1. Promoting Older Driver Safety in Missouri:Education & Outcomes Jacqueline Rogers, Missouri Department of Transportation Tom Meuser, PhD, University of Missouri – St. Louis David Carr, MD, Washington University School of Medicine

2. Agenda • MODOT Division of Highway Safety (Rogers) • Missouri Statistics • Gathering Stakeholders from Five Key Communities • Education Blitz • Educating Driver Examiners, Troopers, & Police Officers (Meuser) • HB-1536 Evaluation & Enhancing DOR Medical Review • Older Driver Safety Pamphlet for Missouri (Carr) • Clinical Evaluation, Screening, & Driver Fitness • Questions?

3. Older Drivers Have Fewer Crashes Crashes per 100,000 drivers (Source NCSA, 2000)

4. Driver Fatality Rate(per 100 million VMT) Fatality Rate Driver Age Group Source: FARS 2001 and NHTSA 2001

5. US Population By Segment (Squaring the U.S. Population Pyramid 1950-2030) Age 85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 1980 1950 2030 2000 (227,658,000) (304,807,000) (150,216,000) (267,955,000)

6. What’s Happening in Missouri?

7. Missouri Traffic Crashes • 3,186 disabling injuries involving an older driver • 42% (1,349) were the older driver • 543 fatalities involving an older driver • 60% (328) were the older driver • 16% of the fatalities involve an older driver

8. Types of Crashes

9. Develop Statewide Program GOALS: • Reduce deaths and injuries related to traffic crashes involving older drivers • Keep people driving safely as long as we can • Participate in National Demonstration Project • Develop Statewide Network of Partners

10. Model for Older Driver Program Activities Public Public Social Services Medical LawEnforcement Licensing Public Public

11. National Demonstration Project • Focus on Five Communities • Columbia, Springfield, Cape Girardeau, St. Louis, and KC • Implement Five Core Programs • DriveWell • AMA – Physician’s Module • Roadwise Review • CarFit • Law Enforcement Module

12. Four hour training • Discuss issues related to older driver safety and community mobility • Toolkit that provides resources for local use • Trained 95 people

13. Assessing & Counseling the Older Driver • Washington University provided Training • Trained 212 people

14. Roadwise Review • Worked with AAA • Distributed approximately 125 copies of the self-assessment tool statewide • Can be accessed on the web at www.aaa.com

15. CarFit Program • Community events • Fit people to their vehicles • Trained 75 people

16. Law Enforcement Module • Trained approximately 500 people • St. Louis County & Municipal Police Academy • Law Enforcement Traffic Safety Advisory Council’s Annual Conference • Missouri State Highway Patrol, Driver Examiners Training

17. Other Accomplishments • Created a display • Created print ads • Created a brochure • Database of over 200 contacts • Received a variety of media coverage across the state • Provided an article in the TRB Newsletter • Held statewide older driver workshops • MoDOT/FHWA sponsored older driver workshop for engineers

18. Tom Meuser, PhD University of Missouri – St. Louis

19. Minority: frail, medically at risk, impaired, dependent, in need of assistance, unfit behind the wheel?… Majority: aware, engaged, active, fit, functional, responsible… “Two” Older Drivers A focus on functional health status recognizes that we age differently on an individual level.

20. Medical Conditions & Crash Risk Many of these conditions are more prevalent in older adults.

21. Medical Fitness to Drive • Medical Fitness to Drive (MFD) is applicable to all age groups, but is especially relevant for older adults. • A number of studies indicate that certain age-related medical conditions may impair driving ability and thereby elevate crash risk. • The management and reporting of MFD concerns is a voluntary process in most states. • The first responsibility for addressing MFD concerns resides with the individual driver. Many States require drivers to notify the DMV of health conditions that may impair driving safety. • Most States allow health professionals, law enforcement personnel, and others to report potentially unfit drivers for re-testing and possible license revocation. A few, such as California, mandate such reporting where dementia and other conditions are concerned.

22. Act to Maximize Ability Act to Promote Driving Retirement & Initiate Mobility Counseling Driving & Mobility Continuum:Drawing the Fitness Line Mild or Reversible Serious & Permanent

23. St. Louis Team • Investigators: • Tom Meuser, PhD, UM – St. Louis (formerly with WU) • Dave Carr, MD, Washington University • Gudmundur Ulfarsson, PhD, University of Iceland (formerly with WU) • Pat Niewoehner, OTR/L, CDRS, St. Louis VA Medical Center • Peggy Barco, OTR/L, DRS, Washington University & Center for Head Injury Services • Marla Berg-Weger, PhD, Saint Louis University • Past Student & Other Assistants: • Joon-Ki Kim, Washington University • Tom Epplin-Zapf, Washington University • Matthew Minn, Southern Illinois University • Jessica Lester, Washington University • Jami Croston, MSOT, Washington University • Katie MacLean, MSW, Alzheimer’s Association, St. Louis Chapter • Emily Kissel, Washington University • Mimi Hilburg & Annie Harmon, University of Missouri – St. Louis • Donna Keller, former part-time on-site data assistant And many others…

24. Active in Driving Education & Research • Research • Beliefs of Stakeholders • Validation of Training Curricula • Dementia & Driver Fitness • Stroke & Driver Fitness • Older Driver Evaluation & Mobility Clinic with On-Road Testing • Education • Dementia & Driving Workshops • Highway Patrol Curriculum • Missouri Senior Driver Pamplet • AMA Older Drivers Project • CarFit, DriveWell • Mobility Counseling Project • Local, Regional & National Talks

25. Education

26. Health, Functional Status & Older Driver Safety A Curriculum for State Highway Patrol Examiners & Officers

27. Learning Objectives At the end, you will understand: • Older driver safety statistics in Missouri. • How age-related changes in health and functional status may impair driving ability and increase crash risk. • An approach to observing and describing such changes in older drivers. • How to document such changes in support of a citation and the license review process. • Complete pre-test questionnaire now, if required, and hand it in to the presenter. Thank you!

28. Case Example – Traffic Stop • Mr. Jim Greene, age 73, was pulled over by State Trooper for weaving and driving through a stop sign. • Mr. Greene has lived in Florissant, Missouri, for just the past two years, after moving here from Madison, Wisconsin, to live closer to his children. • He wears glasses, but does not report a vision problem. • He seems mildly confused, forgetful and rather irritated/embarrassed to have been stopped.

30. Form 4319 (page 1)

31. Form 4319 (page 2)

32. Case Example – Driving Skills Test • Mrs. Mary Brown, age 74, was cited by the Director of Revenue to take a Driver Skills Test. • She is a retired factory worker and lifelong resident of Florissant, MO. • She reports a minor problem with her distance vision (“I think I need new glasses, but I still see OK”) • She is quite anxious about being tested, but tries her best to be cooperative during the examination.

34. Narrative on Form 232 Mrs. Brown was a pleasant, willing participant in the driving skills test. She appeared moderately anxious, as evidenced by rapid breathing, high pitched tone of voice, and many comments on her performance. She wore glasses, but appeared to have difficulty seeing both near and far objects. For example, she misread her driver license number and she could not read signs on nearby buildings. She reported being at the Hazelwood test facility, and she stated her name, address and phone number without difficulty. She gave the correct date and time. She walked to her vehicle, entered it, and fastened her seatbelt properly. She pointed correctly to controls named by the Examiner, and she named common objects giving incorrect names initially, but self-corrected later. During testing, she frequently drove too close to the curb and parked cars. She appeared confused when asked to parallel park between cones, and asked three times to explain what I wanted her to do. I discontinued this maneuver after a few minutes. At the last intersection on the course, she appeared not to see the stop sign and continued driving until I instructed her to stop. She failed due to excessive points.

35. Missouri’s Voluntary Reporting Law • Passed by the MO Legislature in 1998 following a significant lobbying effort by CARD, WU, Alzheimer’s Assoc, & other organizations. • Not age or disease specific. • Intended to promote reporting of impaired drivers by health professionals, particularly physicians. • Forms allow for a range of health and addiction conditions to be reported. • Similar to voluntary laws in 45 other states. • Has never been formally evaluated.

36. Driver Condition ReportDownloadable from http://dor.mo.gov/mvdl/drivers/forms/

37. Project Details • Private University (x2+) – Private Foundation – State Government Collaboration • Characterize the functional impact and efficacy of HB-1536 for the medically impaired older driver in Missouri • Goal to capture data for all reported individuals, aged 50+, reported between 2001 – 2005. • A clear understanding of how the Missouri law works and its efficacy will have broad implications for state policy, traffic safety, public education, and the well-being of medically impaired older drivers. • Our project will also provide a basis for future inter-state comparisons and national policymaking.

38. Missouri Reporting Process • Once reported, the older adult must negotiate each step (hurdle) in the process to retain a valid license. • Failure to submit a physician statement (Hurdle 1) leads to license revocation in all cases.

39. What did we expect coming into this? • Most reported drivers would be evaluated by a physician. • Half or more would be referred on and complete on-road testing. • A quarter or more would pass and retain a valid license to drive. • A quarter or so would have a positive crash history. • A quarter or more would have a positive citation history. • A substantial number would show evidence of ongoing driving subsequent to license revocation.

40. Reporting Trends over Time Why might reports from license office staff be going down?

41. Annual Crash Rates

42. Combined Frequency of Medical Conditions (n= 4,100; cases from which microfilmed documents were reviewed) • Dementia / Cognitive Impairment 45% • Vision Condition 31% • Musculoskeletal / Neuromuscular 28% • Disorders of Consciousness 16% • Cardiac / Cardiovascular 12% • Brain Insult, Tumor or Stroke 10% • Psychiatric Condition 8% • Alcohol / Drug Abuse 3%

43. Summary of Outcomes

44. MODOT-Funded Project2008-2009 • Follow-up project with the Missouri DOR to apply findings from the HB-1536 evaluation effort to improve current forms and system. • Single Form for Reporting from All Stakeholders • Incorporate “best practices” from other States into a new Physician’s Statement (Form 1528) • Enhance education provided to License Office Staffers

45. Issues • States rely significantly on physician input in deciding questions of medical fitness to drive and whether someone should have license restrictions or be de-licensed (permanently or temporarily). • Few physicians are trained to make such determinations, however, and many do not view driving as within their medical purview. • Some States, such as California, provide significant guidance to physicians concerning the medical review process, whereas others provide very little. • The quality of physician input in Missouri has been mixed at best.

46. Physician Statement

47. Best Practices Project • We are in the process of collecting medical review forms and supporting documents from all US States, Canadian Provinces, and from other countries (UK, Australia). • We need to develop a means to rate these forms in terms of the guidance they provide to physicians, their comprehensiveness, ease of use, etc.

48. We will also be improving training provided to license office clerks In Missouri, DMV clerks are encouraged to be on the lookout for impaired drivers and to report those they consider to be a safety risk.

49. David Carr, MD Washington University School of Medicine

50. Disclosures: Carr • Funding Support (Past Year) • National Institute on Aging (NIA) • AAA Foundation Traffic Safety • Missouri Department of Transportation • LongerLife Foundation • Consulting Relationships • American Medical Association (AMA) • ADEPT • SeniorSMART • AAA Foundation Traffic Safety • Speakers Bureau • St. Louis Alzheimer’s Association • Drug Industry Sponsored Trials • Elan • Investment/Stock/Equity: None