaware of33 Hakamies-Blomqvist, L., Wahlstrom, B., 'Why do older drivers give up driving?' Accid Anal Prev 1998;30(3):305-12.34 Klamm, E.R .. 'Auto insurance: needs and problems of drivers 55 and ove'. In: Malfetti JL, editor. Drivers 55+: needsand problems of older drivers: survey results and recommendations. Falls Church, VA: AAA Foundation for Road Safety,1985:87-95.35 Janke, M.K., Age-related disabilities that may impair driving and their assessment, Sacramento: California Departmentof Motor Vehicles, 1994.36 O'Neill,D. 'Physicians, elderly drivers, and dementia'. Lancet 1992;339 (8784):41-3.39 Burkhardt, XXX, 1998.40. Hakamies-Blomqvist L, Wahlstrom B. Why do older drivers give up driving? Accid Anal Prev 1998;30(3):305-12.41, Millar, W.J., 'Accidents in Canada', 1988 and 1993. Health Rep 1995;7 (2):7-1642 White, S., O'Neill, D., 'Health and relicencing policies for older drivers in the European Union'. Gerontology in press.Assessment of Old~eople'sHealth and Social Care Needs and Preferences