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Ann Longterm Care. Author manuscript; available in PMC 2015 October 01. Published in final edited form as: Ann Longterm Care. 2015 July ; 23(7): 21–26.
Older adult drivers living in residential care facilities Hillary D. Lum, MD, PhD1,2, Adit A. Ginde, MD, MPH3, and Marian E. Betz, MD, MPH3 1
Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO
2
Veterans Affairs Eastern Colorado Healthcare System, Denver, CO
3
Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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Abstract
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Residential care facilities (RCF) provide assistance to older adults who cannot live independently, but it is unclear whether these residents have retired from driving. Here, we characterize older adults living in RCFs who still drive from a national cross-sectional survey of residents (2010 National Survey of Residential Care Facilities), representing ~733,000 adults living in RCFs such as assisted living facilities and personal care homes. Key resident characteristics were health, function, mobility and community activity indicators, which could be associated with increased driving risk. Of 8,087 residents, 4.5% (95%CI=3.9-5.1) were current drivers. Many drivers were older than 80 years (74%, 95%CI=67-79), in very good health (31%, 95%CI=25-38) or good health (35%, 95%CI=29-42), and had a median of two medical conditions. Most were independent with activities of daily living, though some needed assistance with walking and used gait devices. Given these results, RCF staff and healthcare providers need a heightened awareness of factors associated with driving risk to promote safety of older drivers and provide resources for likely transition to other transportation.
Keywords Residential facility, Assisted Living Facility; Geriatric; Driving
INTRODUCTION
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Many, though not all, older adults experience changes in health, function and mobility that adversely affect their driving ability, and fatal crash risk rises with age.1 Older drivers pose the biggest risk to themselves and their passengers, rather than other drivers or pedestrians.2,3 Driving difficulties and increased crash risk are related to increased age, medical conditions, impairments in cognitive, mental, physical and sensory functioning, as well as medications used to treat these conditions and impairments.4-7 While no single age signifies the need to “retire” from driving, most older adults will outlive their safe driving ability by 7-10 years and thus should prepare for a transition from driving to other forms of transportation.8
Corresponding author: Hillary D. Lum, MD, PhD, Division of Geriatric Medicine; University of Colorado School of Medicine, 12631 E. 17th Ave, B-179, Aurora, CO 80045, Phone: 303-724-1911; Fax: 303-724-1918; [email protected].
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The same factors that can affect driving ability also impact an individual’s ability to live independently, and some older adults may choose to live in residential care facilities (RCFs). RCFs provide long-term housing and supportive services including assistance with function, mobility and transportation. They are a heterogeneous group of state-regulated facilities and include assisted living facilities, personal care homes, and other residences. RCFs offer a range of personal care (e.g., bathing or dressing) or health-related services (e.g., medication assistance), room and board with at least two meals a day, and on-site supervision.9,10 There are approximately 733,000 residents who live in RCFs, among whom 54% are over age 85.11
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RCF residents are likely to have greater functional limitations than the general public and may therefore be at greater risk of crashes if they are still driving. Direct care providers and staff who work at RCFs may be aware of information about residents that can support identification of driving safety “red flags” such as cognitive impairment or leg weakness.4,12,13 Current evidence suggests that difficulty with performing instrumental activities of daily living (iADLs), especially those that involve cognitive and sensory-motor skills, may be predictive of difficulty with driving.14,15Additionally, RCFs may help support the transition to driving cessation by providing accessible alternatives to residents who no longer drive.16 To date, there are no regional or national studies that describe older adults who live in RCFs and continue to drive.
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The 2010 National Survey of Residential Care Facilities (NSRCF) presents a unique opportunity to characterize residents who live in U.S. long-term facilities that are not nursing homes. Specifically, the goal of this study is to describe the characteristics of RCF residents who drive. Based on factors associated with increased driving risk in older drivers, we explored demographic, health, function, mobility and community activity indicators. This contemporary description of U.S. RCF residents who drive may help target opportunities to assist residents and RCFs in supporting safe driving practices and transition to transportation alternatives as needed.
METHODS Study Design We performed a secondary analysis of the resident data file from the 2010 National Survey of Residential Care Facilities (NSRCF) of the National Center for Health Statistics, a nationally representative, cross-sectional survey of U.S. RCFs.17 We received a waiver from the Colorado Multiple Institutional Review Board as an exempt study.
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Full details of survey methodology, including sampling, questionnaire, and interview processes, are described elsewhere.9 Briefly, RCFs surveyed are assisted living residences, board and care homes, congregate care, enriched housing programs, homes for the aged, personal care homes, and shared housing establishments that are licensed or state-regulated and have four or more beds. Nursing homes and facilities that serve solely mentally-ill or developmentally-disabled populations were excluded. The primary sampling strata of RCFs were defined according to number of beds and census regions, and within these sampling
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strata, 3,650 RCFs were systematically and randomly sampled with probability proportional to size.9 Study Participants
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Surveys were collected via in-person interviews with facility directors or their designated staff (RNs, LPNs, and personal care aides) who were most knowledgeable about the residents and had access to their records. 9 Interviewers underwent rigorous training to identify appropriate survey respondents and used detailed data collection and quality assurance processes to promote accuracy. The NSRCF collected data from 2,302 facilities and 8,094 current residents. Respondents did not know driving status for 7 residents. Thus, there were 8,087 residents with data available on driving status, which represents 732,419 residents nationally. For this study, residents were included based on the question: “Does resident still drive?” This descriptive analysis is based on 287 affirmative cases (3.5% unweighted, or 4.5% [95%CI=3.9-5.1] weighted as described further below). Descriptive Variables
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Variables selected were based on previous studies that identified indicators associated with increased risk for older drivers.4,15 We included demographic, health, function, mobility and community activity indicators. Among the health indicators were measures of health status, sensory limitations, prevalence of the 10 most common medical conditions among RCF residents11, diagnoses associated with motor or cognitive impairment (i.e. arthritis, dementia, stroke), mental status, and healthcare utilization variables. Among the mental status variables, the interview respondent (i.e. facility director/other knowledgeable staff) was asked to respond to: (a) “Is [resident] limited in any way because of difficulty remembering or because [resident] experiences periods of confusion?”; and (b) “During the last 7 days, has [resident] given evidence of a problem with short-term memory, such as difficulty remembering what (he/she) had for breakfast or something you told [resident] a few minutes earlier?” Functional variables included variables related to activities of daily living (ADLs), instrumental ADLs, and gait devices. Mobility indicators included asking: “Without assistance and without equipment, how difficult is it for [resident] to (a) walk ¼ mile, (b) walk 10 steps without resting, (c) stand for 2 hours, or (d) go out to do things like shopping, movies, or sporting events?” Other indicators of community activity included whether the resident “regularly participates in any of these at least twice a month, regardless of whether or not it is arranged by the facility,” including (a) shopping or trips, (b) leaving facility grounds, or (c) going to social activities such as movies, dining out or other social activities. Full details of the NSRCF resident questionnaire are available.18
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Statistical Analysis Variables were categorized based on clinically meaningful thresholds. Statistical analyses were performed using Stata 12.1 (StataCorp, College Station, TX). For each descriptor variable, there were less than 1% with missing data; the missing observations were dropped for analysis of that variable. Using survey commands, the recommended stratified weights for the resident data were applied to accurately represent national estimates RCF residents.9 Results are presented as weighted percentages with 95% confidence intervals (CIs).
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Weighted results for groups smaller than 30 residents were not calculated based on NSRCF directions, due to unreliability of weighted estimates.
RESULTS
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Of 8087 residents surveyed in the 2010 NSRCF, 287 were identified as still driving. Therefore, using survey weights, 4.5% (95%CI=3.9-5.1) of 732,419 residents represented in this national survey were current drivers. For context, in 2011 there were 35 million licensed older drives, making up 16% of all licensed drivers.1 Table 1 shows the demographic characteristics and indicators of health including health status, sensory impairment, medical conditions, mental status, and healthcare utilization. Of current drivers, 74% (95%CI=67-79) were aged 80 years and older and half were women. Most had lived in an RCF for less than five years and had moved there from a private residence. The overall health status of drivers ranged with most reporting very good or good health, and they had a median of two chronic medical conditions. A small number of current drivers had a documented history of Alzheimer’s disease/other dementias or stroke, used oxygen, or had trouble seeing. However, the reported presence of confusion (7.9%, 95%CI=5.3-12) or short-term memory problems (7.5%, 95%CI=4.9-11) were higher.
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Table 2 describes the functional status, gait device usage, mobility, and community activity levels of residents who still drove. The majority of drivers were completely independent with ADLs. However, 21% (95%CI=16-26) of drivers needed help with 1-2 ADLs. Among the drivers who had a functional impairment, approximately 1 in 4 these residents (25% [95%CI=20-32]) needed help with walking. Similarly, 24% (95%CI=19-31) of current drivers used a cane or walker (25%, 95%CI=20-31). Many drivers experienced significant mobility limitations (i.e. activity was somewhat difficult, very difficult or they were unable to perform without help or assistive device) in ability to walk ¼ mile, walk 10 steps without resting, or stand for 2 hours, with standing being the most challenging. Regarding community activity levels, among the RCF residents who still drove, the vast majority had no or only a little difficulty going out to activities without assistance (82%, 95%CI=76-86). These residents regularly left the RCF grounds, went shopping or on other trips, and went out for social activities (Table 2). The Figure shows how current drivers and non-drivers who live in RCFs used assistance for community activities including leaving the RCF grounds, transportation to medical appointments, and transportation for other errands. The residents who still drove did use transportation assistance, although their rates of use were not as high as the rates among the non-drivers.
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DISCUSSION This study provides the first national estimate of older drivers living in U.S. RCFs. Specifically in 2010, 4.5% of residents in these long-term care facilities were current drivers. These current drivers were mostly older than 80 years and in very good or good health. While most were independent with their ADLs, a significant minority needed assistance with walking and experienced various limitations in their personal mobility and community activity levels. In this national, cross-sectional analysis of relatively frail older
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adults in RCFs, we described the prevalence of a wide range of identifiable demographic, health, mental and cognitive characteristics that can be indicators of increased driving risk.13 Although the older adult drivers who live in RCFs make up a very small percentage of the total number of older U.S. drivers, the rate of fatal crashes rises after age 75 and notably increases after age 80, suggesting the need for appropriate screening and counseling regardless of place of residence.19,20
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While there were relatively small percentages of drivers with diagnoses of dementia or stroke, there were larger percentages described as having difficulty remembering, confusion or short-term memory problems. These results are unsurprising since dementia is often underdiagnosed and mild cognitive impairment and delirium are prevalent in older adults. However, the high prevalence of cognitive and mental status issues among this population of older drivers is concerning since cognitive impairment is the most worrisome risk factor for driving-related injuries and crashes.4,12 The discrepancy between a known diagnosis of dementia or stroke and the RCF-based interview respondent’s report of cognitive or mental status issues suggests the need for RCF staff to be aware of driving status, risk reduction strategies, and opportunities to provide critical insights to residents, their loved ones, and healthcare providers.21
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The description of this population of older drivers highlights the functional, mobility and community activities of these residents. About 21% of the RCF residents who still drove required assistance with 1-2 ADLs, including walking, and approximately 25% used a cane or walker. From a mobility perspective, walking ¼ mile, walking 10 steps, or standing for 2 hours were frequently very difficult or impossible. This raises concerns about safe driving ability, as limitations in sensation, strength, and balance have been shown to be highly predictive of unsafe driving.22 These data support a need for heightened awareness of driving safety, including asking about driving patterns in the context of observed or changed mobility levels in the long-term care setting. Healthcare providers can integrate RCF staff input on the resident’s mobility levels with the individual driver’s own perspective, functional screening questions and physical screening tests, such as the Get-up-and-Go test, as part of personalized mobility counseling.23 The American Occupational Therapy Organization suggests that general occupational therapists, many of whom serve older adults who reside in RCFs, can also be involved in driving assessments.15,24,25 An iADL assessment provides information about driving and could identify individuals who might benefit from further evaluation or a driving rehabilitation program.14,24,26
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This study has several limitations. While the responses were based on interviews with a staff member from each facility (including directors, RNs, LPNs, or personal care aides) who knew the residents well through direct care and interactions, the data was not directly verified with residents, which may introduce inaccuracy or bias. In 7 instances the respondent did not know the resident’s driving status. Additionally, interviews with residents about driving patterns or perspectives on driving ability were not available. Future work will need to verify the accuracy of driving prevalence and patterns among older adult residents of RCFs through direct surveys of older adults. This analysis does not focus on
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comparing drivers to non-drivers, as we suspected that non-drivers would have more physical and cognitive impairments and we were most interested in describing the population of current drivers. While the NSRCF includes several medical conditions, it does not include a medication review or allow identification of use of sedating agents (e.g., anticholinergic medications, CNS depressants such as benzodiazepines), which can impair driving ability.7 The available NSRCF data file also does not include information about driving frequency and patterns, which might moderate crash risk. However, the NSRCF is the first nationally representative estimate of driving status among older adults living in RCFs, including a contemporary description of several relevant indicators of driving risk.
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This study has several potential applications. Residents who drive, as well as RCF staff and healthcare providers involved in their care along with family members and friends, should be attentive to methods to maintain safe driving capacity such as maximizing mental alertness, physical activity and exercise, and optimal positioning within the vehicle to facilitate safe driving. Furthermore, residents who drive should consider planning for eventual driving retirement, and their care providers and family members should support them in this process.27 Given our findings that most drivers had moved to the RCF within the past few years, we might hypothesize that driving cessation happens within a relatively short time frame after relocating to a RCF and may be part of that transition. The nature and frequency of discussions about changes in driving patterns among RCF residents should be examined, including how RCF staff and healthcare providers can effectively assist residents and their loved ones with driving cessation.27,28 This study also demonstrated how residents who still drove concurrently used various options that RCFs provided, including transportation assistance to community activities and medical appointments, which suggests that some of these residents had started the process of driving retirement. The extent of unmet transportation needs and how RCFs can assist with the transition to driving cessation warrants further study. Given the association between driving cessation and negative outcomes like depression, the addition of long-term care resources to support quality of life and well-being of older adults who stop driving is an important area of holistic care and research for older adults.29
CONCLUSION
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This is the first national, contemporary description of residents who live in RCFs and still drove. While only a minority of RCF residents still drove, these older adults had multiple health, cognitive, functional and mobility indicators that suggested a potentially increased risk of driving-related injury and crashes. This study highlights the need to support increased awareness and safe-driving counseling in RCFs, an expanding sector of the continuum of care for the aging U.S. population. We identified characteristics that were observed by RCF staff such as memory difficulty or confusion, limitations with ADLs or iADLs, and difficulty with mobility that could trigger discussions about maximizing driving safety or transitioning to driving cessation. Future research is needed to understand the perspectives of residents and their loved ones on driving patterns and best ways to support driving cessation at appropriate times. Clearly, RCFs are a critical setting to provide transportation alternatives for this population with their changing health and functional needs.
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ACKNOWLEDGMENTS All contributors to this study are listed as authors. The authors report that there are no financial, personal or potential conflicts of interest. Two of the authors were supported by the National Institute on Aging. The sponsors had no role in the design, methods, analysis, or preparation of the manuscript. The views in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
REFERENCES
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1. National Highway Traffic Safety Administration, US Department of Transportation. Safety in Numbers: Older Drivers. 2013. www.nhtsa.gov/staticfiles/numbers/ Safety_In_Numbers_Older_Drivers_811864.pdf. Accessed May 22, 2014 2. Dellinger AM, Kresnow MJ, White DD, Sehgal M. Risk to self versus risk to others: how do older drivers compare to others on the road? Am J Prev Med. 2004; 26(3):217–221. [PubMed: 15026101] 3. Tefft BC. Risks older drivers pose to themselves and to other road users. J Safety Res. 2008; 39(6): 577–582. [PubMed: 19064042] 4. Carr, D.; Schwartzberg, J.; Manning, L.; Sempek, J. 2nd. National Highway Traffic and Safety Administration and American Medical Association; Washington DC: 2010. Physician's guide to assessing and counseling older drivers. http://geriatricscareonline.org/ProductAbstract/physiciansguide-to-assessing-and-counseling-older-drivers/B013. Accessed April 27, 2014 5. National Highway Traffic Safety Administration, Department of Transportation (US). NHTSA; Washington (DC): 2014. Traffic Safety 2012: Older Population. http://www-nrd.nhtsa.dot.gov/ Pubs/812005.pdf 6. Papa M, Boccardi V, Prestano R, et al. Comorbidities and crash involvement among younger and older drivers. PLoS One. 2014; 9(4):e94564. [PubMed: 24722619] 7. Hetland AJ, Carr DB, Wallendorf MJ, Barco PP. Potentially driver-impairing (PDI) medication use in medically impaired adults referred for driving evaluation. Ann Pharmacother. 2014; 48(4):476– 482. [PubMed: 24473491] 8. Foley DJ, Heimovitz HK, Guralnik JM, Brock DB. Driving life expectancy of persons aged 70 years and older in the United States. Am J Public Health. 2002; 92(8):1284–1289. [PubMed: 12144985] 9. Moss AJ, Harris-Kojetin LD, Sengupta M, et al. Design and operation of the 2010 National Survey of Residential Care Facilities. National Center for Health Statistics. Vital Health Stat. 1(54) 10. Park-Lee E, Caffrey C, Sengupta M, et al. Residential care facilities: a key sector in the spectrum of long-term care providers in the United States. NCHS Data Brief. 2011; (78):1–8. [PubMed: 22617275] 11. Caffrey, C.; Sengupta, M.; Park-Lee, E.; Moss, A.; Rosenoff, E.; Harris-Kojetin, L. Residents Living in Residential Care Facilities:United States. Hyattsville, MD: 2010. 2012 12. Carr DB, Ott BR. The older adult driver with cognitive impairment: "It's a very frustrating life". JAMA. 2010; 303(16):1632–1641. [PubMed: 20424254] 13. Morris JN, Howard EP, Fries BE, Berkowitz R, Goldman B, David D. Using the community health assessment to screen for continued driving. Accid Anal Prev. 2014; 63:104–110. [PubMed: 24280459] 14. Dickerson AE, Reistetter T, Davis ES, Monahan M. Evaluating driving as a valued instrumental activity of daily living. Am J Occup Ther. 2011; 65(1):64–75. [PubMed: 21309373] 15. Dickerson AE. Screening and assessment tools for determining fitness to drive: a review of the literature for the pathways project. Occup Ther Health Care. 2014; 28(2):82–121. [PubMed: 24754758] 16. Getting Around - Alternatives for Seniors Who No Longer Drive. 2007. http:// gettingaround.seniordrivers.org/home/contact.cfm 17. National Survey of Residential Care Facilities - Survey Methodology, Documentation, and Data Files. 2011. http://www.cdc.gov/nchs/nsrcf/nsrcf_questionnaires.htm 18. 2010 National Survey of Residential Care Facilities (NSRCF) Resident Questionnaire. ftp:// ftp.cdc.gov/pub/Health_statistics/NCHs/Dataset_Questionnaires/nsrcf/ 2010/2010_NSRCF_Resident_Questionnaire.pdf
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19. Centers for Disease Control and Prevention. Older Adult Drivers: Get the Facts. 2013. http:// www.cdc.gov/Motorvehiclesafety/Older_Adult_Drivers/adult-drivers_factsheet.html. Accessed November 15, 2014 20. Insurance Institute for Highway Safety (IIHS). Fatality facts 2012, Older people. IIHS; Arlington (VA): 2013. Available from URL: http://www.iihs.org/iihs/topics/t/older-drivers/fatalityfacts/ older-people Accessed November 21, 2014 21. Kowalski K, Love J, Tuokko H, MacDonald S, Hultsch D, Strauss E. The influence of cognitive impairment with no dementia on driving restriction and cessation in older adults. Accid Anal Prev. 2012; 49:308–315. [PubMed: 23036411] 22. Lacherez P, Wood JM, Anstey KJ, Lord SR. Sensorimotor and postural control factors associated with driving safety in a community-dwelling older driver population. J Gerontol A Biol Sci Med Sci. 2014; 69(2):240–244. [PubMed: 24170672] 23. Betz ME, Jones J, Genco E, et al. Perspectives on Tiered Older Driver Assessment in Primary Care Settings. Gerontologist. 2014 24. Touchinsky S, Chew F, Davis ES. Gaps and pathways project: driving pathways by diagnosis sheets. Occup Ther Health Care. 2014; 28(2):203–206. [PubMed: 24754771] 25. Davis ES. Introduction to this Special Issue: The Gaps and Pathways Project for Medically-at-Risk Older Drivers. Occup Ther Health Care. 2014; 28(2):79–81. [PubMed: 24754757] 26. Dickerson AE, Bédard M. Decision tool for clients with medical issues: a framework for identifying driving risk and potential to return to driving. Occup Ther Health Care. 2014; 28(2): 194–202. [PubMed: 24754770] 27. Betz ME, Jones VC, Lowenstein SR. Physicians and Advance Planning for "Driving Retirement". Am J Med. 2014 28. Berg-Weger M, Meuser TM, Stowe J. Addressing individual differences in mobility transition counseling with older adults. J Gerontol Soc Work. 2013; 56(3):201–218. [PubMed: 23548142] 29. Ragland DR, Satariano WA, MacLeod KE. Driving cessation and increased depressive symptoms. J Gerontol A Biol Sci Med Sci. 2005; 60(3):399–403. [PubMed: 15860482]
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Figure.
Use of transportation services by RCF current drivers or non-drivers, shown as weighted percentages. Assistance could be offered by facility staff or provided at the facility by nonfacility staff.
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Table 1
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Demographic and health indicators of current drivers living in residential care facilities (RCFs). Characteristics
Weighted % (95%CI)
Demographics Age 1-5 years
42 (36-49)
>5 years
18 (13-24)
Location prior to moving to RCF Private residence
90 (85-94)
Different RCF
5.1 (nc)
Othera
4.6 (nc)
Health Indicators Health status
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Excellent
14 (9.6-20)
Very good
31 (25-38)
Good
35 (29-42)
Fair/Poor
20 (15-26)
Uses oxygen
7.4 (nc)
Sensory Has trouble seeing
5.1 (nc)
Uses hearing aid
19 (15-25)
Medical Conditions Number of conditions, median (range) Diagnosis of arthritis
2 (1-6) 29 (23-35)
Diagnosis of Alzheimer’s/other dementia
3.9 (nc)
History of stroke
6.8 (nc)
Mental Status
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Diagnosis of depression
17 (13-22)
Limited by difficulty remembering or confusion
7.9 (5.3-12)
Short-term memory problems
7.5 (4.9-11)
Long-term memory problems
1.1 (nc)
Healthcare Utilization
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Characteristics
Weighted % (95%CI)
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≥1 Emergency Department visits in past year
20 (15-26)
≥1 hospitalizations in past year
14 (10-20)
A – Includes retirement/independent living facilities, nursing homes, and other. nc = Not calculated (unweighted less than 30 residents).
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Table 2
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Function, mobility and community activity levels of RCF current drivers. Characteristics
Weighted % (95% CI)
Function ADLs requiring assistance 0
78 (72-83)
1-2
21 (16-26)
>3
1.6 (nc)
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Assistance with Walking
25 (20-32)
Assistance with Shopping
9.0 (5.9-13)
Assistance with Finances
20 (15-26)
Assistance with Housework
20 (15-26)
Assistance with Medications
37 (31-43)
Gait Devices Cane
24 (19-30)
Walker
25 (20-31)
Wheel chair (Manual or Electric)
8.4 (nc)
Mobility Ability to walk ¼ mile Not at all or only a little difficult
50 (43-57)
Somewhat or very difficult
35 (29-42)
Unable due to health
15 (11-20)
Walk 10 steps without resting
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Not at all or only a little difficult
52 (45-59)
Somewhat or very difficult
35 (29-42)
Unable due to health
13 (9.2-18)
Stand for 2 hours Not at all or only a little difficult
33 (27-40)
Somewhat or very difficult
51 (44-58)
Unable due to health
16 (11-21)
Level of Community Activity Go out to activities without assistance Not at all or only a little difficult
82 (76-86)
Somewhat or very difficult
12 (8.5-17)
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Unable due to health
6.1 (nc)
Leaving facility grounds
86 (80-90)
Shopping or trips
74 (67-79)
Going to social activities
64 (57-71)
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Ann Longterm Care. Author manuscript; available in PMC 2015 October 01. Published in final edited form as: Ann Longterm Care. 2015 July ; 23(7): 21–26.
Older adult drivers living in residential care facilities Hillary D. Lum, MD, PhD1,2, Adit A. Ginde, MD, MPH3, and Marian E. Betz, MD, MPH3 1
Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO
2
Veterans Affairs Eastern Colorado Healthcare System, Denver, CO
3
Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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Abstract
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Residential care facilities (RCF) provide assistance to older adults who cannot live independently, but it is unclear whether these residents have retired from driving. Here, we characterize older adults living in RCFs who still drive from a national cross-sectional survey of residents (2010 National Survey of Residential Care Facilities), representing ~733,000 adults living in RCFs such as assisted living facilities and personal care homes. Key resident characteristics were health, function, mobility and community activity indicators, which could be associated with increased driving risk. Of 8,087 residents, 4.5% (95%CI=3.9-5.1) were current drivers. Many drivers were older than 80 years (74%, 95%CI=67-79), in very good health (31%, 95%CI=25-38) or good health (35%, 95%CI=29-42), and had a median of two medical conditions. Most were independent with activities of daily living, though some needed assistance with walking and used gait devices. Given these results, RCF staff and healthcare providers need a heightened awareness of factors associated with driving risk to promote safety of older drivers and provide resources for likely transition to other transportation.
Keywords Residential facility, Assisted Living Facility; Geriatric; Driving
INTRODUCTION
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Many, though not all, older adults experience changes in health, function and mobility that adversely affect their driving ability, and fatal crash risk rises with age.1 Older drivers pose the biggest risk to themselves and their passengers, rather than other drivers or pedestrians.2,3 Driving difficulties and increased crash risk are related to increased age, medical conditions, impairments in cognitive, mental, physical and sensory functioning, as well as medications used to treat these conditions and impairments.4-7 While no single age signifies the need to “retire” from driving, most older adults will outlive their safe driving ability by 7-10 years and thus should prepare for a transition from driving to other forms of transportation.8
Corresponding author: Hillary D. Lum, MD, PhD, Division of Geriatric Medicine; University of Colorado School of Medicine, 12631 E. 17th Ave, B-179, Aurora, CO 80045, Phone: 303-724-1911; Fax: 303-724-1918; [email protected].
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The same factors that can affect driving ability also impact an individual’s ability to live independently, and some older adults may choose to live in residential care facilities (RCFs). RCFs provide long-term housing and supportive services including assistance with function, mobility and transportation. They are a heterogeneous group of state-regulated facilities and include assisted living facilities, personal care homes, and other residences. RCFs offer a range of personal care (e.g., bathing or dressing) or health-related services (e.g., medication assistance), room and board with at least two meals a day, and on-site supervision.9,10 There are approximately 733,000 residents who live in RCFs, among whom 54% are over age 85.11
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RCF residents are likely to have greater functional limitations than the general public and may therefore be at greater risk of crashes if they are still driving. Direct care providers and staff who work at RCFs may be aware of information about residents that can support identification of driving safety “red flags” such as cognitive impairment or leg weakness.4,12,13 Current evidence suggests that difficulty with performing instrumental activities of daily living (iADLs), especially those that involve cognitive and sensory-motor skills, may be predictive of difficulty with driving.14,15Additionally, RCFs may help support the transition to driving cessation by providing accessible alternatives to residents who no longer drive.16 To date, there are no regional or national studies that describe older adults who live in RCFs and continue to drive.
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The 2010 National Survey of Residential Care Facilities (NSRCF) presents a unique opportunity to characterize residents who live in U.S. long-term facilities that are not nursing homes. Specifically, the goal of this study is to describe the characteristics of RCF residents who drive. Based on factors associated with increased driving risk in older drivers, we explored demographic, health, function, mobility and community activity indicators. This contemporary description of U.S. RCF residents who drive may help target opportunities to assist residents and RCFs in supporting safe driving practices and transition to transportation alternatives as needed.
METHODS Study Design We performed a secondary analysis of the resident data file from the 2010 National Survey of Residential Care Facilities (NSRCF) of the National Center for Health Statistics, a nationally representative, cross-sectional survey of U.S. RCFs.17 We received a waiver from the Colorado Multiple Institutional Review Board as an exempt study.
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Full details of survey methodology, including sampling, questionnaire, and interview processes, are described elsewhere.9 Briefly, RCFs surveyed are assisted living residences, board and care homes, congregate care, enriched housing programs, homes for the aged, personal care homes, and shared housing establishments that are licensed or state-regulated and have four or more beds. Nursing homes and facilities that serve solely mentally-ill or developmentally-disabled populations were excluded. The primary sampling strata of RCFs were defined according to number of beds and census regions, and within these sampling
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strata, 3,650 RCFs were systematically and randomly sampled with probability proportional to size.9 Study Participants
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Surveys were collected via in-person interviews with facility directors or their designated staff (RNs, LPNs, and personal care aides) who were most knowledgeable about the residents and had access to their records. 9 Interviewers underwent rigorous training to identify appropriate survey respondents and used detailed data collection and quality assurance processes to promote accuracy. The NSRCF collected data from 2,302 facilities and 8,094 current residents. Respondents did not know driving status for 7 residents. Thus, there were 8,087 residents with data available on driving status, which represents 732,419 residents nationally. For this study, residents were included based on the question: “Does resident still drive?” This descriptive analysis is based on 287 affirmative cases (3.5% unweighted, or 4.5% [95%CI=3.9-5.1] weighted as described further below). Descriptive Variables
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Variables selected were based on previous studies that identified indicators associated with increased risk for older drivers.4,15 We included demographic, health, function, mobility and community activity indicators. Among the health indicators were measures of health status, sensory limitations, prevalence of the 10 most common medical conditions among RCF residents11, diagnoses associated with motor or cognitive impairment (i.e. arthritis, dementia, stroke), mental status, and healthcare utilization variables. Among the mental status variables, the interview respondent (i.e. facility director/other knowledgeable staff) was asked to respond to: (a) “Is [resident] limited in any way because of difficulty remembering or because [resident] experiences periods of confusion?”; and (b) “During the last 7 days, has [resident] given evidence of a problem with short-term memory, such as difficulty remembering what (he/she) had for breakfast or something you told [resident] a few minutes earlier?” Functional variables included variables related to activities of daily living (ADLs), instrumental ADLs, and gait devices. Mobility indicators included asking: “Without assistance and without equipment, how difficult is it for [resident] to (a) walk ¼ mile, (b) walk 10 steps without resting, (c) stand for 2 hours, or (d) go out to do things like shopping, movies, or sporting events?” Other indicators of community activity included whether the resident “regularly participates in any of these at least twice a month, regardless of whether or not it is arranged by the facility,” including (a) shopping or trips, (b) leaving facility grounds, or (c) going to social activities such as movies, dining out or other social activities. Full details of the NSRCF resident questionnaire are available.18
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Statistical Analysis Variables were categorized based on clinically meaningful thresholds. Statistical analyses were performed using Stata 12.1 (StataCorp, College Station, TX). For each descriptor variable, there were less than 1% with missing data; the missing observations were dropped for analysis of that variable. Using survey commands, the recommended stratified weights for the resident data were applied to accurately represent national estimates RCF residents.9 Results are presented as weighted percentages with 95% confidence intervals (CIs).
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Weighted results for groups smaller than 30 residents were not calculated based on NSRCF directions, due to unreliability of weighted estimates.
RESULTS
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Of 8087 residents surveyed in the 2010 NSRCF, 287 were identified as still driving. Therefore, using survey weights, 4.5% (95%CI=3.9-5.1) of 732,419 residents represented in this national survey were current drivers. For context, in 2011 there were 35 million licensed older drives, making up 16% of all licensed drivers.1 Table 1 shows the demographic characteristics and indicators of health including health status, sensory impairment, medical conditions, mental status, and healthcare utilization. Of current drivers, 74% (95%CI=67-79) were aged 80 years and older and half were women. Most had lived in an RCF for less than five years and had moved there from a private residence. The overall health status of drivers ranged with most reporting very good or good health, and they had a median of two chronic medical conditions. A small number of current drivers had a documented history of Alzheimer’s disease/other dementias or stroke, used oxygen, or had trouble seeing. However, the reported presence of confusion (7.9%, 95%CI=5.3-12) or short-term memory problems (7.5%, 95%CI=4.9-11) were higher.
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Table 2 describes the functional status, gait device usage, mobility, and community activity levels of residents who still drove. The majority of drivers were completely independent with ADLs. However, 21% (95%CI=16-26) of drivers needed help with 1-2 ADLs. Among the drivers who had a functional impairment, approximately 1 in 4 these residents (25% [95%CI=20-32]) needed help with walking. Similarly, 24% (95%CI=19-31) of current drivers used a cane or walker (25%, 95%CI=20-31). Many drivers experienced significant mobility limitations (i.e. activity was somewhat difficult, very difficult or they were unable to perform without help or assistive device) in ability to walk ¼ mile, walk 10 steps without resting, or stand for 2 hours, with standing being the most challenging. Regarding community activity levels, among the RCF residents who still drove, the vast majority had no or only a little difficulty going out to activities without assistance (82%, 95%CI=76-86). These residents regularly left the RCF grounds, went shopping or on other trips, and went out for social activities (Table 2). The Figure shows how current drivers and non-drivers who live in RCFs used assistance for community activities including leaving the RCF grounds, transportation to medical appointments, and transportation for other errands. The residents who still drove did use transportation assistance, although their rates of use were not as high as the rates among the non-drivers.
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DISCUSSION This study provides the first national estimate of older drivers living in U.S. RCFs. Specifically in 2010, 4.5% of residents in these long-term care facilities were current drivers. These current drivers were mostly older than 80 years and in very good or good health. While most were independent with their ADLs, a significant minority needed assistance with walking and experienced various limitations in their personal mobility and community activity levels. In this national, cross-sectional analysis of relatively frail older
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adults in RCFs, we described the prevalence of a wide range of identifiable demographic, health, mental and cognitive characteristics that can be indicators of increased driving risk.13 Although the older adult drivers who live in RCFs make up a very small percentage of the total number of older U.S. drivers, the rate of fatal crashes rises after age 75 and notably increases after age 80, suggesting the need for appropriate screening and counseling regardless of place of residence.19,20
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While there were relatively small percentages of drivers with diagnoses of dementia or stroke, there were larger percentages described as having difficulty remembering, confusion or short-term memory problems. These results are unsurprising since dementia is often underdiagnosed and mild cognitive impairment and delirium are prevalent in older adults. However, the high prevalence of cognitive and mental status issues among this population of older drivers is concerning since cognitive impairment is the most worrisome risk factor for driving-related injuries and crashes.4,12 The discrepancy between a known diagnosis of dementia or stroke and the RCF-based interview respondent’s report of cognitive or mental status issues suggests the need for RCF staff to be aware of driving status, risk reduction strategies, and opportunities to provide critical insights to residents, their loved ones, and healthcare providers.21
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The description of this population of older drivers highlights the functional, mobility and community activities of these residents. About 21% of the RCF residents who still drove required assistance with 1-2 ADLs, including walking, and approximately 25% used a cane or walker. From a mobility perspective, walking ¼ mile, walking 10 steps, or standing for 2 hours were frequently very difficult or impossible. This raises concerns about safe driving ability, as limitations in sensation, strength, and balance have been shown to be highly predictive of unsafe driving.22 These data support a need for heightened awareness of driving safety, including asking about driving patterns in the context of observed or changed mobility levels in the long-term care setting. Healthcare providers can integrate RCF staff input on the resident’s mobility levels with the individual driver’s own perspective, functional screening questions and physical screening tests, such as the Get-up-and-Go test, as part of personalized mobility counseling.23 The American Occupational Therapy Organization suggests that general occupational therapists, many of whom serve older adults who reside in RCFs, can also be involved in driving assessments.15,24,25 An iADL assessment provides information about driving and could identify individuals who might benefit from further evaluation or a driving rehabilitation program.14,24,26
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This study has several limitations. While the responses were based on interviews with a staff member from each facility (including directors, RNs, LPNs, or personal care aides) who knew the residents well through direct care and interactions, the data was not directly verified with residents, which may introduce inaccuracy or bias. In 7 instances the respondent did not know the resident’s driving status. Additionally, interviews with residents about driving patterns or perspectives on driving ability were not available. Future work will need to verify the accuracy of driving prevalence and patterns among older adult residents of RCFs through direct surveys of older adults. This analysis does not focus on
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comparing drivers to non-drivers, as we suspected that non-drivers would have more physical and cognitive impairments and we were most interested in describing the population of current drivers. While the NSRCF includes several medical conditions, it does not include a medication review or allow identification of use of sedating agents (e.g., anticholinergic medications, CNS depressants such as benzodiazepines), which can impair driving ability.7 The available NSRCF data file also does not include information about driving frequency and patterns, which might moderate crash risk. However, the NSRCF is the first nationally representative estimate of driving status among older adults living in RCFs, including a contemporary description of several relevant indicators of driving risk.
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This study has several potential applications. Residents who drive, as well as RCF staff and healthcare providers involved in their care along with family members and friends, should be attentive to methods to maintain safe driving capacity such as maximizing mental alertness, physical activity and exercise, and optimal positioning within the vehicle to facilitate safe driving. Furthermore, residents who drive should consider planning for eventual driving retirement, and their care providers and family members should support them in this process.27 Given our findings that most drivers had moved to the RCF within the past few years, we might hypothesize that driving cessation happens within a relatively short time frame after relocating to a RCF and may be part of that transition. The nature and frequency of discussions about changes in driving patterns among RCF residents should be examined, including how RCF staff and healthcare providers can effectively assist residents and their loved ones with driving cessation.27,28 This study also demonstrated how residents who still drove concurrently used various options that RCFs provided, including transportation assistance to community activities and medical appointments, which suggests that some of these residents had started the process of driving retirement. The extent of unmet transportation needs and how RCFs can assist with the transition to driving cessation warrants further study. Given the association between driving cessation and negative outcomes like depression, the addition of long-term care resources to support quality of life and well-being of older adults who stop driving is an important area of holistic care and research for older adults.29
CONCLUSION
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This is the first national, contemporary description of residents who live in RCFs and still drove. While only a minority of RCF residents still drove, these older adults had multiple health, cognitive, functional and mobility indicators that suggested a potentially increased risk of driving-related injury and crashes. This study highlights the need to support increased awareness and safe-driving counseling in RCFs, an expanding sector of the continuum of care for the aging U.S. population. We identified characteristics that were observed by RCF staff such as memory difficulty or confusion, limitations with ADLs or iADLs, and difficulty with mobility that could trigger discussions about maximizing driving safety or transitioning to driving cessation. Future research is needed to understand the perspectives of residents and their loved ones on driving patterns and best ways to support driving cessation at appropriate times. Clearly, RCFs are a critical setting to provide transportation alternatives for this population with their changing health and functional needs.
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ACKNOWLEDGMENTS All contributors to this study are listed as authors. The authors report that there are no financial, personal or potential conflicts of interest. Two of the authors were supported by the National Institute on Aging. The sponsors had no role in the design, methods, analysis, or preparation of the manuscript. The views in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
REFERENCES
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1. National Highway Traffic Safety Administration, US Department of Transportation. Safety in Numbers: Older Drivers. 2013. www.nhtsa.gov/staticfiles/numbers/ Safety_In_Numbers_Older_Drivers_811864.pdf. Accessed May 22, 2014 2. Dellinger AM, Kresnow MJ, White DD, Sehgal M. Risk to self versus risk to others: how do older drivers compare to others on the road? Am J Prev Med. 2004; 26(3):217–221. [PubMed: 15026101] 3. Tefft BC. Risks older drivers pose to themselves and to other road users. J Safety Res. 2008; 39(6): 577–582. [PubMed: 19064042] 4. Carr, D.; Schwartzberg, J.; Manning, L.; Sempek, J. 2nd. National Highway Traffic and Safety Administration and American Medical Association; Washington DC: 2010. Physician's guide to assessing and counseling older drivers. http://geriatricscareonline.org/ProductAbstract/physiciansguide-to-assessing-and-counseling-older-drivers/B013. Accessed April 27, 2014 5. National Highway Traffic Safety Administration, Department of Transportation (US). NHTSA; Washington (DC): 2014. Traffic Safety 2012: Older Population. http://www-nrd.nhtsa.dot.gov/ Pubs/812005.pdf 6. Papa M, Boccardi V, Prestano R, et al. Comorbidities and crash involvement among younger and older drivers. PLoS One. 2014; 9(4):e94564. [PubMed: 24722619] 7. Hetland AJ, Carr DB, Wallendorf MJ, Barco PP. Potentially driver-impairing (PDI) medication use in medically impaired adults referred for driving evaluation. Ann Pharmacother. 2014; 48(4):476– 482. [PubMed: 24473491] 8. Foley DJ, Heimovitz HK, Guralnik JM, Brock DB. Driving life expectancy of persons aged 70 years and older in the United States. Am J Public Health. 2002; 92(8):1284–1289. [PubMed: 12144985] 9. Moss AJ, Harris-Kojetin LD, Sengupta M, et al. Design and operation of the 2010 National Survey of Residential Care Facilities. National Center for Health Statistics. Vital Health Stat. 1(54) 10. Park-Lee E, Caffrey C, Sengupta M, et al. Residential care facilities: a key sector in the spectrum of long-term care providers in the United States. NCHS Data Brief. 2011; (78):1–8. [PubMed: 22617275] 11. Caffrey, C.; Sengupta, M.; Park-Lee, E.; Moss, A.; Rosenoff, E.; Harris-Kojetin, L. Residents Living in Residential Care Facilities:United States. Hyattsville, MD: 2010. 2012 12. Carr DB, Ott BR. The older adult driver with cognitive impairment: "It's a very frustrating life". JAMA. 2010; 303(16):1632–1641. [PubMed: 20424254] 13. Morris JN, Howard EP, Fries BE, Berkowitz R, Goldman B, David D. Using the community health assessment to screen for continued driving. Accid Anal Prev. 2014; 63:104–110. [PubMed: 24280459] 14. Dickerson AE, Reistetter T, Davis ES, Monahan M. Evaluating driving as a valued instrumental activity of daily living. Am J Occup Ther. 2011; 65(1):64–75. [PubMed: 21309373] 15. Dickerson AE. Screening and assessment tools for determining fitness to drive: a review of the literature for the pathways project. Occup Ther Health Care. 2014; 28(2):82–121. [PubMed: 24754758] 16. Getting Around - Alternatives for Seniors Who No Longer Drive. 2007. http:// gettingaround.seniordrivers.org/home/contact.cfm 17. National Survey of Residential Care Facilities - Survey Methodology, Documentation, and Data Files. 2011. http://www.cdc.gov/nchs/nsrcf/nsrcf_questionnaires.htm 18. 2010 National Survey of Residential Care Facilities (NSRCF) Resident Questionnaire. ftp:// ftp.cdc.gov/pub/Health_statistics/NCHs/Dataset_Questionnaires/nsrcf/ 2010/2010_NSRCF_Resident_Questionnaire.pdf
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19. Centers for Disease Control and Prevention. Older Adult Drivers: Get the Facts. 2013. http:// www.cdc.gov/Motorvehiclesafety/Older_Adult_Drivers/adult-drivers_factsheet.html. Accessed November 15, 2014 20. Insurance Institute for Highway Safety (IIHS). Fatality facts 2012, Older people. IIHS; Arlington (VA): 2013. Available from URL: http://www.iihs.org/iihs/topics/t/older-drivers/fatalityfacts/ older-people Accessed November 21, 2014 21. Kowalski K, Love J, Tuokko H, MacDonald S, Hultsch D, Strauss E. The influence of cognitive impairment with no dementia on driving restriction and cessation in older adults. Accid Anal Prev. 2012; 49:308–315. [PubMed: 23036411] 22. Lacherez P, Wood JM, Anstey KJ, Lord SR. Sensorimotor and postural control factors associated with driving safety in a community-dwelling older driver population. J Gerontol A Biol Sci Med Sci. 2014; 69(2):240–244. [PubMed: 24170672] 23. Betz ME, Jones J, Genco E, et al. Perspectives on Tiered Older Driver Assessment in Primary Care Settings. Gerontologist. 2014 24. Touchinsky S, Chew F, Davis ES. Gaps and pathways project: driving pathways by diagnosis sheets. Occup Ther Health Care. 2014; 28(2):203–206. [PubMed: 24754771] 25. Davis ES. Introduction to this Special Issue: The Gaps and Pathways Project for Medically-at-Risk Older Drivers. Occup Ther Health Care. 2014; 28(2):79–81. [PubMed: 24754757] 26. Dickerson AE, Bédard M. Decision tool for clients with medical issues: a framework for identifying driving risk and potential to return to driving. Occup Ther Health Care. 2014; 28(2): 194–202. [PubMed: 24754770] 27. Betz ME, Jones VC, Lowenstein SR. Physicians and Advance Planning for "Driving Retirement". Am J Med. 2014 28. Berg-Weger M, Meuser TM, Stowe J. Addressing individual differences in mobility transition counseling with older adults. J Gerontol Soc Work. 2013; 56(3):201–218. [PubMed: 23548142] 29. Ragland DR, Satariano WA, MacLeod KE. Driving cessation and increased depressive symptoms. J Gerontol A Biol Sci Med Sci. 2005; 60(3):399–403. [PubMed: 15860482]
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Figure.
Use of transportation services by RCF current drivers or non-drivers, shown as weighted percentages. Assistance could be offered by facility staff or provided at the facility by nonfacility staff.
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Table 1
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Demographic and health indicators of current drivers living in residential care facilities (RCFs). Characteristics
Weighted % (95%CI)
Demographics Age 1-5 years
42 (36-49)
>5 years
18 (13-24)
Location prior to moving to RCF Private residence
90 (85-94)
Different RCF
5.1 (nc)
Othera
4.6 (nc)
Health Indicators Health status
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Excellent
14 (9.6-20)
Very good
31 (25-38)
Good
35 (29-42)
Fair/Poor
20 (15-26)
Uses oxygen
7.4 (nc)
Sensory Has trouble seeing
5.1 (nc)
Uses hearing aid
19 (15-25)
Medical Conditions Number of conditions, median (range) Diagnosis of arthritis
2 (1-6) 29 (23-35)
Diagnosis of Alzheimer’s/other dementia
3.9 (nc)
History of stroke
6.8 (nc)
Mental Status
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Diagnosis of depression
17 (13-22)
Limited by difficulty remembering or confusion
7.9 (5.3-12)
Short-term memory problems
7.5 (4.9-11)
Long-term memory problems
1.1 (nc)
Healthcare Utilization
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Characteristics
Weighted % (95%CI)
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≥1 Emergency Department visits in past year
20 (15-26)
≥1 hospitalizations in past year
14 (10-20)
A – Includes retirement/independent living facilities, nursing homes, and other. nc = Not calculated (unweighted less than 30 residents).
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Table 2
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Function, mobility and community activity levels of RCF current drivers. Characteristics
Weighted % (95% CI)
Function ADLs requiring assistance 0
78 (72-83)
1-2
21 (16-26)
>3
1.6 (nc)
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Assistance with Walking
25 (20-32)
Assistance with Shopping
9.0 (5.9-13)
Assistance with Finances
20 (15-26)
Assistance with Housework
20 (15-26)
Assistance with Medications
37 (31-43)
Gait Devices Cane
24 (19-30)
Walker
25 (20-31)
Wheel chair (Manual or Electric)
8.4 (nc)
Mobility Ability to walk ¼ mile Not at all or only a little difficult
50 (43-57)
Somewhat or very difficult
35 (29-42)
Unable due to health
15 (11-20)
Walk 10 steps without resting
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Not at all or only a little difficult
52 (45-59)
Somewhat or very difficult
35 (29-42)
Unable due to health
13 (9.2-18)
Stand for 2 hours Not at all or only a little difficult
33 (27-40)
Somewhat or very difficult
51 (44-58)
Unable due to health
16 (11-21)
Level of Community Activity Go out to activities without assistance Not at all or only a little difficult
82 (76-86)
Somewhat or very difficult
12 (8.5-17)
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Unable due to health
6.1 (nc)
Leaving facility grounds
86 (80-90)
Shopping or trips
74 (67-79)
Going to social activities
64 (57-71)
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