Transportation and Aging: An Updated Research Agenda for Advancing Safe Mobility

Abstract

This article discusses what is currently known about three important topics related to older driver safety and mobility: screening and evaluation, education and training interventions, and in-vehicle technology. Progress is being made to improve the safe mobility of older adults in these key areas; however, significant research gaps remain. This article advances the state of knowledge by identifying these gaps, and proposing further research topics will improve the lives of older adults. In addition, we discuss several themes that emerged from the review, including the need for multidisciplinary, community-wide solutions; large-scale, longitudinal studies; improved education/training for both older adults themselves and the variety of stakeholders involved in older adult transportation; and programs and interventions that are flexible and responsive to individual needs and differences.

Keywords

older drivers screening in-vehicle technology driver safety driving rehabilitation

Introduction

Most people born today can expect to live beyond their sixties. One important societal impact of our aging population will be its effect on transportation. With aging comes a higher likelihood of medical conditions and medication use, which can negatively impact an individual’s fitness-to-drive (Dickerson et al., 2007). Furthermore, once people stop driving, there are often inadequate transportation options, particularly in suburban and rural areas, where most North American older adults live (Rosenbloom, 2012).

The safe mobility for older adults is the focus of the Transportation and Aging Interest Group (TAIG) of the Gerontological Society of America (GSA). TAIG is an international collective of leaders in research and practice drawn from the many fields of study concerned with the safe mobility for older adults. The group works to enhance the safe, effective, and accessible transportation of older people by facilitating communication and collaboration among its members. TAIG periodically assesses the current state of research and practice on topics that influence transportation or show promise for improving transportation for older adults, and identifies within these topics, areas needing further attention. This article represents a third effort. In the group’s first effort (Dickerson et al., 2007), important topics related to aging and transportation were assessed (e.g., screening/assessment, rehabilitation, vehicle modifications, vehicle technologies, roadway design, transitioning to nondriving, alternate transportation). The second effort (Classen, Eby, Molnar, Dobbs, & Winter, 2011) undertaken by the conveners of TAIG focused on specific stakeholders (law enforcement, driver licensing, planning, policy, programming).

Dickerson et al. (2007) presented a framework for transportation and aging that conceptualized transportation along a continuum (Figure 1). In this framework, the primary foci of research, practice, policy, and intervention programs evolve along the continuum, from crash prevention for older adults who drive, crash prevention and maintenance of mobility for older drivers who are transitioning to nondriving, and maintenance of mobility for people who have stopped driving. This conceptualization is still relevant today and serves as the framework for this article. In another paper (Dickerson et al., 2017), the issues of transitioning and continued mobility are addressed. In this article, we aim to present what is currently known about maintaining driving among older adults and to emphasize areas needing further research.

Figure 1.

Transportation and aging continuum (based on Dickerson et al., 2007).

Screening and Evaluation

What Do We Know?

Driving safely requires abilities encompassing visual, physical, and cognitive functions. Some aging drivers will experience declines in these abilities (often in relation to medical conditions or medication use) that may result in a higher crash risk. The identification of these drivers is important for personal and public safety, and also for optimal management of reasons underlying these declines. Importantly, individuals may be able to return to driving after recovery, rehabilitation, or vehicle modification. Hence, the focus should remain on functional abilities, not age nor medical diagnoses.

Many studies were designed to develop and test screening and assessment tools to measure fitness-to-drive. We now recognize that a single tool will not be adequate (e.g., Bédard & Dickerson, 2014; Bédard, Weaver, Darzins, & Porter, 2008) and refocusing research on tools for specific conditions may be valuable (e.g., stroke, Akinwuntan et al., 2006; dementia, Carr, Barco, Wallendorf, Snellgrove, & Ott, 2011; Parkinson’s disease, Crizzle, Classen, & Uc, 2012). A recent study also suggests that driving-specific tests have greater association with safety outcomes than general neuropsychological tests, at least with individuals with mild cognitive impairment (Anstey, Eramudugolla, Chopra, Price, & Wood, 2017).

Researchers are also increasingly focusing on statistical approaches aimed at determining the predictive value of tools rather than relying on measures of association. Receiver operating characteristic (ROC) curves and test characteristics such as sensitivity, specificity, and predictive values of positive and negative tests have become the statistical benchmark for evidence-based research (Dickerson, Meuel, Ridenour, & Cooper, 2014; Weaver & Bédard, 2012). These approaches illustrate the trade-off between the tools’ ability to identify “true positives” (i.e., sensitivity, the proportion who are unfit to drive and correctly identified as unfit by the test) and their ability to identify “true negatives” (i.e., specificity, the proportion who are truly fit to drive and correctly identified as fit by the test). This allows practitioners to understand the amount of error (i.e., misclassification of drivers) to expect with a given cutoff score. Information on the predictive value of positive and negative tests also provides information regarding the risks of using the tools with populations that differ from those used to develop the tools (e.g., Stroke Drivers’ Screening Assessment; Akinwuntan et al., 2012). Researchers should be able to report and interpret their results accordingly, and clinicians should be sufficiently versed in these approaches to critically appraise the literature and make informed decisions about various tools (Weaver, Walter, & Bedard, 2014).

Determining fitness-to-drive is generally achieved through multitiered processes involving screening and driving evaluations administered by qualified professionals. Screening should be considered a form of “triage,” whereby one uses the results to determine the next step (e.g., American Geriatrics Society & Pomidor, 2015). Hence, a screening test may provide the trigger for further evaluation but by itself does not support a decision to restrict or stop driving. This is one of many important consensus statements that have emerged since the original article was published in 2007 (e.g., Bédard & Dickerson, 2014; Hogan, Scialfa, & Caird, 2014).

Screening tools may also be self-administered or completed by family members. Self-screening tests are best viewed as an educational intervention as the evidence suggests that self-administered tools do not identify unsafe drivers accurately (Bédard, Riendeau, Weaver, & Clarkson, 2011; Scialfa, Ference, Boone, Tay, & Hudson, 2010) and may create concerns among fit drivers without raising awareness among drivers who are less fit (Myers, Paradis, & Blanchard, 2008). Nonetheless, self-administered tools have the potential to promote better awareness of driving issues arising with age (Molnar, Eby, Kartje, & St. Louis, 2010) and planning for future transportation needs (Eby & Molnar, 2005). Assessments completed by family members are more accurate than those completed by drivers themselves but still lag in accuracy behind tests administered by professionals (Classen, Velozo, Winter, Wang, & Bédard, 2015).

The step following screening typically takes some form of a comprehensive driving evaluation, the accepted term to be used for the process aimed at determining fitness-to-drive (Transportation Research Board [TRB], 2016).¹ Such evaluations are more extensive and require personnel with specialized training (Korner-Bitensky, Menon, von Zweck, & Van Benthem, 2010), generally occupational therapists or driver rehabilitation specialists. The evaluations are meant to be diagnostic and may result in licensing recommendations (Lane et al., 2014). Hence, a complex framework is required to ensure accurate determinations of fitness-to-drive (Dickerson & Bédard, 2014).

Where Do We Go From Here?

An increasing number of older drivers will require driving evaluations in coming years, and we are unlikely to have sufficient capacity to deal with this challenge (Dickerson, 2014). This situation is tenuous because its solution lies with better screening tools, but a stand-alone predictor of fitness-to-drive is unlikely feasible (Gamache, Hudon, Teasdale, & Simoneau, 2010). One priority is to work differently with the tests currently available. Such approaches include combining several tests into one estimate (e.g., Bowers, Goldstein, Bronstad, Peli, & Albu, 2013; Carr et al., 2011), using serial trichotomization (e.g., Gibbons, Smith, Middleton, & Bédard, 2017; Molnar, Patel, Marshall, Man-Son-Hing, & Wilson, 2006) and developing risk stratification tools (e.g., Marshall et al., 2013).

An additional priority is to demonstrate the administrative feasibility and value of screening approaches when they are taken out of the research environment and applied in real-world settings (Martin, Marottoli, & O’Neill, 2013). This will require the refinement of cutoff scores to reduce the number of “false positives” while ensuring that drivers with limitations are referred appropriately. Furthermore, clarification of the types of services and/or driving programs that best address specific issues would allow more appropriate referrals (Lane et al., 2014). Continuing education of health professionals will enhance their abilities to address driving issues and make timely and appropriate referrals to specialists (Dickerson & Bédard, 2014).

Research is also needed to determine the appropriate reevaluation intervals for drivers with progressive conditions and to standardize the comprehensive driving evaluation to be streamlined for specific diagnoses. Currently, the body of research and practice literature provides limited guidance about these matters. This speaks to a broader issue, namely, the absence of rigorous guidelines to support clinicians in the evaluation of older drivers (e.g., Rapoport et al., 2015), and the lack of uniformity in evaluation practices within and across jurisdictions (Myers, Trang, & Crizzle, 2011). Focusing on the priorities we outlined will help minimize inconvenience to the public and help alleviate evaluation capacity shortfalls.

Finally, while any form of driving evaluation supports the determination of one’s fitness-to-drive, evaluations also have the potential to identify remediation/training opportunities and initiate discussions about transitioning to nondriving status. Thus, driving evaluations should be highlighted as the starting point of a wider process to support older adults’ transportation needs, rather than the end of a process resulting only in driving cessation.

Education and Training Interventions

What Do We Know?

Interventions encompass education and/or training to facilitate skill improvement and remediation strategies to allow older drivers to compensate for their limitations (Golisz, 2014). Rehabilitation strategies are particularly relevant to prolonging driving when an older driver has been identified as having a functional impairment. New research has addressed intervention strategies for aging adults since the Dickerson et al. (2007) paper.

Healthy aging adults

In a systematic review of driving interventions aimed at older drivers, Kua, Korner-Bitensky, Desrosiers, Man-Son-Hing, and Marshall (2007) suggested that the use of skill-specific training may play a role in retraining driving skills of older individuals. In an updated review, Korner-Bitensky, Kua, von Zweck, and Van Benthem (2009) concluded there is strong evidence that classroom-type educational interventions improve awareness and promote self-regulation (i.e., modification of one’s driving in response to declining abilities; Molnar et al., 2013). However, they found no evidence that such interventions are effective in improving on-road driving performance or reducing crashes. However, Korner-Bitensky et al. also found moderate evidence that education interventions in combination with on-road training improved driving knowledge; strong evidence that the combined interventions improved on-road driving performance; but no evidence that supported or refuted reductions in crash rate (Bédard et al., 2008; Marottoli et al., 2007). Finally, the authors concluded there was moderate evidence that physical retraining improved on-road driving performance (Marottoli et al., 2007); however, crash risk was not examined. Golisz (2014), with a systematic review, reported that physical fitness programs that simultaneously engaged cognitive-perceptual skills may prolong driving skills and delay cessation; using hazard perception training on the simulator, in clinic, or on the road can assist drivers in learning to anticipate and focus on potential hazards (e.g., Horswill, Anstey, Hatherly, & Wood, 2010; Romoser & Fisher, 2009); and personalized feedback or coaching on driving performance, whether on a simulator or on road, had strong evidence of effectiveness for improving driving performance. More recently, Coxon et al. (2017) found that an individualized safe transportation education program can promote behavior change with at-risk and higher functioning drivers, although driving exposure did not decrease over 12 months. However, this study did reinforce that at-risk drivers were more likely to report depressive symptoms with education about safe transportation.

Medically at-risk older drivers

Classen, Monahan, Auten, and Yarney (2014) published a review examining the effectiveness of rehabilitation interventions for medically at-risk older drivers, specifically with stroke, visual deficits, and cognitive impairment. Regarding stroke, they recommended that trained occupational therapists provide a simulator intervention with increasing complexity, test knowledge of traffic theory, and provide on-road training. However, there was insufficient evidence to recommend providing visual perceptual training. With only two papers on older adults with cognitive impairment (Freund & Petrakos, 2008; Man-Son-Hing, Marshall, Molnar, & Wilson, 2007), Classen et al. (2014) found weak evidence that driving restrictions improve driving outcomes and suggested that attention must be paid to the multiple factors that may affect fitness-to-drive (e.g., client insight, driving environment). There was insufficient evidence to suggest that compensatory strategies enhance driving performance in dementia.

Where Do We Go From Here?

Evidence demonstrating the effectiveness of interventions for enhancing or maintaining driving ability is one of the most encouraging developments of the last decade. Educational interventions coupled with on-road training or a physical exercise intervention program can improve knowledge and on-road behavior/performance in healthy older drivers. However, there is no evidence that interventions can change crash risk. Similarly, targeted interventions can improve on-road performance of drivers with some impairment, although there exists only weak evidence to support improved driver fitness among those with cognitive impairments.

Nevertheless, we need to understand who benefits most from an intervention and, conversely, whether it increases risk for others. Many early intervention studies limited their participant population to a particular range of ability or impairment, but have not answered the question whether these results are generalizable. Are there unintended consequences, such as increased exposure, that might increase overall risk and counterbalance the beneficial effects of an intervention (e.g., the association between attendance and increased crashes for men over age 75 found by Nasvadi and Vavrik, 2007)? Studies also use different outcomes (e.g., raising awareness, enhancing performance, reducing risk) and interventions that address one outcome may not impact others. For example, Brelet et al. (2016) suggested that telling older drivers they are at-risk may impair their self-regulatory skills, and Ferring, Tournier, and Mancini (2015) recommended avoiding using chronological age as a sole driving risk factor to stop negative stereotyping and premature driving cessation. Thus, while the last decade has been exciting, overall, with the unveiling of multiple effective interventions, the coming years—with emerging vehicle technology—may offer opportunities to further optimize the safety and mobility of older adults.

In-Vehicle Technology

What Do We Know?

Considerable progress has been made in developing advanced in-vehicle technologies for improving driver safety, comfort, and mobility. Although there are many ways to categorize in-vehicle technologies, one approach is to divide them into crash avoidance systems (CASs) and advanced driver assistance systems (ADASs; Eby & Molnar, 2014; Eby et al., 2015). CASs are designed to provide warnings about and/or prevent/mitigate potential crashes (e.g., lane departure warning/mitigation, forward collision warning/mitigation, and blind-spot warnings). ADASs provide timely information to drivers to assist in the driving task (e.g., navigation assistance, night vision enhancement systems, adaptive cruise control [ACC], congestion warnings, and adaptive headlights). An important focus of continuing system development will be to automate various aspects of the driving task, with a trajectory toward fully autonomous vehicles (Eby et al., 2015; National Highway Traffic Safety Administration [NHTSA], 2013; Reimer, 2014; Simões & Pereira, 2009).

Use of CAS and ADAS technologies

Studies report that older drivers use CAS and ADAS technologies often, especially when they perceive them to be operating correctly (Band & Perel, 2007; Eby et al., 2015; Jenness, Lerner, Mazor, Osberg, & Tefft, 2008; Yannis, Antoniou, Vardaki, & Kannellaides, 2010). For example, older drivers were found to use navigation assistance systems more frequently than younger drivers in unfamiliar locations (Band & Perel, 2007; Jenness et al., 2008). However, older drivers reported that some technologies such as blind-spot warnings were distracting, limiting their use (e.g., Eby et al., 2015; Zhan, Porter, Polgar, & Vrkljan, 2013). Other technologies can reduce mental workload (e.g., parking assistance systems; Reimer, Nehler, & Coughlin, 2010). Furthermore, there is evidence that some technologies can improve safety-related driving behaviors for older adults and possibly prevent crashes (e.g., forward collision warning systems; LeBlanc et al., 2006; LeBlanc, Bao, Sayer, & Bogard, 2013). Others have found unintended behavioral changes that might compromise safety, such as a reduction in turn-signal use when using a blind-spot warning system (Kessler et al., 2012).

Knowledge of technology operation

Evidence suggests that older drivers do not fully understand the operation of in-vehicle technologies (Eby et al., 2015; Koppel, Clark, Hoareau, Charlton, & Newstead, 2013; Shaw, Polgar, Vrkljan, & Jacobson, 2010; Zhan et al., 2013). For example, drivers using ACC in a simulator study were found to be at higher risk of hitting a stopped car in front of them than those not using ACC (Piccinini, Rodrigues, Leitão, & Simões, 2015). These results and others suggest that drivers may incorrectly attribute collision prevention/mitigation features to ACCs (Bato & Boyle, 2011; Piccinini et al., 2015). Older drivers also appear to have greater difficulties with and take longer learning how to use technologies than younger drivers (AAA Foundation for Traffic Safety [AAAFTS], 2008), although there is a paucity of research in this area.

Specific older driver issues

The interaction among driver needs, capabilities, and technology may create issues specific to older drivers. Researchers agree that technology design should take into account the abilities and needs of older adults to enhance their mobility and safety (Eby & Molnar, 2014; Eby et al., 2015; Yang & Coughlin, 2014). Of special interest are changes in driving behavior from use of new technologies. Older adults are accustomed to performing driving tasks in certain ways without in-vehicle technologies. When new technologies are introduced, previous skills can change or disappear (Eby & Molnar, 2014; Meyer, 2009; Yang & Coughlin, 2014), which Simões and Pereira (2009) refer to as “behavioral adaptation.” This is beneficial when the technology complements existing driver skills, but becomes problematic when reliance on the technology results in changes in, or loss of, previous skills necessary for safe driving (Jenness et al., 2008; Meyer, 2009; Simões & Pereira, 2009; Yang & Coughlin, 2014). Problems can also result from using technology in an unsafe manner, such as programming a navigation system while driving (Band & Perel, 2007; Jenness et al., 2008).

Functional changes in vision, cognition, or sensorimotor abilities due to age-related medical conditions can adversely affect the use of in-vehicle technologies (Band & Perel, 2007; Eby & Molnar, 2014; Eby et al., 2015; Jenness et al., 2008; Yang & Coughlin, 2014). Recommendations on technology design to accommodate different functional abilities include providing multimodal sources of information (e.g., visual or auditory prompts), minimizing the complexity of information and steps required to use the technology, and ensuring that information, such as feedback provided by the technology, is accessible and understandable (Band & Perel, 2007; Denaro, Zmud, Shladover, Walker Smith, & Lappin, 2014; Emerson et al., 2012; Simões & Pereira, 2009; Yang & Coughlin, 2014).

Recommended technologies

Although a comprehensive review of in-vehicle technologies is beyond the scope of this article, a recent report synthesized the literature on 18 advanced in-vehicle technologies with respect to the value that these technologies may have for older drivers in terms of safety and comfort (Eby et al., 2015). The following technologies were judged to be of high value: forward collision warning/mitigation, rearview cameras with alerts and backup assistance displays, cross-traffic warning for backing up, semi-autonomous parking assistance, navigation assistance, and automatic crash notification. Several others were judged to be either of moderate value or too early in development to determine their value.

Where Do We Go From Here?

Despite the potential of in-vehicle technologies to improve safety for older drivers, there are still many outstanding questions. First, we need to better understand how older adults learn to use technologies, as well as develop ways to inform this age group about new technologies, based on their unique needs and learning styles. Second, we need to increase our knowledge about how in-vehicle technologies are used, what behavioral adaptations occur, and what safety benefits are produced when these technologies are used in real-world settings. Naturalistic driving studies, although resource-intensive, are the best way to answer these questions. Third, technologies need to be tested with a range of older adults. Many studies on in-vehicle technologies either do not include older adults as participants or define them as being younger than 65. Older adults are different from younger age groups on several dimensions related to technology use, and these differences need to be investigated. In addition, given the projected growth of the oldest old (i.e., age 80 or older), researchers need to consider this age group as studies are developed.

Finally, vehicle technology is moving toward the development of self-driving vehicles, with older adults often cited as the group that may benefit the most (Kessler, 2015). Regardless of progress toward fully autonomous vehicles, technologies will require that drivers retain situational driving awareness and the ability to take over control of the vehicle under certain circumstances. We may have a long way to go before the benefits of self-driving vehicles are realized, and several important questions remain: How can the transfer of control be designed to maximize older adults’ ability to take back control of the vehicle safely? Are there special scenarios in which autonomous vehicles could be safely deployed to meet specific mobility needs (e.g., in a senior living community)? Should there be special training and/or certification requirements to use an autonomous vehicle? Are there policy and social inequity issues related to older adults and autonomous vehicles?

Discussion

Our objective was to highlight what we know about maintaining safe driving mobility among older adults and emphasize opportunities for future research. Topics were organized under a framework developed by the TAIG, which views older adult transportation as a continuum progressing from independent driving to nondriving. Although there are other critical components in the transportation continuum (e.g., licensing policy, law enforcement, medical conditions, medications), we addressed driving-related issues by highlighting the complexity of challenges facing older adults that will require an interdisciplinary effort.

There has been progress in areas highlighted in this article. Regarding screening and evaluation, there is less pursuit of a single screening tool, in recognition that the complex nature of medical conditions and/or driving impairments will require an array of tools. Education/training intervention strategies for healthy older adults and those with medical conditions show promise but require more development and investment. Education for older adults must become more interactive (e.g., on road) if we are to see changes in behavior. Finally, the development of advanced transportation technologies may hold much promise for improving the safe mobility of older adults, although there is still much to learn in terms of how to best utilize these technologies.

In light of this diverse research agenda, specific needs in each topic area must be addressed to continue progress (see Table 1). However, there are several themes that cut across the areas discussed. One is that solutions for older adult transportation are complex, requiring interdisciplinary and community-wide efforts. Indeed, some states have begun to develop and implement statewide, comprehensive strategies for helping older adults maintain mobility such as such as Florida’s Safe and Mobile Seniors program (Florida Department of Transportation, 2016) or Michigan’s Safe Drivers Smart Options program (Michigan Department of State, 2016). A related theme is that future research approaches should incorporate large-scale and longitudinal methodology. Clearly, training and education will play an increasing role in addressing mobility challenges. Such training and education are not limited to older adults, but will be increasingly necessary for the variety of stakeholders involved in older adult transportation: family members and/or caregivers, health professionals, law enforcement, and state and local governments. Finally, an important theme is that older adults are individuals who differ in many ways including functional ability, lifestyle, personal resources, and attitudes toward transportation solutions. Effective programs and interventions will need to be flexible and responsive to individual needs and differences if they are going to significantly improve transportation and continued mobility for older adults.

Table 1.

Research Issues for Maintaining Older Adult Safe Transportation.

Topic	Research issues for older adult transportation
Screening and assessment	Develop validated driver screening protocols that are feasible in real life.
	Standardize and validate fitness-to-drive evaluations completed by medical professionals.
	Determine what types of services and/or driving programs best address specific issues for medically at-risk drivers and develop standard protocols so that more appropriate referrals for older adults can be made.
	Empirically determine the appropriate reassessment intervals for drivers with progressive medical conditions.
Interventions	Empirically determine the effect of interventions on at-fault crash risk as well as increased mobility.
	Determine the comprehensive costs and benefits of interventions, including unintentional consequences.
	Determine whether interventions can be combined to address impairments in different domains to synergistically reduce crash risk and increase mobility of the medically at-risk.
In-vehicle technology	Improve the knowledge and skills of older adults about the operation, use, and benefits of in-vehicle technologies through training and/or education.
	Develop greater knowledge about how in-vehicle technologies are used, what behavioral adaptations occur, and what safety benefits are produced when these technologies are used in real-world settings.
	Document the unique issues that will affect older adults when using connected and automated vehicles to implement strategies for improving use of helpful technologies with this age group.

Footnotes

Authors’ Note

Sherrilene Classen has moved to University of Florida, Gainesville, FL, USA.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Notes

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