You can't be too careful (or … falling down and crashing cars)

You can't be too careful (or … falling down and crashing cars)

No one likes to fall down or crash a car. But older people, in their presumed frailty, seem most at risk. Is this because they actually fall and crash more than anyone else? Should we worry about our own older relatives whenever they go out on their own? What about making sure they get out from behind the driver's seat when they reach a certain age? The facts we examine in this section lead to the conclusion that the answer to each of these questions is a resounding yes and no. Older people do fall down. But maybe they don't worry about it as much as their younger relatives worry about it for them. As for problems behind the wheel, getting a driver for every Miss Daisy is not practical. Furthermore, it is not especially useful because older drivers don't crash cars all that much – it is safer to be on the road with them than it is to be on the road with certain other age groups. Maybe we should consider getting a driver for every Ferris Bueller instead.

Myth #3 Older people worry too much about falling

Falls are a more serious concern for older adults than most people (including older adults themselves) actually realize. According to the Centers for Disease Control and Prevention (CDC, 2012), one out of every three adults over age 65 experiences a fall every year. Furthermore, plenty of folks fall more than once in a given year. In fact, falls are the leading cause of injury-related death in this age group. What about lasting consequences for those who do recover? Twenty to thirty percent of those who fall suffer moderate to severe injuries (e.g., hip fractures and head trauma), which can increase the risk of loss of independence and even early death. Although most otherwise healthy people who sustain these injuries are able to pick up their routines after treatment, those who had physical or cognitive problems before the injury may not be capable of returning to their former lifestyle.

Falls can happen anywhere, but well over half of them happen at home – during everyday activities (National Institute on Aging, National Institutes of Health, 2013). So staying home is not a good way to avoid falling. The floor might be wet, the rug might be loose, the nightlight might be out, and your shoes may be in the way. What if the bathroom does not have grab bars? If you lose your balance in the shower, you are going down!

The National Council on Aging (2013) sponsors a National Falls Prevention Awareness Day to convince older people not to think of falling as a normal part of aging. Some of the risk factors for falling include muscle weakness, balance or gait problems, blood pressure dropping when standing up, slow reflexes, foot problems, vision problems, confusion (even if it is brief), and medication side effects that lead to dizziness or confusion (and the more medications the greater the risk of that). When you think about it, most of these risks can be managed. People don't have to have weak muscles. They can exercise. They can use a cane or a walker if they have balance problems that can't be handled with medication. Many vision problems can be treated to some extent. Medication side effects can be monitored by a physician so that the person taking the medication does not have to fall down while taking it. Also, all of the things around the house that pose a danger can be improved.

Paradoxically, it turns out that fear of falling is itself a risk factor for falling. The fear can result in gait abnormalities and changes in postural control, both of which can increase the risk of falling (Delbaere, Crombez, Van Den Noortgate, Willems, & Cambier, 2006). Also, people who are afraid of falling down might limit their activities in order to avoid falls. This is a bad idea. Restricting activities can lead to physical decline (such as deconditioning, muscle atrophy, and poor balance) and could ultimately increase the risk of falls. Limiting activities might also result in limiting social contacts – this can lead to loneliness or depression (Scheffer, Schuurmans, van Dijk, van der Hooft, & de Rooij, 2008).

Despite the prevalence of falling, there is evidence that plenty of older people are not as worried as they should be. For example, Yardley, Donovan-Hall, Francis, and Todd (2006) held focus groups with 66 community-dwelling adults aged 61 to 94 in the U.K. to explore their perceptions of fall-prevention advice. These individuals tended to react positively to advice about the benefits of exercise for balance and mobility. However, their attitude was mixed when it came to lifestyle-related fall prevention suggestions. They explained that they had good reasons for the type of eyewear or footwear they used or for the furnishings in their homes, all of which carried some risk. For example, women who were 74, 78, and 88 years old and who had recently fallen rejected the idea of wearing padded hip protectors for reasons of vanity. A common response to the necessity for prevention advice was that it was important only for other people, typically people older than themselves. Some who had themselves recently fallen attributed the fall to a one-time lapse (e.g., inattention or illness). Some of the participants indicated that it was an issue of pride – getting a leaflet on fall prevention would imply that they are senile, ancient, or devoid of common sense.

In sum, if one in three of your peers fell down this year, why shouldn't you be worried? And not only that, but among some of your friends who have experienced a fall, life will not be the same ever again. Clearly, some older adults may worry about falling, but it is hard to say that they worry too much – the threat is real and should be taken more seriously by everyone. Of course, if fear limits older adults' enjoyment of life outside the home, it is too much fear – especially because the real threat is right there in the home! People do have to see to it that their homes are made as safe as possible. If a worry is based in reality, as is the fear of falling, then interventions (even at the family level) that aim to reduce the worry without reducing the risk are not ameliorating a problem that really can be helped. And let's not forget that only some older adults worry about falling. A significant number think that falling is someone else's problem.

Myth #4 Older people get into more car accidents than younger people

In a study of older driver stereotypes, young adult participants described typical older drivers as unsafe and dangerous (Joanisse, Gagnon, & Voloaca, 2012). News reports about accidents caused by older drivers are certainly sensational. There was the incident in an open-air market in Santa Monica in 2003 in which an 86-year-old man stepped on the gas pedal instead of the brake pedal. Ten people were killed and 63 were injured. We also read about incidents in which older drivers crash through walls, like the 89-year-old woman on her way to a hair salon in Marlboro, Massachusetts, in 2012. She was aiming for a handicap parking space in front of a storefront office but instead went flying though the hedges and into the building. No one was hurt that time, but she missed a group of people by only a few inches. Reports like these contribute to the myth that older people are more prone than any other age group to get into accidents and that we need to get older folks off the road.

However, the drivers we should really be most afraid of are the 16- to 19-year-olds. They actually have the highest number of moving violations and crashes. According to the U.S. Census Bureau (2012), in 2009, people 19 years and younger made up 4.9% of the drivers but accounted for 12.2% of the accidents. By contrast, people 75 and older made up 6.5% of the drivers but accounted for only 3.3% of the accidents. It is true that older people drive fewer miles overall than do people in other age groups, but even by those calculations they are not as dangerous as teenagers.

According to the Centers for Disease Control and Prevention (CDC, 2013b), older adults are doing some things right. More than three-quarters of older drivers and passengers who were in fatal car crashes in 2009 were wearing seat belts – a higher proportion than in any other age group. Older drivers are also more likely to take to the road when conditions are the safest, avoiding nighttime and bad weather. Furthermore, they are less likely to be driving while impaired. For example, only 5% of older drivers involved in fatal crashes had a blood alcohol concentration higher than .08, compared with 25% of drivers between the ages of 21 and 64.

According to the Insurance Institute for Highway Safety (IIHS, 2014), between 1997 and 2012, fatal crash involvement for drivers aged 70 and older declined at a faster rate than did fatal crash involvement for drivers aged 35 to 54. Furthermore, these reductions were the greatest among the oldest drivers (80+). Also, based on insurance claims, the IIHS found that property damage claims start increasing after about age 65, but they never reach as high a level as the claims for the youngest drivers.

In a study of U.S. data on both fatal and non-fatal crashes, including data supplied by nine insurers, Braver and Trempel (2004) found that drivers aged 75 and older had actually killed fewer people outside of their own cars than did drivers aged 30 to 59. However, people inside their cars, including older drivers themselves, were not so lucky, perhaps because both they and their passengers tend to be frail. Non-fatal injury and property losses are a different story, however. Bodily injury liability claims nearly doubled for drivers aged 85 and older compared with those aged 30 to 59. Property damage liability claims were at their lowest for drivers aged 60 to 69 but increased dramatically after that, doubling for drivers 85 and older.

Let's get back to crashing into crowds at open-air markets and storefronts when drivers confuse the gas pedal with the brakes. What situations are really the most risky for older drivers? Intersections. Older drivers are much more likely than younger drivers to crash at intersections (Mayhew, Simpson, & Ferguson, 2006). Therefore, Braitman, Kirley, Chaudhary, and Ferguson (2007) studied the causes of intersection crashes among two groups of older drivers, those aged 70 to 79 and those aged 80 and older. Failure to yield the right of way was a problem that increased with age among older drivers, and it occurred mostly at stop signs, especially when drivers were trying to turn left. Admittedly, this is a complex situation, and it is particularly fraught for many of us. The researchers found that the drivers aged 70 to 79 made more evaluation errors such as seeing another car approaching but being wrong about how much time there was available to make the turn. Those 80 and over who crashed were more likely to have failed to notice the other car at all. Yikes! Thank goodness older drivers are not likely to be texting while driving.

As of June 2014, 29 states and the District of Columbia had implemented special requirements for people aged 65 or 70 and older who want to renew their drivers' licenses. These requirements vary, but include accelerated renewal cycles with shorter periods between renewals, requirements to renew in person rather than by mail or electronically, and testing that is over and above what is routinely required for younger drivers (e.g., road tests). If there is an issue about continued fitness for driving (e.g., a history of crashes, a report by a physician, or something noticed in the person's demeanor at renewal), states may require physical exams or a full retake of the standard licensing test – again, something not required for a typical renewal. Rather than refusing to renew a license altogether, a state might impose restrictions based on the outcome of the tests. Restrictions might include prohibition of nighttime driving, requiring additional mirrors on the vehicle, or limiting the distance from home that a person may drive (IIHS, 2014).

Unfortunately, the effectiveness of such special regulations for license renewal has not yet been established. The Insurance Institute for Highway Safety cites studies showing that vision testing for older adults is associated with lower fatal crash rates. According to the IIHS (2014), one study found that states with laws requiring in-person driver's license renewals had a 17% lower fatality rate per licensed driver among the oldest drivers (85+) compared with states without such laws. However, the IIHS notes that another study found that for drivers aged 65 and older, fatality rates per licensed driver did not differ between states with laws and states without laws for vision testing, road testing, or shortened renewal periods.

There is some self-limiting going on, however. An IIHS study (2014) of over 2,500 drivers aged 65 and older in three states showed that as people get older, they drive fewer miles. They avoid night driving, make fewer trips, travel shorter distances, and avoid driving on interstate highways and roads that are icy or snowy. Even people who know they have been diagnosed with mild Alzheimer's disease have been shown (through real-life in-car video recording) to confine their driving to daytime hours, sunny weather, light traffic, residential environments, and situations that involve no passengers. In this case, it is likely that although they had passed their state road test in order to be eligible to participate in the study, they regulated their driving behavior based on the knowledge of their diagnosis (Festa, Ott, Manning, Davis, & Heindel, 2012).

With regard to the effectiveness of driver education for older adults, Marottoli (2007) conducted a study for the AAA Foundation for Traffic Safety to assess the effectiveness of an education program that included classroom and road training. Participants were 126 drivers aged 70 and older. The experimental group had two four-hour classes and two one-hour on-road sessions that were focused on common problem areas for older drivers. The control group had a different course in vehicle, home, and environment safety that was presented to them individually. They had no on-road sessions. After the intervention, the experimental group did better than the control group on both written tests and road tests. The IIHS (2014) notes, however, that we should be cautious about taking findings like this at face value because drivers who take these courses tend to have lower crash rates even before taking the course than do those who opt not to take these courses. That makes the effectiveness of these courses difficult to evaluate.

Now let's consider the reasons older people may have reduced competency behind the wheel. One we have hinted at already: visual acuity. The type of vision required for driving is quite complex. Researchers have focused on useful field of view (UFOV) to identify vision requirements for driving that may capture the type of vision needed for driving more realistically than the typical acuity test. As reported in the Monitor on Psychology (DeAngelis, 2009, November), psychologist Karlene Ball developed the concept of UFOV while still a graduate student. As its name implies, UFOV is the spatial area that you can pay attention to in a glance – without head or eye movement. It varies depending on the task and it also varies across individuals. Obviously, acuity is part of it, but so is the ability to ignore distraction, to divide your attention, and to process what is going on in that visual space both quickly and effectively. Thus, in addition to pure visual acuity, UFOV includes some cognitive abilities. There is ample evidence that UFOV declines with age (e.g., Sekuler, Bennett, & Mamelak, 2000) and that it is associated with driving performance in older adults (Ball et al., 2005).

Ball initiated the development of a computerized UFOV test (Visual Awareness Research Group, Inc., 2009) that consists of three parts designed to assess visual processing under increasingly complex task demands. In the first part (processing speed), the examinee identifies a target that is presented briefly (an icon of either a car or a truck) in a box in the center of a screen. In the second part (divided attention), the examinee does the same thing, but this time must also indicate where on the periphery another target (always a car) appears simultaneously. In the third part (selective attention), the task is the same as in the second part, but the car on the periphery is embedded in a field of 47 triangles. “‘We do all kinds of things to mess them up!'” quipped Ball (DeAngelis, 2009, November).

UFOV seems to be amenable to improvement with training. In one study (Roenker, Cissell, Ball, Wadley, & Edwards, 2003), older adults who received speed-of-processing training were tested 18 months later. They improved on their UFOV test and undertook fewer dangerous maneuvers in an open-road driving evaluation. Unfortunately, it is not yet standard practice for states to test UFOV as a requirement for obtaining a driver's license.

In addition to UFOV problems, older adults experience more difficulties with divided attention than do younger adults. In one study (McKnight & McKnight, 1993), young, middle-aged, and older adults viewed videos of traffic situations and responded to them using simulated vehicle controls. At the same time, some of them engaged in distracting activities such as talking on a cell phone. The oldest group (aged 50 to 80) was more likely than the other groups to make inappropriate responses on the simulated controls when distracted.

Additional factors may impair the ability of older drivers. For example, cataracts reduce contrast sensitivity by increasing glare. Reaction time slowing is a consequence of normal aging (Kausler, Kausler, & Krupshaw, 2007), and it is easy to see how reaction time could be a problem when drivers have to make a split-second decision about whether to step on the gas or the brake.

We've provided a few reasons why older adults might be at a disadvantage when driving. At the same time, we should recognize the wide variability among older adults with regard to reaction time and attentional capabilities. Also, many older adults recognize their limitations. As we have noted, they self-limit and drive only when they consider it likely that they will not have difficulties. Also, some older adults know that it can be risky to carry on conversations while driving – they recognize they must focus all their attention on the road when traveling to their destination. We know of one older driver who refuses to drive with a passenger because she realizes that she is safest if she is not distracted with conversation.

Giving up a driver's license is fraught with issues of independence for older adults. This is not surprising, given that (with a few exceptions in urban areas such as New York City) public transportation is not an adequate substitute for being able to drive one's own car. It would be reasonable, however, to initiate changes in the driving environment. More left-turn lanes and traffic light arrows would mitigate the dangers at intersections. So would replacing stop signs with traffic lights. Obviously, there is room for improvement by making signs more visible and by posting warning signs well in advance of danger areas. Making improvements in automobiles themselves is more problematic. If we add extra information to the dashboard that might help younger drivers, older drivers may be overloaded with too many things to pay attention to. However, devices could be installed to enhance environmental warnings. An extra sound coming from the car would be useful for someone who cannot hear the ambulance siren soon enough to pull over.

In conclusion, where do we stand on the myth that older people get into more accidents than younger people? They are emphatically safer than the youngest drivers. They are cautious about when and where they drive, they wear seatbelts, and they don't drink and drive as much as do younger people. True, age-related perceptual and cognitive difficulties can impair driving. Older people tend to be aware of these problems, but we can do better as a society to make the roads safer for them and thus for all of us. There is a lot of room for creativity in this endeavor, and understanding the needs of older people in this regard is the place to start.