Updated Systematic Review on Older Adult Community Mobility and Driver Licensing Policies

Abstract

An updated systematic review of literature related to the effects of driver licensing policies, community mobility programs, and driving cessation programs on older adult performance and participation was completed as a part of the American Occupational Therapy Association’s Evidence-Based Literature Review Project. The results revealed that relicensing policies instituted by states yield inconsistent results in terms of reducing traffic crashes, traffic violations, and traffic-related fatalities. The evidence related to community mobility and driving cessation programs has suggested that programming to support the transition from driving to other modes of mobility can be beneficial for older adults and their family members. In addition, community contexts that are supportive of pedestrian travel significantly increase this mode of mobility. This evidence-based review informs occupational therapy practice and suggests that increased therapeutic attention should be directed toward supportive transitions from driving and sustaining community mobility for optimal engagement and participation.

Occupational therapy practice in the area of driving and community mobility has become increasingly based on evidence over the past decade. This positive trend toward evidence-based practice is dependent on the selection and review of informative evidence conducted by the American Occupational Therapy Association’s (AOTA’s) Evidence-Based Practice Project. The project initially coordinated a systematic review “to identify evidence supporting interventions that affect safety, performance, and participation of older adults engaging in driving and community mobility” (Stav, 2008, p. 149). At that time, one of the focused questions targeted the effect of driver licensing policies and community mobility programs on older adults’ participation (Stav, 2008).

The objective of this current systematic review was to extend the previous review to capture literature published since then on the focused question, What is the evidence for the effect of policy and community mobility programs (e.g., alternative transportation, walkable communities, education, driving cessation programs, and pedestrian programs) on the performance and participation of older adults? The updated review is similar to the 2008 review in its inclusion of effectiveness of driver licensing policies and community mobility programs; however, it also incorporates studies of the effects of community design for walkability and driving cessation programs. In addition, the outcome of participation is clarified to include the constructs of performance specific to the driving outcomes of crashes and violations and participation specific to engagement in occupations.

The results of this systematic review continue to be relevant, with 32.2 million drivers older than age 65 as of 2008 and an anticipated increase to 40 million by 2020 (National Highway Traffic Safety Administration [NHTSA], 2010a). In 2009, older adult involvement in traffic incidents resulted in 5,288 fatalities and 187,000 injuries (NHTSA, 2010b). These high rates of injuries and fatalities emphasize the need to develop and implement sound policies related to driver licensing among older adults. Licensure policies alone will not adequately address older adults’ community mobility issues because some older adults can no longer drive and need to remain mobile in the community for enhanced occupational engagement (Stav, 2008). To comprehensively support elder mobility, licensure policies and transportation programs must be reviewed and critiqued to determine their effectiveness in supporting community engagement among older adults (Stav, 2008).

Statement of the Problem

Driving and community mobility are an integral part of the lives of most community-dwelling adults because they not only serve as means of transport but also are an occupation enabler in that travel throughout the community is essential for engagement in many other occupations (Stav & Lieberman, 2008). Mobility in the community has also been reported to have positive health outcomes in the areas of physical health, psychological health, socialization, and overall life satisfaction (Metz, 2000). Thus, it is increasingly important for older adults to sustain their driving ability as long as possible or transition to another viable means of mobility throughout the community to maintain their health and quality of life.

Occupational therapy practitioners are in a position to support continued driving and transition to other modes of mobility at the individual client and population levels because of their understanding of human performance and the influence of context and environments on that performance. In addition, driving and community mobility are within the scope of occupational therapy practice and are identified in the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014) as an instrumental activity of daily living. Attention to community mobility concerns is particularly important when the issues limit the client’s meaningful engagement in daily occupations. These concerns affect most older adults, 88% of whom continue to prefer travel in their private automobiles, although the National Household Travel Survey (Lynott & Figueiredo, 2011) reported a 40% increase in transit use from 2001 to 2009.

The social context surrounding the occupation of driving, specifically laws and policies, may support or hinder a person’s ability to engage in the occupation of driving (Stav, 2008). Therefore, it is the responsibility of occupational therapy practitioners to fully understand the implications of these policies as they affect the community engagement of their clients (Stav, 2008). Integration of these laws into intervention planning and critical reasoning will shape practice. For example, “knowledge of the state-imposed conditions of licensure specific to length of the licensure period, testing requirements for renewal, or driving restrictions is essential to maximizing engagement in driving to the fullest extent that each state will allow” (Stav, 2008, p. 150).

When a client’s health status is such that promoting driving of an automobile is contraindicated for performance and safety reasons, the objective of occupational therapy continues to be promotion of engagement in occupation to support participation (AOTA, 2014). The occupational therapy practitioner’s therapeutic efforts then focus on identifying and training the client in the use of the most appropriate and effective transportation alternatives available in his or her context (Stav, 2014). It is imperative that occupational therapists and occupational therapy assistants understand the ability of available community mobility and transition programs and the effect of community design to effectively support engagement and participation of older adults.

The scope of influence of community mobility issues extends beyond clinical practice. The needs of society with regard to community mobility become important when considering laws related to licensure and community design to support other modes of mobility. As a society, Americans are dependent on automobiles to access the community, with the exception of a few urban areas with well-developed transit systems. Laws that limit licensure in areas with little or no community mobility infrastructure can essentially immobilize thousands of people. The impact on individuals can be devastating, but the trickle-down effect to merchants and restaurants in areas that are densely populated with older adults can be equally disastrous. Policy issues, policy development, and community design can have far-reaching effects and should consider all areas of outcomes, including crash, injury, and fatality rates as well as implementation expenses and lifestyle and travel patterns of road users.

Policies that do not consider the impact on community mobility can be costly to individuals. For example, in 2006, the Florida legislature began requiring drivers ages 79 or older to pass a vision test when renewing their driver’s license (“Original Applications, Licenses, and Renewals; Expiration of Licenses; Delinquent Licenses,” Florida Stat. Ann. § 322.18, 2006). After the law passed, only 80% of those eligible for license renewal chose to do so, which translates into more people needing transportation alternatives. Of those who chose not to renew their license, approximately half reported that their decision was based on fear of failing the vision test (McGwin, McCartt, Braitman, & Owsley, 2008). Further analysis of the older adults who chose not to renew showed that they were older, in poorer health, and more likely to be female than those choosing to renew their license. Most older adults who failed the vision test or chose not to renew their license reported using transportation alternatives (McGwin, McCartt, et al., 2008). Although this policy was written and accepted with public safety in mind, the law did not consider the implications for community mobility and the resulting need for increased services or improved publicity about existing resources. Interpreting and disseminating the evidence related to policies and community mobility for older adults is important to advancing occupational therapy practice and to the practice of other health care disciplines and stakeholders.

Synthesis of the research on driving and community mobility and its implications for occupational therapy practice and education is important because it highlights the global nature of occupational engagement beyond client performance. Practitioner understanding of policy implications and community resources broadens practice to provide more comprehensive services by instilling an appreciation for the impact of contextual factors such as policy and community resources and increases the likelihood of practitioner involvement in community- or population-based initiatives to support participation at a community level.

Background

A search of the literature related to older adults and transportation revealed the urgency of the need for local, state, and national governments and age- and transportation-related agencies to resolve the impending community mobility crisis in the United States as the population ages. The substantial growth of the older adult population from 12.4% of the population in 2000 to 19% in 2030 (Administration on Aging, 2013) combined with the inadequate community mobility infrastructure in the United States (Womack & Silverstein, 2012) has catalyzed a nationwide call to action for community mobility resources.

The increased injury and fatality rates among older drivers relative to their younger counterparts are also a concern for health, safety, and transportation officials. Federal and state governments and transit agencies have been mobilized into action, or at least planning for action, by the projected growth in the older adult population, the associated increase in licensed older adult drivers, and the anticipated need for transportation options. Many driver licensing agencies across the United States and internationally have sought to alleviate concerns about older drivers through driver licensing policies and programs to improve safety. Several licensing jurisdictions have implemented programs and policies such as community outreach; driver screening and assessment; training of law enforcement, examiners, and licensing staff; medical review processes; and driver licensing and renewal guidelines (Stutts & Wilkins, 2009).

The success of driver licensing efforts was examined in this review, but note that although the injury and fatality rates are high relative to the amount of driving exposure for older adults, the decades-long trend of injury and fatality increases appears to have shifted. Cheung and McCartt (2011) examined crash, injury, and fatality rates across 13 states between 1997 and 2005 and discovered that older driver trends are changing. Their review of the data found that traffic-related fatalities among older adults declined significantly more than among middle-aged drivers and that injury and property damage rates dropped as well, but not significantly compared with declines among middle-aged drivers (Cheung & McCartt, 2011). The improvements in crash outcomes could not be attributed to a single factor, but the researchers suggested that improved general health, advances in vehicle crashworthiness, and progress in emergency and trauma services may have played a role in improving the crash outcomes among older adults (Cheung & McCartt, 2011).

For some people, driving a private automobile is not the safest option, so other modes of community mobility are necessary. The need for alternatives to driving is apparent but may be difficult to implement, in part because of a tendency for older adults to prefer driving themselves or riding as passengers in private automobiles (Lynott & Figueiredo, 2011). Despite the unenthusiastic response by the older adult segment of the population, the transportation industry is making an effort to optimize existing services or create new mechanisms to transport people. Efforts such as United We Ride, a federal interagency initiative, aim to improve “the availability, quality, and efficient delivery of transportation services for older adults, people with disabilities, and individuals with lower incomes” (United We Ride, 2009, para. 1). The Federal Coordinating Council on Access and Mobility, another federal interagency collaboration, has furthered these efforts, and it strives to “continue to improve mobility, employment opportunities, and access to community services for persons who are transportation-disadvantaged” (Federal Coordinating Council on Access and Mobility, n.d., para. 3). The influence of these initiatives on community engagement has yet to be examined.

Method for Conducting the Systematic Review

The portion of the evidence-based literature review reported in this article addressed the impact of policy, community mobility programs, and driving cessation programs on the performance and participation of older adults. Detailed information about the methodology for the entire systematic review can be found in the article “Method for the Systematic Reviews on Occupational Therapy and Driving and Community Mobility for Older Adults” (Arbesman, Lieberman, & Berlanstein, 2014) in this issue of the American Journal of Occupational Therapy. The results of this aspect of the review are reported as separate policy and community mobility domains.

Results

The systematic review included 4 Level I articles, 7 Level II articles, and 5 Level III articles and included policy interventions related to licensing policies, driving cessation programs, community mobility, and walkable communities. Supplemental Table 1 summarizes the design, procedures, outcome measures, findings, and limitations of the 16 published articles that were relevant to the topic of policy and community mobility and reviewed in this project (available online at http://otjournal.net; navigate to this article, and click on “Supplemental”).

Driver Licensing Policy

Driver licensing jurisdictions in the United States and abroad have implemented a variety of relicensing policies in an attempt to identify at-risk drivers, reduce crashes and violations, minimize injuries and fatalities, and improve overall safety on the roadways. In the United States, 14 states require some type of accelerated renewal for older drivers, and 17 states have special or additional renewal requirements for older drivers in an attempt to identify those who may be at risk for crashes, injuries, or fatalities (Molnar & Eby, 2005). These policies for older adults are well intentioned for public safety, but they are financially and personally costly, and several studies have revealed inconsistent outcomes, with mostly no significant effect on safety or performance.

One strategy has been to implement licensing restrictions, which have yielded inconsistent results. One Level III study (Braitman, Chaudhary, & McCartt, 2010) found positive effects of issuing licensing restrictions on renewal for older drivers who presented with performance concerns. The drivers with restricted licenses had fewer moving violations, crashes, or fatalities; however, they were also significantly older, drove significantly fewer miles per week, drove less at night, drove less on high-speed roads, and drove closer to home (≤5 mi) than unrestricted drivers. Another study (Nasvadi & Wister, 2009; Level II) identified safety benefits of licensing restrictions among older adults, with restricted drivers having fewer crashes after implementation of restrictions than unrestricted drivers over the 6.5-yr duration of the study.

McGwin, Sarrels, Griffin, Owsley, and Rue (2008; Level II) examined a recently instituted state law requiring vision testing for older adults during license renewal by comparing crash-related fatality rates with those of two other bordering states, neither of which had age- or vision-related license renewal policies. Older drivers in the state with the new law experienced a decreased fatality rate after implementation of the law, but the decline was consistent with the preexisting trend of reduced fatalities.

Langford and Koppel (2011; Level II) found conflicting results in their examination of the safety benefits of license restrictions, with inconsistent results for risk of crash and type of restriction. Some restrictions resulted in higher relative risk, as with required automatic transmission and required hearing aids. These studies suggested that restrictions or testing requirements for license renewal may have safety benefits, but they also revealed an increase in license forfeiture that may not have been necessary and could lead to decreased community access and, possibly, community engagement. Contrary results were also found by Dobbs (2008; Level I) in a systematic review that revealed current licensing policies as ineffective in identifying high-risk older drivers. Langford, Bohensky, Koppel, and Newstead (2008; Level II) found similar results in Australia when comparing two states and discovered that age-based assessments were not effective at improving safety.

Driving Cessation Programs

The transition from driving can be difficult for many individuals and families as they deal with the loss of independence, reduced ability to be spontaneously mobile in the community, and transition to other means of community access. Several groups of researchers have studied the transition to driving cessation and examined the effectiveness of programs in supporting that transition.

Dobbs, Harper, and Wood (2009; Level II) studied the effectiveness of a support group intervention and found the approach was effective in alleviating depression and improving quality of life. A similar study conducted with caregivers by Stern et al. (2008; Level I) also found positive effects for supportive group interventions in the areas of self-efficacy, preparedness, and acceptance. Research to examine the influence of driving cessation on social integration and perceived support from relatives and friends revealed that drivers who transitioned from driving were more likely to be female and non-White and to have lower levels of education (Mezuk & Rebok, 2008; Level III). For those who ceased driving, the inability to use public transportation was a predictor of reduced social integration.

The effects of driving cessation on health were explored by Edwards, Lunsman, Perkins, Rebok, and Roth (2009; Level I) as they sought to determine the causality or exacerbation of health declines by driving cessation. Results suggested that significant declines in the areas of physical, social, and self-rated health were consistent with precessation health trajectories; however, the trajectories were significantly steeper in decline after driving cessation (Edwards et al., 2009).

The influence of driving cessation can extend beyond individual health into overall health and community consumption. Kim and Richardson (2006; Level III) examined the association between self-rated health and functional status and consumption expenses and driving status among older people. The study revealed a significant decrease in community engagement and consumption, measured by spending on tickets, dining out, and trips, after driving cessation (Kim & Richardson, 2006).

Community Mobility Programs

Alternatives for community mobility are necessary for people who cannot demonstrate medical fitness to drive or who are approaching voluntary driving cessation. Reasonable alternatives for those who desire or need to access the community are transit resources that exist in varying types and degrees of availability depending on geographic region and population density. Availability of resources alone is not sufficient, because riders need to be comfortable with the use of the transit options and to have the cognitive and physical capabilities to use them. Studies were conducted to examine the effect of programs targeting the use of community mobility.

Di Stefano, Lovell, Stone, Oh, and Cockfield (2009; Level III) explored an educational health promotion program designed to assist older adults in choosing transportation alternatives. The educational program informed older adults about mobility transition choices and significantly increased knowledge of community mobility at the time of the posttest and at the follow-up interview. Stepaniuk, Tuokko, McGee, Garrett, and Benner (2008; Level I) examined the effect of group transit training for older adults across a control group, a group receiving transit training, and a group receiving transit training and a free bus pass. The researchers found no significant differences in the number of days participants drove their cars, but both groups who received group transit training used the bus more frequently.

Walkable Communities

Pedestrian travel is a viable mode of community mobility for older adults; in fact, it is the most preferred mode of mobility after the private automobile (Lynott & Figueiredo, 2011). However, for older adults to engage in pedestrian travel as a mobility option, the context must be supportive in terms of distance to destinations, terrain, and infrastructure design.

Gómez et al. (2010; Level III) examined the association between built environment and walking patterns of older adults and found that the amount of walking was dependent on the connectivity and density of their environment. The results suggest that environments that are too densely populated or too rural limit engagement in walking by older adults, whereas environments that are in the middle range of density and connectivity are the most conducive to older adults walking (Gómez et al., 2010). The slope of the environment also contributed to walkability, with participants living with slopes ≤5% being more likely to walk 60 min/wk (Gómez et al., 2010).

Another study of walkable communities (Frank et al., 2007; Level II) examined rates of driving and physical activity across communities of differing walkability. People living in walkable neighborhoods were likely to walk more (23.8% vs. 5.9%) and drive less (28.2 mi/day vs. 45.5 mi/day) than those living in less walkable neighborhoods, suggesting higher levels of physical activity for people living in walkable environments (Frank et al., 2007).

Discussion and Implications for Occupational Therapy Practice, Education, and Research

AOTA’s (2007) Centennial Vision is guiding occupational therapy practitioners toward science-driven, evidence-based practice to meet society’s occupational needs. Therefore, the policy and community mobility evidence examined in this systematic review should be used to direct occupational therapy practice, influence occupational therapy education, and generate further inquiry.

Implications for Practice

The evidence in this review supports the practice shift in recent years from solely addressing driving to addressing the broader construct of community mobility. The evidence has clearly identified the negative impact of community mobility loss (Edwards et al., 2009; Frank et al., 2007) and should therefore facilitate the broadening of occupational therapy practice into the area of community mobility to support occupational engagement and health. Attention to community mobility should encompass services for a full spectrum of clients, ranging from individual travelers to organizations providing transportation services to populations who travel via pedestrian and transit modes.

Many clinical and consultative roles exist for occupational therapists to support community mobility (Stav & McGuire, 2012). These roles will be increasingly in demand as the number of older drivers increases. Occupational therapists working in general practice and driver rehabilitation settings need to fully understand community mobility options and operation and limitations of area programs when making recommendations for specific clients. Efficient referral pathways need to be established to expedite transition to driving cessation without gaps in community mobility.

Opportunities for development of new roles for occupational therapists will continue as well in the area of driver licensing, including serving on medical advisory boards, contributing to the development of driver screenings used at the state level, and developing and delivering training to licensing personnel. Occupational therapy practitioners can also contribute to the delivery of transit services through identification of transportation options, provision of travel training for new transit users, and development and implementation of training to transit staff, schedulers, and drivers specific to sensitivity training, transfer training, driver safety, and use of vehicle safety features by drivers and passengers for injury prevention. Clients and families who are facing license revocation or voluntarily surrendering a license can benefit from the development of driving cessation programs, and entire communities can benefit from an occupational therapy perspective infused into community design and planning for walkable communities and transit options.

From a population standpoint, occupational therapy practitioners should contribute their perspective during policy development or policy revision of licensure laws by educating policymakers about the implications of proposed policies for their constituents' health and emotional well-being and possible economic consequences for businesses. Supplemental policies and programs should also be suggested to sustain community mobility when licensing policies become more restrictive. When testing policies are proposed, occupational therapy practitioners should educate policymakers about the inconclusive results from the evidence as well as the heterogeneity of the aging process across the population. Once policies have been implemented, more roles for occupational therapy will emerge.

The research findings from this review have practice implications specific to community mobility and meeting the occupational needs of the older adult population. Occupational therapists and occupational therapy assistants working in both general practice and driver rehabilitation settings need to support driver licensing policies that favor safe occupational engagement, fully understand community mobility options and promote the development of those options, and facilitate smooth transitions from driving cessation to alternative community mobility without gaps in community engagement.

Implications for Education

Occupational therapy educational standards require inclusion of academic content on driving and community mobility, specifically Standard B.5.13, which states, “Provide recommendations and training in techniques to enhance community mobility, including public transportation, community access, and issues related to driver rehabilitation” (Accreditation Council for Occupational Therapy Education, 2011, p. 25). The foundation of that content emphasizes driving and community mobility as an instrumental activity of daily living that significantly contributes to the life and well-being of older adults. Along with an understanding that community mobility is linked to the health of older adult clients, professional education, postprofessional education, and professional development activities should stress the importance of community mobility as a means for many other areas of occupational engagement. To that end, educational programs should highlight multiple modes of community mobility, not solely driving, in support of community access and meaningful engagement in the community. In addition, the practice area of driving and community mobility lends itself well to examples of organizations or populations as clients, particularly when referring to transit agencies, walkable communities, or state residents influenced by driver licensing policies. The evidence from this review should be infused into occupational therapy education using the appropriate type of client to facilitate understanding of practice with organizations and populations.

Implications for Research

This systematic review update revealed additional research that is needed to identify the impact of policy and community mobility programs on occupational engagement. Future studies should focus on outcomes and examine

• Community-based occupational engagement and quality of life of older adults when using transportation alternatives;

• Changes in community-based occupational engagement after restrictive license renewal;

• Use of community transportation programs in jurisdictions with restrictive license renewal;

• Differences in occupational engagement between drivers with restricted licensure versus license revocation;

• The influence of walkable communities on the health and community mobility of older adults;

• The effect of transit training programs on occupational engagement after driving cessation; and

• Comparison of occupational engagement across varying modes of transportation alternatives.

Conclusion

Occupational therapists and occupational therapy assistants must recognize the influence of the cultural context, which includes the laws and policies of society (AOTA, 2014), because these contexts affect how older adults retain their driver’s licenses and thus influence occupational therapy practice. Likewise, occupational therapists and occupational therapy assistants need to consider the physical context, including the community environment and modes of transportation within the community (AOTA, 2014), because this context affects how easily clients can move within the community. Finally, practitioners must take the social context into account, which includes the expectations of the members of society (AOTA, 2014); this context dictates how people view and accept driving cessation and transportation options and ultimately shapes older adult use of transit.

The issues of policy and community mobility directly reflect the context in which occupational therapy practitioners work and can either hinder or foster the therapeutic agenda. Practice opportunities abound for occupational therapy as the population ages and continues to require community access for successful engagement and participation. However, the profession must seize the opportunities and advocate for the profession’s role in meeting society’s occupational needs. Occupational therapy must participate in discussions when policy decisions are being made so these policies support community mobility for enhanced older adult participation and engagement. Practitioners must also work to develop and improve programs in the areas of driving cessation, transit training, and walkable communities.

Although the findings of the studies included in this review are informative, further research is needed. Much of the research related to driver licensing uses negative performance outcomes such as crashes, violation, injuries, or fatalities. From an occupational therapy perspective, the outcome of concern is occupational performance, not merely a negative event such as a crash or fatality. In an effort to generate results more applicable to occupational therapy practice, studies measuring occupational engagement in the community through the use of transportation options as an outcome are necessary. These studies should measure quality of life; frequency of access to community occupations such as medical care, shopping, and leisure interests; and social participation to determine whether community mobility options are effective in improving participation among older adults.

In the area of community mobility, research applicable to occupational therapy is lacking. Specific to intervention, studies are needed to examine the effectiveness of travel training programs and mobility management on occupational engagement, health, and quality of life. In terms of programming, research on different forms of community mobility is needed to examine the effect on older adult ridership, the capability of meeting all older adult community needs, and cost–benefit analyses of different programs.

The work mentioned here, and the research included in this review, begins to inform the profession about available options for licensure policies and community mobility programs. Similar to the original review of policy and community mobility evidence, this updated evidence-based review is informative for occupational therapy practice; however, it still does not reveal the association or influence between policy and community mobility interventions and improved engagement and participation.

These findings suggest a role for occupational therapists and occupational therapy assistants to assist in policy development and community mobility programming to promote engagement in community-based occupations. The literature has suggested a growing need for occupational therapy practitioner awareness of the impact of policy and the logistics of community mobility programs and resources. This awareness, combined with occupational therapy expertise, should be used to bring the perspective of enabling participation to the policy development process and community mobility resources. The presence and role of occupational therapy should increase in federal, state, and local policymaking agencies and in transportation companies to facilitate attention to older adult participation through engagement in community mobility. Introduction of the notion that policy and programming should enable participation in addition to preserving safety will yield results that are beneficial to the agencies and to older adult consumers.

Supplemental Materials

Supplemental Material

Supplementary material for Updated Systematic Review on Older Adult Community Mobility and Driver Licensing Policies

Supplementary material, sj-pdf-1-aot-10.5014_ajot.2014.011510.pdf for Updated Systematic Review on Older Adult Community Mobility and Driver Licensing Policies by Wendy B. Stav in The American Journal of Occupational Therapy

681_ds001.pdf

Supplementary material for Updated Systematic Review on Older Adult Community Mobility and Driver Licensing Policies

Supplementary material, sj-pdf-2-aot-10.5014_ajot.2014.011510.pdf for Updated Systematic Review on Older Adult Community Mobility and Driver Licensing Policies by Wendy B. Stav in The American Journal of Occupational Therapy