Older Drivers

1
Older Drivers

• A Perspective for Malaysian Consideration
• Michael Hull
• Research Director
• Pan Pacific Research Pty Ltd

2
Objectives

• To establish the demographic case for taking
  prompt action in anticipation of an ageing
  population.
• To briefly consider political and social issues
  around older drivers
• To examine dementia as an example of older driver
  health concerns
• To summarise major health concerns around older
  drivers

3
Demographic Change2000 - 2010
4
Demographic Change2020 - 2050
5
Summary of Population Change - Malaysia
Wong Chay Nee, Policy Response for the Aging in
Malaysia, Malaysian Institute of Economic
Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s
2_02.pdf
6
Why Changes in Malaysia?

• Declining fertility
• Falling mortality rates
• Improved health nutrition
• Longer life expectancy

Wong Chay Nee, Policy Response for the Aging in
Malaysia, Malaysian Institute of Economic
Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s
2_02.pdf
7
Move from Rural to Urban - Malaysia
Wong Chay Nee, Policy Response for the Aging in
Malaysia, Malaysian Institute of Economic
Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s
2_02.pdf
8
Growth in Nuclear Family Homes Malaysia
decrease in extended family homes
Adapted from NDFBP Malaysia, Malaysian
Population Family Survey, 1994
9
Quantifying Household Change - Malaysia
10
Income Growth - Malaysia
Adapted from Zin, Ragaya, Explaining the Trend
in Malaysian Income Distribution,
www.eadn.org/reports/webfiles/i06.pdf Data after
1995 are my regressions based on above data 1970
1995.
11
Malaysia Education Levels of Older Persons 1970
2020 (percentage)

• Source Department of Statistics, Malaysia (1998).

12
Recognition of Coming Change Malaysia
Wong Chay Nee, Policy Response for the Aging In
Malaysia, Malaysian Institute of Economic
Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s
2_02.pdf
13
Summary of Expected Change

• Increasing urbanisation of older Malaysians
• Decreasing numbers of older Malaysians living
  with extended family
• Increasing income of older Malaysians
• Increasing education of older Malaysians
• Increasing proportion of older Malaysians

14
Implications for Malaysias Future

• All these things suggest the same changes seen
  elsewhere
• Increasing demand for personal mobility
• Increasing capacity to pay for personal mobility
• Increasing political and economic power to get
  what they want
• Additionally an increasing number of ageing
  Malaysians who have been driving for many years
  will not want to stop driving

15
The Bad NewsAustralia

• There is an increased serious injury crash risk
  amongst older drivers, starting from about age
  60.
• The black line shows the unadjusted crash risk
• The red line shows the crash risk adjusted for
  vulnerabity Older drivers are more frail and
  therefore more easily injured
• Research suggests that a significant proportion
  of the remaining risk after allowing for frailty
  rests from older people driving more frequently
  on local roads with many intersections, mostly
  without 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
16
The Bad NewsMalaysia
The blue line represents fatal and serious
injuries to drivers in car crashes The pink line
represents fatal and serious injuries to riders
of motorcycles. Only the motorcycle curve shows
the U-shaped curve seen in Australia.
Motorcycles
Cars
Derived from official Malaysian statistics by
Jenny Oxley, and adapted by me.

• Why?

17
Time differences in Vehicle Ownership
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.
Australia
Malaysia
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. Malaysian Source (1999)
Malaysian Roads General Information, Malaysian
Road Transport Dept Australian Source (number of
cars only) Australian Bureau of Statistics
(2005), Year Book of Australia, ABS Canberra
18
Normal Changes in Ageing People

• Slowing reaction time, taking longer to make
  complex decisions.
• Difficulty with multi-tasking and selective
  attention.
• Less accurate in judging speed and distance.
• Pupils become smaller and slower to adapt to
  sudden changes in light intensity, such as
  headlights.
• Driving issues correlate with measures of
  frailty, falls, and dementia.
• However
• older drivers do tend to curb night driving
• often choose not to drive at peak traffic
  periods
• often choose not to drive in rain.
• With the great heterogeneity in older populations
  in health and function, age should not be the
  determining factor for driver licensing.
• Driving is already considered one of the most
  dangerous activities at any age. So when is the
  risk unacceptable? This is a societal and
  political question

Odenheimer G (2006),. Driver safety in older
adults. The physicians role in assessing driving
capabilities of older patients. Geriatrics
61(Oct)14-21.
19
Increasing Morbidity in Older People

• INCREASE IN DISEASES AND MEDICATIONS.
• At least 30 over age 75 have significant vision
  impairment
• 50 over age 75 have significant hearing
  impairment.
• Nearly all elderly have some degenerative joint
  disease.
• Because of the increase in disease, the average
  number of medications also rises with age,
  further increasing the likelihood for negative
  effects on driving safety.
• INCREASED FRAGILITY AND MORTALITY.
• crash rates increase with age, but mortality
  rates are even more impressive. Drivers over age
  85 are nine times more likely to die in a crash
  than drivers age 25 to 69
• Even when controlling for crash severity, older
  drivers are four times more likely to die than a
  20-year-old driver.
• INADEQUATE COMPENSATORY BEHAVIORS.
• Crash and mortality statistics become more
  significant when noting that older drivers tend
  to drive less, slower, and avoid high-risk
  situations (eg, driving at night, in bad weather,
  and on unfamiliar roads).

Odenheimer G (2006),. Driver safety in older
adults. The physicians role in assessing driving
capabilities of older patients. Geriatrics
61(Oct)14-21.
20
Increasing Life Expectancy

• With increasing life expectancy
• Normal changes
• Normal changes accompanying ageing will become
  more common
• As people live to be older, normal changes will
  become more severe
• Diseases associated with ageing
• There will become more common
• As people live to be older
• these diseases will become more severe
• These diseases will require more medical
  attention medication

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How Safe will Older Malaysian Drivers Be?

• Increasing life expectancy increases
• the probability of multiple medical conditions
• The probability of multiple medications

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.

22
Example Alzheimers First Problems Noticed

• Confusion with everyday tasks
• Cooking/housekeeping
• Forgetting people/names
• Repetitive behaviour or speech
• Losing things or getting lost
• Problems managing money
• Personality or behaviour changes
• INSIGHT Patients may be unaware that they have
  these symptoms and not 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/New
s/Conferencesandevents/asc20071/Abstracts07/Mental
health07/ASC2007Speechly.pdf
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Alzheimers Anecdotal Driving Issues

• Gets lost whilst driving. Stops in middle of
  busy road to work out where to go.
• Talking through a driving assessment Patient
  says, there is a Stop Sign ahead. That means I
  have to stop and look both ways before driving
  through. Then drives through without stopping.
• Patient with no previous convictions, drives
  unroadworthy car to shops, twice in one day,
  despite having had licence cancelled for health
  reasons.

24
Alzeimers DiseaseThe Australian Experience

• Time to diagnosis
• Retrospective 2 to 2.5 years
• Prospective up to 5 years
• In one study, GPs referred only 23 of those they
  suspected might have dementia
• On average, carers and family members delayed 2
  2.5 years before 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/New
s/Conferencesandevents/asc20071/Abstracts07/Mental
health07/ASC2007Speechly.pdf
25
AD - A Malaysian Problem?

• In Malaysia an estimated 50,000 people suffer
  from dementia Very few private nursing homes are
  dedicated to the care of the AD sufferer although
  some homes will accept a few AD sufferers if they
  are not behaviourally challenged said Philip
  Poi head of geriatric medicine at Universiti
  Malaya
• Malaysia is starting to appreciate there is a
  problem but currently caregiving is provided
  mainly by the informal carers such as the spouse
  or child
• China has up to eight million dementia patients
  but very few hospitals in the country have
  independent dementia units By 2030 one in every
  four Chinese will be over 60.

Source The Malaysian Insider, 3 September 2010
http//www.themalaysianinsider.com/features/articl
e/alzheimers-scourge-hangs-over-ill-prepared-asia/
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Reliable Assessment of Incidence of Alzheimers
in Malaysia
Reliable data is not readily available because of
the relative recent concern about Alzheimers
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

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, 2159-162
27
What Malaysian experts say

• Although dementia has always been somewhat
  common, it has become even more common among the
  elderly in recent history. It is not clear if
  this increased frequency of dementia reflects a
  greater awareness of the symptoms, or if people
  simply are living longer and thus are more likely
  to develop dementia in their older age.
  Dementia caused by nervous system disease,
  especially Alzheimer's disease, is increasing in
  frequency more than most other types of dementia.
  Some researchers suspect that as many as half of
  all people over 80 years old develop Alzheimer's
  disease.

Source Malaysian Psychiatric Association,
Statement on Dementia, July 2006 http//www.psychi
atry-malaysia.org/article.php?aid80
28
Health conditions a concern

• The elderly, in both Australia and Malaysia,
  often go to a health professional as a last
  resort.
• One result is that health conditions that could
  be treated are not diagnosed until late in the
  progression of the disease.
• In Australia, and probably in Malaysia, this is
  especially true for men.
• Unless family and friends speak to older people
  about their driving, they may not be aware of the
  danger they create for other road users

29
Multiple conditions

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

30
Sub-clinical undiagnosed multiple conditions

• Multiple medical conditions may each be at an
  early stage and difficult to diagnose.
• Multiple medical conditions may be at a more
  advanced stage in people who dont attend doctors
  regularly
• For example
• Reduced vision can be overcome, to some extent by
  scanning the road ahead and to the sides by
  moving the head from side to side
• But if the patient has arthritic conditions and
  cannot move the neck, what then?

31
Polypharmacy

• People with multiple diagnosed medical conditions
  may be taking medicines, prescribed by different
  medical specialists.
• Medical specialists are not good at reporting to
  each other or to GPs about a shared patient.
• Who knows about ALL the medicines that one
  patient takes?

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What to do about increasing numbers of older
drivers?

• Require all persons over age ___ (60?) to have a
  driving or medical test before they can renew
  their licence
• The problem will be an increasing demand for
  alternative transport services more time off
  work by family members to transport older
  relatives
• Older drivers may go doctor shopping for a
  health professional who will say they are OK to
  drive.
• Danger of corruption
• Danger that people wont go to see doctors out of
  fear of losing licence

33
Older Driver Testing in Australia

• The 8 different driver licence authorities in
  Australia (States Territories) have different
  rules about testing older drivers to determine if
  they are still able to drive.
• Only the State of Victoria does not impose any
  tests on drivers because of their age. Victoria
  relies on self-reporting, the reporting of
  family, Police and Health Professionals instead.
• Langford and his colleagues found, in 2004, that
  older drivers in Victoria were no more likely to
  be involved in casualty crashes than older
  drivers in States Territories that require
  mandatory, age-based testing. In some States
  Territories the older driver crash rate was
  higher than Victoria, where there are no
  mandatory tests.
• Langford, J, Fitzharris, M, Koppel, S.
  Newstead, S (2004), Effectiveness of Mandatory
  License Testing for Older Drivers in Reducing
  Crash Risk Among Urban Older Australian Drivers,
  Traffic Injury Prevention, Volume 54 pp 326 -
  335

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Why doesnt Older Driver Testing work?

• No one is quite sure.
• Some possible explanations suggested by
  researchers
• If doctors are legally required to report, then
  people simply dont go to the doctor not good
  for national health!
• If licence tests are required when you reach a
  set age, less confident drivers simply dont
  attempt to renew their licence only the
  determined and those without insight attempt to
  renew their licences.

35
A Possible Answer

• Education of older drivers and their families and
  friends
• Continuing medical education of health
  practitioners to alert them to additional
  responsibilities in an ageing and driving
  population (this includes optometrists).
• A requirement for older drivers to report health
  conditions to JPJ by way of a legal declaration
• Enabling families, friends, health professionals
  and maybe Police to report older drivers whose
  driving is dangerous
• Legally protect anonymity of those reporting and
  protect them from all possible legal action.
• The answer is not simple because older people
  will be at greater risk of serious injury if they
  are walking than if they are driving!

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Finally

• The Malaysian answer to this emerging problem of
  ageing drivers must be a Malaysian answer,
  carefully tuned to Malaysian culture and
  expectations.
• But it must also act to keep older people, and
  the rest of the community safe.
• Asking appropriate questions is a logical first
  step
• You might like to consider Malaysian answers to
  the questions at the end of each Chapter in the
  Discussion Paper of the Victorian Parliaments
  Road Safety Committee Discussion Paper.

Hull, M (principal author) (2000), Improving
Safety for Older Road Users, Road Safety
Committee, Parliament of Victoria, Melbourne