INJURY PREVENTION/NHTSA NOTES

National Highway Traffic Safety Administration (NHTSA) NotesCommentator

Christopher Kahn, MD, MPH

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Training for Healthy Older Drivers1

[National Highway Traffic Safety Administration.Training for healthy older drivers. Ann Emerg Med.2013;62:419-420.]

Recently, a growing number of programs have beendeveloped to maintain and promote greater mobility for olderAmericans. This project examined the effectiveness of 4 types oftraining techniques designed to improve the drivingperformance of normally aging adults. Each technique issuitable for a broad cross-section of the healthy older driverpopulation. The study did not include training programsdesigned for a specific clinical condition; for example,rehabilitation regimens for patients after stroke.

The research team measured training effectiveness bycomparing the on-road performance of drivers aged 65 yearsand older in each treatment group with that of a control group(that received a neutral intervention) before and immediatelyafter training, and again after a 3-month delay. Thus, studyresults reflected planned comparisons between each treatmentgroup and the control group but did not compare treatmentgroups to one another.

The training activities examined in this study included (1)classroom driver education delivered in a group setting,supplemented by an hour of one-on-one, behind-the-wheelinstruction; (2) computer-based exercises designed to improvespeed of visual information processing and divided attention;(3) occupational therapy–based exercises to improve visual skillsand attention; and (4) physical conditioning to improvestrength, flexibility, and movement.

Hospital staff or project consultants provided training toeach group, which included 8 hours of direct contact with studyparticipants. The providers identified driver improvement as anexplicit goal of participation in the training activities. Thecontrol group participants received 8 hours of relaxationtraining or health and wellness counseling that was notassociated with driver improvement.

Researchers randomly assigned 20 volunteer older driversrecruited at the Roger C. Peace Rehabilitation Hospital inGreenville, SC, to each training group, as well as to the controlgroup, for a total of 100 participants. Attrition during thecourse of the study reduced the number who finished theposttreatment assessments and were included in analyses of

training effectiveness to between 15 and 17 participants per a

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roup. The mean age across groups ranged from 71.5 to 74.1ears.

A certified driver rehabilitation specialist (CDRS), who waslind to the type of training each participant received,onducted the on-road performance evaluations. The CDRSeveloped different routes of equal driving difficulty to avoidaving participants become familiar with the route acrossuccessive assessments: before, immediately after, and 3 monthsfter training.

The CDRS scored participants’ competence on 33 subscalesomprising tactical and strategic domains of drivingerformance. Strategic skills include attending to central anderipheral visual cues, planning, following directions, andnowing the rules of the road. Tactical skills include managingpeed and lane position, anticipating hazards, and navigating inmanner appropriate to traffic laws, as well as prevailing trafficnd environmental conditions.

Scores were based on an ordinal scale from 0 to 4. Ratingsndicated how often a driver demonstrated a particular skill orehavior in relation to the number of opportunities toemonstrate it during each on-road assessment. Because theDRS evaluated participants on the road, normal variability in

raffic conditions produced different numbers of opportunitiesrom person to person and from drive to drive for the samearticipant.

The CDRS provided feedback to study participants aboutheir driving only after the delayed posttreatment assessment,ot after the baseline evaluation or immediate posttreatmentvaluation. The CDRS also talked to participants about theiriews of the validity and utility of the driving evaluation andraining activities they took part in during the study.

For the few drivers who demonstrated some deficiency onhe baseline assessment, 2 training groups achieved significantlymproved scores on their posttreatment evaluation relative tohe control group (P�.05). These were the occupationalherapy–based exercises group and the classroom plus behind-he-wheel training group. However, these gains were notetained at the 3-month evaluation.

The occupational therapy–based visual skills training, whichhowed the strongest gains relative to the control group, pointso an opportunity for professionals without the relatively scarceDRS credential to enhance seniors’ safety behind the wheel

nd merits further research because they could be implementedn many types of clinical setting.

Results for the classroom plus behind-the-wheel trainingroduced more limited but still significant performance gains,

nd more study participants perceived practical value in this

Annals of Emergency Medicine 419

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NHTSA Notes

intervention than in any other. The other 2 treatments alsoshowed potential benefits; physical conditioning holds thepromise of health and wellness benefits well beyond improveddriving performance, and computer-based training can becompleted at home at the driver’s own pace, providing aconvenient and relatively inexpensive training option.

The generalizability of these findings is limited by therelatively small sample size and to the restriction in range ofdriving skill levels for all of the healthy older driver groups onthe baseline assessment. In addition, the training protocols onlyensured that participants were engaged in the respective trainingactivities for an equal amount of time across groups. The studydid not document performance on the training tasks themselvesor analyze performance differences on these tasks in relation tothe on-road measures of effectiveness. Of concern is theapparent decay of the training effects. Consumers who invest 8hours in a training program, perhaps at substantial cost, couldreasonably expect a benefit that lasts not months but years.Finally, the CDRS rating system, based on ordinal measures,limited the application of inferential statistical techniques fordata analysis, and its focus on isolated behaviors does notnecessarily provide a gauge of how well a driver integrates thesevarious component skills for successful whole-task performance.

Copies of the 68-page Traffic Tech, Training for HealthyOlder Drivers, can be obtained from the National HighwayTraffic Safety Administration, 1200 New Jersey Avenue, SE,Washington, DC 20590 or downloaded from the NHTSA Website at http://www.nhtsa.gov/Driving�Safety/Older�Drivers.

Section editors: Christopher Kahn, MD, MPH; Todd Thoma,MD; Catherine S. Gotschall, ScD

Author affiliations: From the Department of EmergencyMedicine, University of California, San Diego, San Diego, CA.

http://dx.doi.org/10.1016/j.annemergmed.2013.07.496

REFERENCE1. National Highway Traffic Safety Administration. Training for Healthy

Older Drivers. National Highway Traffic Safety Administration:Washington, DC; 2013. Report No. DOT HS 811 771. Available at:http://www.nhtsa.gov/Driving�Safety/Older�Drivers. AccessedJuly 14, 2013.

COMMENTARY: DRIVING INTO THESUNSET

[Kahn C. Commentary: driving into the sunset. AnnEmerg Med. 2013;62:420-422.]

One of the conversations I always hate having with a patientis the “Maybe you should not be driving anymore” discussion. Igrew up in the greater Los Angeles area, where driving wasalways taken for granted. Walking a quarter mile to the cornerstore was something you only did if you were not old enough

for a license or (gasp!) were somehow of age yet bereft of this s

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rivilege. The band Missing Persons may have summed it upest more than 3 decades ago: “Nobody walks in L.A.”

Of course, it is not just Southern Californians who rely onheir cars for transportation. Readers of the related literature wille quite familiar with the theme that being able to drive is notust a source of pride but also a bulwark of independence for aignificant number of persons across all walks of life and all areasf the nation. Telling patients that they should give this up caneel a little bit like suggesting to them that you should cut offheir legs. Unfortunately, the evidence is mounting that thisiscussion is increasingly becoming an important part ofrotecting the health of our senior citizens and ourommunities.

The recent report by the National Highway Traffic Safetydministration (NHTSA) called Training for Healthy Olderrivers1 helps bring to mind some of the several issues that arisehen discussing driver safety in the older driving population.irst, of course, is who is considered an “older” driver? At theisk of offending my mother, most studies focus on drivers aged5 years or older. Perhaps more importantly, this report discusseshe effect (both immediately and 3 months postintervention) of 4ifferent training techniques designed to help rehabilitate and

mprove the driving skills of older drivers. The resultshemselves are unlikely to change our practice in the emergencyepartment. However, this report raises the obvious question:hy do we need this? What is it about older drivers that makes

hem worthy of special targeting for skills improvement?There is no question that incidents involving older drivers

end to capture the attention of the news media and theommunity. From the infamous Santa Monica farmers’ marketrash 10 years ago to the centenarian driver who crashed into 11hildren at an elementary school last year, news reportsrequently cite incidents (both major and minor) involvinglderly drivers.2,3 Although this is likely related to reportingias, the available data support a statement that fatal crash rateser miles traveled tend to follow a U-shaped distribution,ottoming out from approximately aged 30 to 69 years andhen trending upward, with a sharp increase by aged 80 years;rivers older than 85 years have the highest fatal crash rates periles traveled of all passenger vehicle drivers in the United

tates (Figure 1).4 Given these data, the questions again arise:hy do older drivers have higher fatal crash rates? Should we be

argeting them for skills improvement?As with many things in life, the answers seem reasonably

lear at first but leave plenty of room for confusion. Majorontributors to decrements in driving skills of older driversppear to include age-related physiologic changes (eg, loss oferipheral vision and other visual changes, slower reactionimes, changes in hearing) and medical issues (eg, cognitivempairment, chronic illnesses that can affect sensory input and

otor skills, polypharmacy).5-8 One confounder is the conceptf frailty; as people age, their likelihood of surviving any givenrash tends to decrease because their injuries tend to be more

evere and their ability to recover decreases as well. There are

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