Interventions to reduce the adverse psychosocial impact of driving cessation on older adults - Windsor & Anstey - 2006 - Article

Changes in the ageing of populations means that more and more drivers will have to face with the fact that they might have to give up driving due to health or functional limitations. Many studies in different countries have shown that many people after the age of 80-85 should rely on alternative modes of transport. Studies have shown that there are negative social and psychological consequences of driving cessation. For many older people, the feeling of being able to drive to being an ex-driver goes together with a sense of lost independence, depression and social isolation. Mental health and social integration is important for the general wellbeing and it is also important for the prevention of dementia and other health problems when people age. It is therefore important to have interventions that address the negative consequences of driving cessation. There have only been a couple of interventions that target older drivers and most of these programs aim to promote safety. This article is a review in which two areas of research are surveyed. Some studies that are reviewed are about the implications for intervention programs designed to promote safety for older adults. Other studies that are studied are studies about reducing the negative consequences of driving cessation, when safe driving is not an option anymore.

Interventions for driving safely for longer

Although we know that there are issues associated with older driver safety, there have only been a couple of studies conducted to evaluate the effectiveness of existing intervention programs. These studies describe approaches to interventions that fall into two categories. The first one is the cognitive speed-of-processing intervention. These are designed to improve aspects of visual processing and attention. The second category is the educational intervention. This is designed to promote effective self-regulation and good adaptation of driving behaviour.

Cognitive interventions

Studies have shown that cognitive abilities are important factors when it comes to safe driving. Visual-processing speed and visual selective attention are important aspects of cognition for driving. These things have been assessed among older drivers by using the so-called ‘useful field of view test,’ UFOV. The UFOV looks at to which extent older adults are capable of extracting visual information without movement of they head or eyes. The testing process sometimes requires localization, detection or identification of certain targets. Studies have showed that older drivers with UFOV impairments have more at-fault crashes and driver simulator crashes. These studies have also shown that with the appropriate training (speed-of-processing training) performance on the UFOV can improve. This suggests that the driving capacity of older adults could be improved, or maintained at acceptable levels. Of course, this could only be done through interventions that give speed of processing training.

Some studies have looked at the impact of speed-of-processing training on driving outcomes. One study looked at individuals with high-risk scores according to the UFOV. Some of these people received speed-of-processing training and others received traditional driver training. There was also a low-risk control group. The results showed that the group that received speed-of-processing training improved on the UFOV task to a level that looked like the level of the low-risk group. The group that underwent traditional driver training did not show an improvement in UFOV performance. Speed-of-processing training also had a beneficial effect on driving performance. Other studies have also shown that the UFOV might be of particular use for improving the driving outcomes of people who have an impaired speed of visual processing. The ACTIVE trial is a large-scale randomized controlled trial of cognitive training interventions with older adults. It has looked at the effects of speed of processing training on cognitive tests and functional activities. This trial has also shown that speed of processing training had a positive effect on the cognitive measures of an old person. So it seems that studies have found results that have positive implications for clinical interventions for older drivers’ cognitive capacity. With these interventions, they can drive more safely and longer. But, more research is needed to determine whether there is a certain age at which those interventions are most beneficial. Research should also look at whether benefits of training in preventing decline are ‘better’ than benefits for improving performance. Studies must also examine what the most effective mode is of delivering the cognitive training. It could be the case that there are other techniques that can enhance the driving ability, and not just the ones based on UFOV.

Educational interventions

There are a couple of studies that have looked at the education-based driving interventions and outcomes. One such study gave older drivers a driving decision workbook. This is a self-assessment tool which asks older drivers to identify potential problems faced in the domains of driving attitudes, driving ability, health and behaviour. This book also provided the older adults with feedback as to how certain problems might be addressed. The results of the study showed that the people who completed the workbook indicated that the exercise increased their awareness of age-related changes that could affect driving and they also indicated that is served as a reminder of issues that relate to road-safety. This study was limited because of the sample and a lack of follow-up data, but it does show that using a workbook has promise. Another study shows that older drivers have the ability to improve on a driving task that they had familiarity with. Both the group that received educational training about the driving environment and driving performance as well as the control group that just underwent the on-road testing without the educational intervention improved.

The most comprehensive designed educational program for older drivers is the Knowledge Enhances Your Safety (KEYS) project. This intervention was developed to improve the safety of older drivers who have visual impairments. These older individuals are at high risk of accident involvement. The project used the social-cognitive theory and models that emphasize motivation, knowledge and self-efficacy for adaptive behaviour change. The older adults received a one-on-one session with a health educator. The educator told them about the implications of visual impairment for driving, strategies for avoiding hazards and he/she thought them more about the development of skills and build their confidence up. The project was evaluated and it revealed that drivers who had received the KEYS showed a greater awareness of their visual limitations and they also reported a higher degree of self-regulation of driving behaviour. However, another study that evaluated the KEYS found that older drivers that received educational training from KEYS did not show less crashes than the control group. This suggests that educational interventions may have only limited value in promoting older driver safety.

Other studies also looked at a model which saw vision and physical functioning as important for improving the capacity of driving safely. This model saw cognition as playing a crucial role in enabling driving capacity and effective self-monitoring. Many interventions also try to improve the cognitive abilities of older people. These interventions often use speed-of-processing training (UFOV) to enhance basic driving skills. Educational interventions try to promote better understanding of issues and difficulties associated with driving. Some studies suggest that educational interventions for older people benefit the people by facilitating the discussion of issues related to driving cessation with family members. This suggests that education programs might be more effectively targeted at helping older drivers to prepare for life after not driving anymore and not enhancing safety.

Clinical interventions for driving cessation

The most effective methods for reducing negative consequences of driving cessation are applied to the population level. These include improvements to existing transport services, to make them more accessible for older adults. Also, there are community-owned transport services that provide for the needs of older adults who don’t drive anymore. There are different interventions to address adverse psychological consequences of driving cessation. Social cognitive theory seems to offer a promising theoretical framework for interventions. People see giving up driving often as lost independence. The social cognitive theory focuses on self-efficacy, control over the environment and self-regulation and it helps older adults to re-evaluate what remains achievable in terms of mobility after driving cessation and to get a sense of control over the environment. Ceased drivers often face depression which results from reduced mobility, social isolation or threats to self-concept. This might also be lessened by interventions informed by social cognitive theory. Especially the promotion of self-efficacy has been identified as an important element for success in interventions to reduce depressive symptoms in older adults. So, social cognitive theory addresses threats to the self and independent mobility by promoting efficacy and knowledge about availability of alternative transportation.

It is important to have interventions informed by appropriate theory, but practical considerations are also important in the creation of approaches that address negative outcomes associated with driving cessation. One important approach that fits with the social cognitive theory framework is the active planning for driving cessation while people remain capable of driving. Strategies that can be used to plan for life after driving might include familiarization with transport alternatives, like public transport. They also include considering housing relocation when transport alternatives are not available and also initiating conversations of transport arrangements with family and friends. These activities provide benefits and also reinforce efficacy beliefs and allow older adults to adapt emotionally better to cessation. When you expect a negative event as part of a normal transitional process, you will more likely better adjust to it than experiencing a sudden loss. There are some interventions that have used educational approaches that help assist older adults to plan for driving cessation. Residents of the Australian Capital Territory (ACT) are given an educational booklet that addresses safe driving practices and techniques for self-evaluation when they turn 70. When these people 75, they receive another booklet that provides strategies in planning for driving cessation.

Future studies

Interventions that directly address problems like social isolation and reduced mobility are needed to help individuals who have already ceased driving and are experiencing a reduction in quality of life because of it. Problem-solving treatment is in line with the principles of social cognitive theory and could address the mobility, psychosocial and emotional difficulties. Psychosocial symptoms are a result of everyday problems and problem-solving treatment therefore equips people to better deal with current difficulties. This is done by outlining a problem-solving framework within the person identifies the problems, identifies achievable solutions and also identifies the mechanisms for attaining those solutions. This framework emphasises on people using their own skills and resources to solve problems and it will therefore enhance efficacy. This approach can also be administered by health professionals who did not have had psychotherapy training. This approach has also been found to be effective in improving depression outcomes for older adults. Interventions that try to reduce the negative consequences of driving cessation will probably also benefit from the involvement of supportive family and friends of the older person. Former drivers often rely on family and friends for the maintenance of mobility. This reliance can be associated with feelings of lost independence and because of this people may be reluctant to ask for help with non-essential trips. The educational intervention could stimulate discussion and family counselling could also provide an effective approach. This is probably best initiated while the older person is still driving.

Interventions for former drivers should be flexible, because they should be tailored to the specific needs of the older adult. Interventions should take into account where somebody lives (urban, regional or isolated areas) , the availability of public transport, the availability of residents willing to provide transport and the subjective experience of driving cessation. Interventions should also be different for older people who are still driving and older people who aren’t driving anymore. Someone who just stopped driving might be feeling distressed because of a loss of independence, while somebody who hasn’t been driving for a couple of years could be depressed because of social isolation. These people should receive different intervention programs. In the United States, a project was formed from a range of backgrounds like medical practice, seniors advocacy groups and traffic safety administrations. This project is called the Older Drivers Project and it’s goal is developing an improved approach to manage issues related to older drivers at a policy level. This project promotes the safety of road users and helps older adults to drive safely for as long as possible. This projects want to optimize the health status of drivers and it wants to create a safer driving environment through improvements to roads and traffic control devices. This project and other interventions should be explored really well, because the negative consequences of driving cessation for older adults are inevitable for a proportion of older road users.