Occupational Therapy and Driving and Community Mobility for Older Adults

The 2005 White House Conference on Aging identified mobility and transportation options for older Americans as a critical priority. If the Older Americans Act (S. 1028, 113th Congress) is reauthorized and a conference on aging is held in 2015, transportation will most likely be a top issue again. Twelve million baby boomers will already have turned 65 by 2015, with 66 million more to follow. This generation, which has a rich history of social activism, will influence public, social, and economic policies to ensure their ability to drive and engage in the civic and social life of their communities.

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Kathleen Golisz, OTD, OTR/L

Kathleen Golisz, OTD, OTR/L

A state-granted driver’s license is so much more than a photo identification card granting the holder the privilege of driving a motor vehicle to engage in life tasks in the community. In the older adult population, the driver’s license symbolizes functional and social competency, and the task of driving is linked to independence, feelings of freedom, and the ability to participate in meaningful occupations and social roles closely linked to self-perceived health and well-being (Shope, 2003; Vrkljan & Polgar, 2006). Driving a personal vehicle is part of community mobility and an instrumental activity of daily living (American Occupational Therapy Association [AOTA], 2014c). Often referred to as an enabling occupation, driving supports older adults’ ability to obtain the goods and access the services needed to support healthy aging (Stav & Lieberman, 2008).

Driving cessation will likely be an issue people need to address if they are fortunate enough to live a long life. The 85-and-older population is projected to increase from 5.7 million in 2011 to 14.1 million in 2040; many of these people will continue to drive personal vehicles (Administration on Aging [AoA], 2011). Today, people reaching age 65 have an average life expectancy of an additional 19.2 yr (20.4 yr for women and 17.8 yr for men; AoA, 2011). Older women typically have a 10-yr period when they are dependent on forms of transportation other than driving a personal vehicle; men typically have 6 yr (Foley, Heimovitz, Guralnik, & Brock, 2002). A large percentage of the anticipated growth in older drivers over the next 20–30 yr will consist of female drivers. Women from the boomer generation are more likely to drive than their mothers, began driving at a younger age, and are more independent and self-sufficient in meeting their travel needs (Burkhardt, Berger, & McGavock, 1996).

The baby boomer generation is more likely to age in place in suburbia because they will be working longer as a result of older Social Security retirement ages (D’Ambrosio, Coughlin, Pratt, & Mohyde, 2012). The ideal vision of aging adults moving to a planned retirement community with a structured public transportation system that could decrease their need to drive a private automobile may be only that—a vision. For the majority of the older driver population, alternatives such as a comprehensive public transportation system may not be viable because these options do not exist in their rural and suburban communities (Houser, 2005). Urban areas have a greater selection of alternative transportation options; however, publicly funded transportation is often focused on the needs of the paid workforce and does not meet the destination and timetable preferences and requirements of older adults (Liddle, McKenna, & Broome, 2004).

Communities across the United States are addressing the issue of balancing older adults’ driving privileges with public safety. Various levels of government, along with professionals from health care, social services, education, business, and law enforcement, are collaborating to meet the community mobility needs of older adults. The role of occupational therapists in the area of driving rehabilitation and community mobility is recognized by these public–private collaborations, and occupational therapists are sought to serve on community coalitions. For example, in several counties in New York, occupational therapists serve on Older Driver Family Assistance Networks, hosted through regional county Departments of Senior Programs and Services. These coalitions educate older adults and their caregivers about driving safety, offer information on driving assessment and rehabilitation services, host CarFit events, train law enforcement officers to recognize medically at-risk drivers, encourage regional physicians and health care providers to standardly ask clients about driving skills and screen for conditions potentially affecting driving, advocate for legislative changes to support reporting of medically at-risk drivers, and foster development of both public and private alternative transportation options for people who have “retired” from driving. In collaboration with these coalitions, occupational therapy students have completed health promotion projects through CarFit events and community presentations during National Older Driver Safety Week.

As a profession, occupational therapy must expand the knowledge and capacity of both occupational therapy generalists and driver rehabilitation specialists to remain in the forefront of driving and community mobility services (AOTA, 2010a). Accredited occupational therapy programs are required to ensure graduates are proficient in providing “recommendations and training in techniques to enhance community mobility, including public transportation, community access, and issues related to driver rehabilitation” (Standard B.5.13; AOTA, 2014a). AOTA offers Specialty Certification in Driving and Community Mobility, yet in January 2014 only four occupational therapists and one occupational therapy assistant were certified (AOTA, 2014b). Approximately 200 of the 350 Association for Driving Rehabilitation Specialists’ (ADED) certified driving rehabilitation specialists are occupational therapists; however, not every state has an occupational therapist certified in driving rehabilitation (ADED, 2014). Professional toolkits from AOTA (available at http://www.aota.org/older-driver), along with training programs, continuing education, and strategies from both AOTA and partner organizations (e.g., AAA, AARP, National Highway Traffic Safety Administration) can assist therapists in addressing the contextual issues (i.e., fiscal support, infrastructure, physical environment, institutional culture) that may pose barriers to developing driver rehabilitation programs (Stav, Snider Weidley, & Love, 2011).

Our clients’ roles as drivers need to be considered in all areas of practice. General-practice occupational therapists have skills and knowledge to identify potentially at-risk drivers and engage in a clinical reasoning process to determine occupational therapy services for community mobility and when a referral to a driver specialist is warranted (Dickerson, Reistetter, Schold Davis, & Monahan, 2011). Occupational therapists providing comprehensive driving evaluations typically use a combination of clinical and performance-based simulated or real-world behind-the-wheel driving assessments. In this special issue of the American Journal of Occupational Therapy, Dickerson, Meuel, Ridenour, and Cooper (2014) report that no single assessment exists that predicts behind-the-wheel performance or when a driver should stop driving, although several assessments have significant research supporting their use in the decision regarding driving status. To make recommendations, most driver rehabilitation specialists use a combination of tools or a clinical driving battery in addition to a behind-the-wheel assessment of driving performance.

Academic institutions across the country with occupational therapists as research project coordinators or team members have generated evidence that can inform our practice with older drivers. In a systematic review of interventions affecting driving ability, performance, and safety of older adults, Golisz (2014) notes that the evidence supporting person-related interventions ranges from low to moderate. Occupational therapists in both general and specialized practice with older drivers must continually monitor the growing body of evidence for effective interventions for personal factors such as cognition, vision, and motor and driving skills, as well as educational interventions focused on older drivers’ beliefs, awareness, and self-regulation (Golisz, 2014).

Opportunities abound for occupational therapists to address older driver safety within both medical and social models of health. Occupational therapists can and should develop community transition groups to help older drivers plan for a successful driving retirement. These groups can support older drivers’ access to and participation in their communities using alternative transportation and approaches to civic involvement. Few older drivers plan for the requisite lifestyle changes that are associated with driving cessation (Yassuda, Wilson, & von Mering, 1997), and age-associated cognitive changes may make the transition to a nondriving status challenging. We need to engage policymakers to proactively address the issue of older driver safety and provide accessible transportation options to support older adults when driving cessation is required. In this issue, Stav (2014) explores the inconsistent evidence regarding the effects of current policies related to licensing, license renewal, and driving restrictions on older adults’ safety and community engagement. Occupational therapy practitioners should be appointed to serve on state department of motor vehicle medical review boards to help determine which drivers have potential to retain their driving privileges and which drivers should have their privileges revoked to ensure their safety and that of the public (Stav, 2014). AOTA continues to advocate for consistent Medicare coverage of occupational therapist–performed driver assessment and rehabilitation as an instrumental activity of daily living in the domain of occupational therapy (AOTA, 2014c) and within occupational therapy’s scope of practice (AOTA, 2010a, 2010b).

The evidence-based systematic reviews on older driver safety in this issue facilitate the translation of research to inform occupational therapy practice, education, advocacy, and future research in this area of practice (Arbesman, Lieberman, & Berlanstein, 2014). Awareness of the research findings related to older driver safety is critical for occupational therapists to offer evidence-based assessments, interventions, and meaningful recommendations to older drivers, their caregivers, and community agencies and organizations. All occupational therapy practitioners, whether generalists or driver rehabilitation specialists, share the common goal of supporting older adults’ independent and safe access to and participation in their communities through driving or other forms of community mobility (AOTA, 2010a).