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Older Drivers

Older Drivers. A Perspective for Malaysian Consideration Michael Hull Research Director Pan Pacific Research Pty Ltd. Objectives. To establish the demographic case for taking prompt action in anticipation of an ageing population.

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Older Drivers

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  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/s2_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/s2_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/s2_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/s2_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 Malaysia’s 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. Why? Motorcycles Cars Derived from official Malaysian statistics by Jenny Oxley, and adapted by me.

  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 physician’s 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 physician’s 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

  21. 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: Alzheimer’s 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/News/Conferencesandevents/asc20071/Abstracts07/Mentalhealth07/ASC2007Speechly.pdf

  23. 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. Alzeimer’s 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 havedementia • 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/News/Conferencesandevents/asc20071/Abstracts07/Mentalhealth07/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/article/alzheimers-scourge-hangs-over-ill-prepared-asia/

  26. Reliable Assessment of Incidence of Alzheimer’s in Malaysia 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 % 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

  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.psychiatry-malaysia.org/article.php?aid=80

  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 don’t 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?

  32. 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 won’t 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 5:4 pp 326 - 335

  34. Why doesn’t 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 don’t go to the doctor – not good for national health! • If licence tests are required when you reach a set age, less confident drivers simply don’t 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!

  36. 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 Parliament’s Road Safety Committee Discussion Paper. Hull, M (principal author) (2000), Improving Safety for Older Road Users, Road Safety Committee, Parliament of Victoria, Melbourne

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