Driving While Old

In the United States there are more older-adults drivers on the road and as a result many will end-up in hospitals.

In 2015 there were more than 47.8 million licensed drivers ages 65 and older in the United States. The fastest growing driving population. With this increase we are also seeing more accidents. That same year 6,800 older adults were killed—compared to 2,333 teens ages 16–19—and more than 260,000 were treated in emergency departments for motor vehicle crash injuries.

A quick review of the National Institutes on Aging website on older drivers quickly provides a simplistic answer. The website that address older adults and driving includes such enlightened subheadings as: Stiff Joints and Muscles; Trouble Seeing; Trouble Hearing; Dementia; Slower Reaction Time and Reflexes; Medications. It is not surprising therefore to see that fatal crashes, per mile traveled, increases the older the driver is—particularly males. It seems that these physical diminished capacities have direct negative consequences when driving.

Despite this obvious conclusion—that diminished physiology results in more accidents—the evidence is not so clear-cut.

A 2015 report by the Insurance Institute for Highway Safety suggests that such increased fatalities are more likely due to increased susceptibility to injury and medical complications rather than the increased risk of crashing. Older people are more likely to be killed when in an accident. Frail bodies as well as driving older and less safe cars are to blame. There are a lot of older pedestrian deaths as well which does not involve them driving.

Older drivers might have impaired capabilities but they are not all impaired drivers. In fact they are safer than some younger groups. In general older drivers are more likely to use seat belts, tend to drive when conditions are safest and are less likely to drive while under the influence of alcohol. In comparison, teen drivers—at the zenith of their physiological prowess—have a higher rate of fatal crashes, mainly because of their immaturity, lack of skills, and lack of experience. It’s not all about biology.

Teenagers have taught us that driving a car requires more than just physical attributes. Even if we just focus on the most obvious, vision, the results are surprising.

Cynthia Owsley and her colleagues with the Department of Ophthalmology, University of Alabama, found that the best predictor of accidents was not visual acuity but a combination of early visual attention and mental status. Having 3-4 times more accidents (of any type) and 15 times more intersection accidents than those without these problems. Driving, it seems, primarily requires a sense of spatial awareness—knowing what is around you and predicting how objects and people are moving. This perceptual capacity is known as the “useful field of view”—the area from which you can take in information with a single glance.

The psychologist Karlene Ball and her colleagues with Western Kentucky University, reported that older adults with substantial shrinkage in the useful field of view were six times more likely to have a crash. What was surprising was that when compared with eye health, visual sensory function, cognitive status, and age—although these all correlated with crashes—they were poorer in predicting crash-prone older drivers. Our perception and how we can predict the immediate environment is more important than having excellent vision.

Our useful field of view narrows with age. We take in less of the visual field in front of us resulting in greater susceptibility for accidents. This is not a negative, although it has negative consequences. This is a result of years of excellent driving and training our brain that now we do not need to concern ourselves with peripheral events. We are such good drivers. As a result our peripheral view has become unimportant, and we have erroneously eliminated that aspect of driving at a time when it becomes important because we have started losing other sensory sharpness.

But luckily there are ways to enhance our perception. There are great computer-based tools for improving useful field of view and to retrain our brain to drive safer. As a result of training, these studies have shown that drivers make a third less fewer dangerous driving maneuvers, can stop sooner when they have to and feel greater mastery of driving in difficult conditions—such as at night, in bad weather, or in new places. All of which translates to a reduction in at-fault crash risk by nearly half. This is all good news that will ensure that older drivers can keep their license longer, and more importantly drive safer, despite having diminished physiological capacities.


© USA Copyrighted 2017 Mario D. Garrett 

References

Ball, K. K., Roenker, D. L., Wadley, V. G., Edwards, J. D., Roth, D. L., McGwin, G., ... & Dube, T. (2006). Can High‐Risk Older Drivers Be Identified Through Performance‐Based Measures in a Department of Motor Vehicles Setting?. Journal of the American Geriatrics Society, 54(1), 77-84.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA: CDC; 2017 [cited 2017 Nov 29]. Available from URL: https://www.cdc.gov/injury/wisqars/index.html

Insurance Institute for Highway Safety (IIHS). Fatality facts 2015, Older people. Arlington (VA): IIHS; November 2016. [cited 2016 Dec 21]. Available from URL: http://www.iihs.org/iihs/topics/t/older-drivers/fatalityfacts/older-people/2015

Owsley, C., Ball, K., Sloane, M. E., Roenker, D. L., & Bruni, J. R. (1991). Visual/cognitive correlates of vehicle accidents in older drivers. Psychology and aging, 6(3), 403.

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Is Citizenship the New Care for People With Dementia?

After a century and an immeasurable amount of resources pumped into research for dementia—particularly for the all encompassing Alzheimer’s disease—the breakthroughs we are witnessing are not in a cure but in care. Care—ignored in funded research—is emerging as the innovator in dementia research.

It is telling that Auguste Deter the first woman to die of Alzheimer’s disease, did not die of Alzheimer’s disease, but of bedsores. Despite this painful death, Alzheimer's disease was the one that gained prominence, and has now dominated research in geriatrics. For a hundred years the mantra among clinicians has been that the disease follows a set course. Even though we do not understand the disease we continue to follow the belief that we can perhaps stop the disease. And we believe that we can make it go away.

Unlike with children, diseases in older age tend to stay. Some are companions to the death (e.g., prostate cancer) while others will likely cause our death (e.g., heart disease.) For sure, few diseases in older age will be cured, Alzheimer’s disease (or dementia in general) being one of these incurable diseases. Although dementia is now the fifth or sixth primary cause of death, in fact, like Auguste Deter it is always something else that kills you other than dementia. It is therefore important not to ignore other diseases and to treat the whole person.

The idea that the expression of dementia is purely biological has been shown to be false. For Thomas Kitwood, for example, people with dementia were not only disadvantaged by the disease itself which hinders thinking and behaving, but he also saw that the attitudes and actions of those around them increased this disadvantage. Agitation being a case in point, caused by a combination of the incapacities of the disease together with the rigid expectations of their caregivers. Kitwood, for all of his theoretical flaws, revolutionized care for people with dementia. He both named and framed Person-Centered Therapy. Opened up a way of caring for someone with dementia by allowing the individual to dictate what is best for them. This approach was well understood in the field of disability.

Instead of people with dementia being warehoused until death released them from their misery, as Auguste Deter endured, the person-centered approach ensured a focus on the person’s well being. Personhood remains a caring philosophy rather than a curative one. But this was not enough.

In a world where we see our cognition as the ultimate representation of who we are, we need a stronger system to protect people with dementia. And this came from the disability field and pushed dementia research into the political arena through the concept of citizenship. Citizenship is the idea that all individuals have rights and goes beyond personhood. In 2007 British Ruth Bartlett and Canadian Deborah O'Connor argued that although “the idea that people with dementia have rights has long been recognized” but the idea of citizenship where those rights are enforced has rarely, if ever, been explicitly applied to people with dementia.

Citizenship can be applied to promote the status of discriminated groups. However the concept of citizenship assumes that the individual has the capacity to exercise their rights and to honor their responsibilities. Such assumptions are not obvious among people with severe dementia. And there's the rub.

To get around this conundrum, the concept of ‘intimate citizenship’ has been put forward that focus on citizenship moderated and mediated by family and caregivers. But such membership does not address any institution discrimination. Clive Baldwin with the Bradford Dementia Group would argue that people with dementia still have a story to tell. More importantly they might influence the stories of those who interact with them. In lieu of having independent advocacy organization that lobby on behalf of people with dementia, reliance on caregivers remains. And that could be an issue if there is discord between the person living with dementia and their caregiver or companion.

We discriminate against people with dementia in getting costly treatment for another health issue that they might have. For example we deny hip replacements or surgeries for non-life threatening issues. We have laws that restrict the ability for people with dementia to drive and to conduct business. Legal status is dependent on whether an individual has mental capacity. This status determines what rights a person has.  Although these laws are justified because they protect others in society, there remain other discriminations inherent in a society. Discriminations based on our power to make decisions on behalf of someone. We have inherited “cognitive citizenship.”  In her 2004 PhD thesis Petula Mary Brannelly reported that it is not policy or legislation but clinicians personal values that resulted in one in ten people with dementia being detained against their will and result in having the most restrictive of care outcomes.

Again, Ruth Bartlett who has devoted much of her research on defining citizenship in dementia care, followed sixteen dementia activities campaigning for social change. She revealed that although campaigning can be energizing and reaffirming there were also drawbacks. Other than fatigue due to their disease, the activists reported oppression related to how they were expected to behave.  Although the struggle for citizenship has only just begun for people living with dementia, there is still a missing piece. Bartlett recently examined ‘dementia friendly communities’ where citizenship is perhaps most clearly enacted. But again in disability, the concept of equal but separate remains an issue. Citizenship needs to occur in public social spaces. It is about a redistribution of power.

Susan Behuniak discusses the many different definitions of power and how the person with dementia has been treated in the past, and more importantly, how they need to be treated in the future. The problem is that  legal status remains dependent upon cognition. The question whether an individual has mental capacity or not, determines whether a legal person exists or not, and this status then determines the rights the person can have. The move is to reimagine the person with dementia. Initially through the medical interpretation the person with dementia was simply a “patient” than through Kitwood we came to see a “person” together with an “embodied self” and now, with legal rights we see people with dementia as a “citizen.” The problem with citizenship is that the people interpret the law as requiring competency and capacity. But this is not true. We have laws that protect fetuses,, children, animals even trees. Eventually the aim is to see a person with dementia as a “vulnerable person” who has both rights and protections. We are at a time when organizations and caregivers/family are supporting the individual to ensure that laws to protect these rights are not being ignored through discrimination. Organizations will have to transform themselves from promoting a cure to promoting care. This is already happening. In the United States, Alzheimer's Association has experienced this move from cure to care. Local agencies concerned about care divorced themselves from the national organization that remain concerned with cure. Citizenship of vulnerable persons is the next frontier in care for people with dementia.

© USA Copyrighted 2017 Mario D. Garrett