older drivers

Older DriversOlder DriversA Perspective for Malaysian A Perspective for Malaysian

ConsiderationConsideration

Michael HullMichael HullResearch DirectorResearch Director

Pan Pacific Research Pty LtdPan Pacific Research Pty Ltd

ObjectivesObjectives

• To establish the demographic case To establish the demographic case for taking prompt action in for taking prompt action in anticipation of an ageing population.anticipation of an ageing population.

• To briefly consider political and To briefly consider political and social issues around older driverssocial issues around older drivers

• To examine dementia as an example To examine dementia as an example of older driver health concernsof older driver health concerns

• To summarise major health concerns To summarise major health concerns around older driversaround older drivers

Demographic ChangeDemographic Change2000 - 20102000 - 2010

Demographic ChangeDemographic Change2020 - 20502020 - 2050

Summary of Population Summary of Population Change - MalaysiaChange - Malaysia

Wong Chay NeeWong Chay Nee, , Policy Response for the Aging in MalaysiaPolicy Response for the Aging in Malaysia, ,

Malaysian Institute of Economic Research. Malaysian Institute of Economic Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s2_02.pdfwww.mof.go.jp/jouhou/soken/kenkyu/h18/s2_02.pdf

Why Changes in Why Changes in Malaysia?Malaysia?

• Declining fertilityDeclining fertility• Falling mortality ratesFalling mortality rates• Improved health & nutritionImproved health & nutrition• Longer life expectancyLonger life expectancy



Move from Rural to Urban - Move from Rural to Urban - MalaysiaMalaysia



Growth in Nuclear Family Growth in Nuclear Family Homes: Malaysia Homes: Malaysia

[= decrease in extended family homes][= decrease in extended family homes]Growth of Nuclear Family Households Malaysia 1980 - 2020

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Adapted from: NDFBP Malaysia,

Malaysian Population & Family Survey, 1994

Quantifying Household Quantifying Household Change - MalaysiaChange - Malaysia

Income Growth - Income Growth - MalaysiaMalaysia

Mean Monthly Income (RM)Malaysia

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Adapted from: Zin, Ragaya, Explaining the Trend in Malaysian Income Distribution, www.eadn.org/reports/webfiles/i06.pdfData after 1995 are my regressions based on above data 1970 – 1995.

Malaysia: Education Levels Malaysia: Education Levels of Older Persons 1970 – of Older Persons 1970 –

2020 (percentage)2020 (percentage)

Source:Source: Department of Statistics, Malaysia (1998). Department of Statistics, Malaysia (1998).

Recognition of Coming Recognition of Coming Change MalaysiaChange Malaysia

Wong Chay NeeWong Chay Nee, , Policy Response for the Aging In MalaysiaPolicy Response for the Aging In Malaysia, ,


Summary of Expected Summary of Expected ChangeChange

• Increasing urbanisation of older Increasing urbanisation of older MalaysiansMalaysians

• Decreasing numbers of older Decreasing numbers of older Malaysians living with extended Malaysians living with extended familyfamily

• Increasing income of older MalaysiansIncreasing income of older Malaysians• Increasing education of older Increasing education of older

MalaysiansMalaysians• Increasing proportion of older Increasing proportion of older

MalaysiansMalaysians

Implications for Malaysia’s Implications for Malaysia’s FutureFuture

All these things suggest the same changes All these things suggest the same changes seen elsewhereseen elsewhere

• Increasing demand for personal mobilityIncreasing demand for personal mobility• Increasing capacity to pay for personal Increasing capacity to pay for personal

mobilitymobility• Increasing political and economic power to Increasing political and economic power to

get what they wantget what they want• Additionally an increasing number of Additionally an increasing number of

ageing Malaysians who have been driving ageing Malaysians who have been driving for many years will not want to stop for many years will not want to stop drivingdriving

The Bad NewsThe Bad NewsAustraliaAustralia

• There is an increased serious There is an increased serious injury crash risk amongst older injury crash risk amongst older drivers, starting from about drivers, starting from about age 60.age 60.– The black line shows the The black line shows the

unadjusted crash riskunadjusted crash risk– The red line shows the crash The red line shows the crash

risk adjusted for vulnerabity – risk adjusted for vulnerabity – Older drivers are more frail Older drivers are more frail and therefore more easily and therefore more easily injuredinjured

• Research suggests that a Research suggests that a significant proportion of the significant proportion of the remaining risk after allowing remaining risk after allowing for frailty rests from older for frailty rests from older people driving more frequently people driving more frequently on local roads with many on local roads with many intersections, mostly without intersections, mostly without traffic lights.traffic lights.

Langford, J, Andrea, D, Fildes, B, Williams, T & Hull, M (2006), Assessing Responsibility for Older Drivers’ Crashes, Austroads Project No . SS1111, Austroads, Sydney

The Bad NewsThe Bad NewsMalaysiaMalaysia

Why?Why?

Fatal & Serious Injuries Malaysia 2007

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Motorcycles

The blue line The blue line represents represents fatal and fatal and serious serious injuries to injuries to drivers in car drivers in car crashescrashes

The pink line The pink line represents represents fatal and fatal and serious serious injuries to injuries to riders of riders of motorcycles.motorcycles.

Only the Only the motorcycle motorcycle curve shows curve shows the U-shaped the U-shaped curve seen in curve seen in Australia.Australia.

Derived from official Malaysian statistics by Jenny Oxley, Derived from official Malaysian statistics by Jenny Oxley, and adapted by me.and adapted by me.

Time differences in Time differences in Vehicle OwnershipVehicle Ownership

Motor Vehicle Ownership 1975 - 2005 Malaysia & Australia

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Australian data does not include motorcycles, but these are a very small proportion of motor vehicles in Australia. Malaysian data does include motorcycles.

2005 data for Malaysian is based on my regression of official statistics for previous years.

1999Malaysian Source: ( ) Malaysian GGGGGGG GGGGGGGGGGGG GGGGGGGGG GGGG G,GGGGGGGG GGGG

GGGG GGGG GG GGGGGGGGGG GGG (): (20 05),,GGGGGGGG

The increasing demand, in both countries, for private motor vehicles

can be seen in the graph.

It is obvious that the gap in vehicle ownership is getting smaller.

But a much larger proportion of Malaysian vehicle ownership is of

motorcycles, rather than cars.

Motorcycles are a great deal less safe than cars for those using them.

But the main point of this graph for our discussion here, is the higher

level of vehicle ownership in Australia 40 years ago (1975). A higher

proportion of people who are now old have been driving all their adult lives

and will resist any attempt to stop them now!

Malaysia is just beginning to encounter this problem.

Normal Changes in Ageing Normal Changes in Ageing PeoplePeople

• Slowing reaction time, taking longer to make complex Slowing reaction time, taking longer to make complex decisions. decisions.

• Difficulty with multi-tasking and selective attention. Difficulty with multi-tasking and selective attention. • Less accurate in judging speed and distance. Less accurate in judging speed and distance. • Pupils become smaller and slower to adapt to sudden changes Pupils become smaller and slower to adapt to sudden changes

in light intensity, such as headlights. in light intensity, such as headlights. • Driving issues correlate with measures of frailty, falls, and Driving issues correlate with measures of frailty, falls, and

dementia. dementia. • However:However:

– older drivers do tend to curb night driving;older drivers do tend to curb night driving;– often choose not to drive at peak traffic periods;often choose not to drive at peak traffic periods;– often choose not to drive in rain.often choose not to drive in rain.

• With the great heterogeneity in older populations in health and With the great heterogeneity in older populations in health and function, function, age should not be the determining factor for driver age should not be the determining factor for driver licensinglicensing. .

• Driving is already considered one of the most dangerous Driving is already considered one of the most dangerous activities at any age. So when is the risk unacceptable? This is a activities at any age. So when is the risk unacceptable? This is a societal and political question…societal and political question…

Odenheimer G (2006),. “Driver safety in older adults. The physician’s role in assessing driving capabilities of older patients”. Geriatrics 61(Oct):14-21.

Increasing Morbidity in Older Increasing Morbidity in Older PeoplePeople

• INCREASE IN DISEASES AND MEDICATIONS.INCREASE IN DISEASES AND MEDICATIONS. – At least 30% over age 75 have significant vision impairmentAt least 30% over age 75 have significant vision impairment– 50% over age 75 have significant hearing impairment. 50% over age 75 have significant hearing impairment. – Nearly all elderly have some degenerative joint disease. Nearly all elderly have some degenerative joint disease. – Because of the increase in disease, the average number of Because of the increase in disease, the average number of

medications also rises with age, further increasing the medications also rises with age, further increasing the likelihood for negative effects on driving safety. likelihood for negative effects on driving safety.

• INCREASED FRAGILITY AND MORTALITY.INCREASED FRAGILITY AND MORTALITY. – crash rates increase with age, but mortality rates are even more crash rates increase with age, but mortality rates are even more

impressive. Drivers over age 85 are nine times more likely to die impressive. Drivers over age 85 are nine times more likely to die in a crash than drivers age 25 to 69in a crash than drivers age 25 to 69

– Even when controlling for crash severity, older drivers are four Even when controlling for crash severity, older drivers are four times more likely to die than a 20-year-old driver.times more likely to die than a 20-year-old driver.

• INADEQUATE COMPENSATORY BEHAVIORS.INADEQUATE COMPENSATORY BEHAVIORS. • Crash and mortality statistics become more significant when Crash and mortality statistics become more significant when

noting that older drivers tend to drive less, slower, and noting that older drivers tend to drive less, slower, and avoid high-risk situations (eg, driving at night, in bad avoid high-risk situations (eg, driving at night, in bad weather, and on unfamiliar roads).weather, and on unfamiliar roads).Odenheimer G (2006),. “Driver safety in older adults. The physician’s role in

assessing driving capabilities of older patients”. Geriatrics 61(Oct):14-21.

Increasing Life Increasing Life ExpectancyExpectancy

With increasing life expectancyWith increasing life expectancy• Normal changes Normal changes

– Normal changes accompanying ageing will Normal changes accompanying ageing will become more commonbecome more common

– As people live to be older, normal changes will As people live to be older, normal changes will become more severebecome more severe

• Diseases associated with ageingDiseases associated with ageing– There will become more commonThere will become more common– As people live to be older As people live to be older

• these diseases will become more severe these diseases will become more severe • These diseases will require more medical attention These diseases will require more medical attention

& medication& medication

How Safe will Older How Safe will Older Malaysian Drivers Be?Malaysian Drivers Be?

• Increasing life Increasing life expectancy expectancy increases increases – the probability of the probability of

multiple medical multiple medical conditions conditions

– The probability of The probability of multiple multiple medicationsmedications

Life Expectancy at Birth - Malaysia 1990 - 2020

$66

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1988 1992 1996 2000 2004 2010 2015 2020

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Ag

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Adapted from World Bank Indicators, 2003.

Data beyond 2002 are my regressions

• Increasing efficiency of health services and better diagnosis of diseases offers increased detection of many common diseases

•Increasing age brings increasing risk of disease and multiple disease.

• The cumulative effect of multiple conditions, each of which may not, by itself, be significant, and the medications used to treat them, may combine to create an unsafe driver.

Example: Alzheimer’s Example: Alzheimer’s First Problems Noticed First Problems Noticed

• Confusion with everyday tasksConfusion with everyday tasks • Cooking/housekeeping Cooking/housekeeping • Forgetting people/names Forgetting people/names • Repetitive behaviour or speechRepetitive behaviour or speech • Losing things or getting lostLosing things or getting lost • Problems managing money Problems managing money • Personality or behaviour changesPersonality or behaviour changes• INSIGHT: Patients may be unaware that INSIGHT: Patients may be unaware that

they have these symptoms and not they have these symptoms and not understand the impact on road safety.understand the impact on road safety.Speechley, C & Bridges-Webb, C, undated, The Pathway to Dementia Diagnosis, Research & Development Unit Project, Royal Australian College of General Practitioners, http://www.racgp.org.au/Content/NavigationMenu/News/Conferencesandevents/asc20071/Abstracts07/Mentalhealth07/ASC2007Speechly.pdf

Alzheimers: Anecdotal Driving Alzheimers: Anecdotal Driving IssuesIssues

• Gets lost whilst driving. Stops in middle of Gets lost whilst driving. Stops in middle of busy road to work out where to go.busy road to work out where to go.

• ““Talking through” a driving assessment: Talking through” a driving assessment: Patient says, “Patient says, “there is a Stop Sign ahead. there is a Stop Sign ahead. That means I have to stop and look both ways That means I have to stop and look both ways before driving throughbefore driving through”. Then drives through ”. Then drives through without stopping.without stopping.

• Patient with no previous convictions, drives Patient with no previous convictions, drives unroadworthy car to shops, twice in one day, unroadworthy car to shops, twice in one day, despite having had licence cancelled for despite having had licence cancelled for health reasons. health reasons.

Alzeimer’s DiseaseAlzeimer’s DiseaseThe Australian ExperienceThe Australian Experience

• Time to diagnosisTime to diagnosis– Retrospective: 2 to 2.5 yearsRetrospective: 2 to 2.5 years– Prospective: up to 5 yearsProspective: up to 5 years

• In one study, GPs referred only 23% In one study, GPs referred only 23% of those they suspected might haveof those they suspected might have dementiadementia

• On average, carers and family On average, carers and family members delayed 2 – 2.5 years before members delayed 2 – 2.5 years before taking concerns to doctor taking concerns to doctor Speechley, C & Bridges-Webb, C, undated, The Pathway to Dementia Diagnosis, Research & Development Unit Project, Royal Australian College of General Practitioners. http://www.racgp.org.au/Content/NavigationMenu/News/Conferencesandevents/asc20071/Abstracts07/Mentalhealth07/ASC2007Speechly.pdf

AD - A Malaysian AD - A Malaysian Problem?Problem?

• In Malaysia an estimated 50,000 people suffer In Malaysia an estimated 50,000 people suffer from dementia “Very few private nursing homes from dementia “Very few private nursing homes are dedicated to the care of the AD sufferer are dedicated to the care of the AD sufferer although some homes will accept a few AD although some homes will accept a few AD sufferers if they are not behaviourally challenged sufferers if they are not behaviourally challenged ” said Philip Poi head of geriatric medicine at ” said Philip Poi head of geriatric medicine at Universiti Malaya Universiti Malaya

• ““Malaysia is starting to appreciate there is a Malaysia is starting to appreciate there is a problem but currently caregiving is provided problem but currently caregiving is provided mainly by the informal carers such as the spouse mainly by the informal carers such as the spouse or child ” or child ”

• China has up to eight million dementia patients China has up to eight million dementia patients but very few hospitals in the country have but very few hospitals in the country have independent dementia units By 2030 one in every independent dementia units By 2030 one in every four Chinese will be over 60.four Chinese will be over 60.

Source: The Malaysian Insider, 3 September 2010 http://www.themalaysianinsider.com/features/article/alzheimers-scourge-hangs-over-ill-prepared-asia/

Reliable Assessment of Reliable Assessment of Incidence of Alzheimer’s in Incidence of Alzheimer’s in

MalaysiaMalaysia

Source: Krishnaswami, S, Kadir, K, Ali, R & Mathews, S, (1997) “Prevalence of dementia among elderly Malays in an urban settlement in Malaysia”, Neurol J Southest Asia, 2:159-162

Reliable data is not readily available because of the relative recent concern about Alzheimer’s Disease and because of diagnosis difficulties.

These data come from a scientific study of 522 elderly Malays living in a Malay urban settlement in Kuala Lumpur.

The authors report that prevalence rates are similar to those reported for similar populations in Singapore.

As numbers of the elderly increase and as life expectancy increases the absolute number of cases and the prevalence rate will both increase

%

What Malaysian experts What Malaysian experts saysay

• Although dementia has always been somewhat Although dementia has always been somewhat common, it has become even more common among common, it has become even more common among the elderly in recent history. It is not clear if this the elderly in recent history. It is not clear if this increased frequency of dementia reflects a greater increased frequency of dementia reflects a greater awareness of the symptoms, or if people simply are awareness of the symptoms, or if people simply are living longer and thus are more likely to develop living longer and thus are more likely to develop dementia in their older age. dementia in their older age.

Dementia caused by nervous system disease, Dementia caused by nervous system disease, especially Alzheimer's disease, is increasing in especially Alzheimer's disease, is increasing in frequency more than most other types of dementia. frequency more than most other types of dementia. Some researchers suspect that as many as Some researchers suspect that as many as half of half of all people over 80 years oldall people over 80 years old develop Alzheimer's develop Alzheimer's disease. disease. Source: Malaysian Psychiatric Association, Statement on Dementia, July 2006Source: Malaysian Psychiatric Association, Statement on Dementia, July 2006http://www.psychiatry-malaysia.org/article.php?aid=80http://www.psychiatry-malaysia.org/article.php?aid=80

Health conditions: a Health conditions: a concernconcern

• The elderly, in both Australia and Malaysia, The elderly, in both Australia and Malaysia, often go to a health professional as a last often go to a health professional as a last resort.resort.– One result is that health conditions that could One result is that health conditions that could

be treated are not diagnosed until late in the be treated are not diagnosed until late in the progression of the disease.progression of the disease.

– In Australia, and probably in Malaysia, this is In Australia, and probably in Malaysia, this is especially true for men.especially true for men.

• Unless family and friends speak to older Unless family and friends speak to older people about their driving, they may not be people about their driving, they may not be aware of the danger they create for other aware of the danger they create for other road usersroad users

Multiple conditionsMultiple conditions

• Diagnosed multiple conditionsDiagnosed multiple conditions– Some multiple conditions commonly go Some multiple conditions commonly go

together – like diabetes and cardiovascular together – like diabetes and cardiovascular illness, but both require separate illness, but both require separate medications. Safe driving concerns may medications. Safe driving concerns may be quite different however. Each be quite different however. Each condition, considered separately may not condition, considered separately may not be at a severe enough stage to prevent be at a severe enough stage to prevent driving. But what are the cummulative driving. But what are the cummulative effects, each treated by a separate medical effects, each treated by a separate medical specialist?specialist?

Sub-clinical undiagnosed Sub-clinical undiagnosed multiple conditionsmultiple conditions

• Multiple medical conditions may each be at Multiple medical conditions may each be at an early stage and difficult to diagnose.an early stage and difficult to diagnose.

• Multiple medical conditions may be at a Multiple medical conditions may be at a more advanced stage in people who don’t more advanced stage in people who don’t attend doctors regularlyattend doctors regularly

• For example:For example:– Reduced vision can be overcome, to some extent Reduced vision can be overcome, to some extent

by scanning the road ahead and to the sides by by scanning the road ahead and to the sides by moving the head from side to sidemoving the head from side to side

– But if the patient has arthritic conditions and But if the patient has arthritic conditions and cannot move the neck, what then?cannot move the neck, what then?

PolypharmacyPolypharmacy

• People with multiple diagnosed People with multiple diagnosed medical conditions may be taking medical conditions may be taking medicines, prescribed by different medicines, prescribed by different medical specialists.medical specialists.

• Medical specialists are not good at Medical specialists are not good at reporting to each other or to GPs reporting to each other or to GPs about a shared patient.about a shared patient.

• Who knows about ALL the medicines Who knows about ALL the medicines that one patient takes? that one patient takes?

What to do about What to do about increasing numbers of increasing numbers of

older drivers? older drivers? • Require all persons over age ___ (60?) to Require all persons over age ___ (60?) to

have a driving or medical test before they have a driving or medical test before they can renew their licencecan renew their licence– The problem will be an increasing demand for The problem will be an increasing demand for

alternative transport services; more time off work alternative transport services; more time off work by family members to transport older relativesby family members to transport older relatives

– Older drivers may go “doctor shopping” for a Older drivers may go “doctor shopping” for a health professional who will say they are OK to health professional who will say they are OK to drive.drive.• Danger of corruptionDanger of corruption• Danger that people won’t go to see doctors out of fear of Danger that people won’t go to see doctors out of fear of

losing licencelosing licence

Older Driver Testing in Older Driver Testing in AustraliaAustralia

• The 8 different driver licence authorities in Australia The 8 different driver licence authorities in Australia (States & Territories) have different rules about testing (States & Territories) have different rules about testing older drivers to determine if they are still able to drive.older drivers to determine if they are still able to drive.

• Only the State of Victoria does not impose any tests on Only the State of Victoria does not impose any tests on drivers because of their age. Victoria relies on self-drivers because of their age. Victoria relies on self-reporting, the reporting of family, Police and Health reporting, the reporting of family, Police and Health Professionals instead.Professionals instead.

• Langford and his colleagues found, in 2004, that older Langford and his colleagues found, in 2004, that older drivers in Victoria were no more likely to be involved in drivers in Victoria were no more likely to be involved in casualty crashes than older drivers in States & casualty crashes than older drivers in States & Territories that require mandatory, age-based testing. Territories that require mandatory, age-based testing. In some States & Territories the older driver crash rate In some States & Territories the older driver crash rate was higher than Victoria, where there are no was higher than Victoria, where there are no mandatory tests.mandatory tests.

Langford, J, Fitzharris, M, Koppel, S. & Newstead, S (2004), “Langford, J, Fitzharris, M, Koppel, S. & Newstead, S (2004), “ Effectiveness of Mandatory License Testing for Older Drivers in Reducing Cras Effectiveness of Mandatory License Testing for Older Drivers in Reducing Cras h Risk Among Urban Older Australian Drivers h Risk Among Urban Older Australian Drivers”, ”, Traffic Injury PreventionTraffic Injury Prevention, , Volume 5:4 pp 326 - 335Volume 5:4 pp 326 - 335

Why doesn’t Older Driver Why doesn’t Older Driver Testing work?Testing work?

• No one is quite sure.No one is quite sure.• Some possible explanations suggested Some possible explanations suggested

by researchers:by researchers:– If doctors are legally required to report, If doctors are legally required to report,

then people simply don’t go to the doctor – then people simply don’t go to the doctor – not good for national health!not good for national health!

– If licence tests are required when you If licence tests are required when you reach a set age, less confident drivers reach a set age, less confident drivers simply don’t attempt to renew their licence simply don’t attempt to renew their licence – only the determined and those – only the determined and those without without insightinsight attempt to renew their licences. attempt to renew their licences.

A Possible AnswerA Possible Answer• Education of older drivers and their families and friendsEducation of older drivers and their families and friends• Continuing medical education of health practitioners to Continuing medical education of health practitioners to

alert them to additional responsibilities in an ageing – alert them to additional responsibilities in an ageing – and driving – population (this includes optometrists).and driving – population (this includes optometrists).

• A requirement for older drivers to report health A requirement for older drivers to report health conditions to JPJ by way of a legal declarationconditions to JPJ by way of a legal declaration

• Enabling families, friends, health professionals and Enabling families, friends, health professionals and maybe Police to report older drivers whose driving is maybe Police to report older drivers whose driving is dangerousdangerous– Legally protect anonymity of those reporting and protect them Legally protect anonymity of those reporting and protect them

from all possible legal action.from all possible legal action.

• The answer is not simple because older people will be The answer is not simple because older people will be at greater risk of serious injury if they are walking than at greater risk of serious injury if they are walking than if they are driving!if they are driving!

Finally …Finally …

• The Malaysian answer to this emerging The Malaysian answer to this emerging problem of ageing drivers must be a problem of ageing drivers must be a Malaysian answer, carefully tuned to Malaysian answer, carefully tuned to Malaysian culture and expectations.Malaysian culture and expectations.

• But it must also act to keep older people, and But it must also act to keep older people, and the rest of the community safe.the rest of the community safe.

• Asking appropriate questions is a logical first Asking appropriate questions is a logical first stepstep– You might like to consider Malaysian answers to You might like to consider Malaysian answers to

the questions at the end of each Chapter in the the questions at the end of each Chapter in the Discussion Paper of the Victorian Parliament’s Discussion Paper of the Victorian Parliament’s Road Safety Committee Discussion Paper.Road Safety Committee Discussion Paper.Hull, M (principal author) (2000), Improving Safety for Older Road Users, Road Safety

Committee, Parliament of Victoria, Melbourne

older drivers

Documents

older driversto

ndfbp malaysia

malaysian income distribution

older driversa perspective

policy response

economic power

urban malaysiawong chay

ageing population