Older Drivers by wulinqing


									    Older Drivers
A Perspective for Malaysian Consideration

                 Michael Hull
               Research Director
          Pan Pacific Research Pty Ltd
• To establish the demographic case for taking
  prompt action in anticipation of an ageing
• To briefly consider political and social issues
  around older drivers
• To examine dementia as an example of older
  driver health concerns
• To summarise major health concerns around
  older drivers
Demographic Change
    2000 - 2010
Demographic Change
    2020 - 2050
  Summary of Population Change -

                  Wong Chay Nee, Policy Response for the Aging in Malaysia,
Malaysian Institute of Economic Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s2_02.pdf
           Why Changes in Malaysia?
•    Declining fertility
•    Falling mortality rates
•    Improved health & nutrition
•    Longer life expectancy

                      Wong Chay Nee, Policy Response for the Aging in Malaysia,
    Malaysian Institute of Economic Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s2_02.pdf
         Move from Rural to Urban -

                  Wong Chay Nee, Policy Response for the Aging in Malaysia,
Malaysian Institute of Economic Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s2_02.pdf
Growth in Nuclear Family Homes:
                                     [= decrease in extended family homes]
                                       Growth of Nuclear Family Households Malaysia 1980 - 2020

  Percent Nuclear Households

                                       1980       1990        1994          2000       2010       2020

                                               Adapted from: NDFBP Malaysia,
                                          Malaysian Population & Family Survey, 1994
Quantifying Household Change -
           Income Growth - Malaysia
                                                  Mean Monthly Income (RM)

                       6000           National
                       5000           Urban





                              1970 1976 1979 1984 1987 1990 1995 1997 1999 2005 2010 2015 2020

Adapted from: Zin, Ragaya, Explaining the Trend in Malaysian Income Distribution, www.eadn.org/reports/webfiles/i06.pdf
                           Data after 1995 are my regressions based on above data 1970 – 1995.
 Malaysia: Education Levels of Older
  Persons 1970 – 2020 (percentage)

Source: Department of Statistics, Malaysia (1998).
 Recognition of Coming Change

                  Wong Chay Nee, Policy Response for the Aging In Malaysia,
Malaysian Institute of Economic Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s2_02.pdf
  Summary of Expected Change

• Increasing urbanisation of older Malaysians
• Decreasing numbers of older Malaysians living
  with extended family
• Increasing income of older Malaysians
• Increasing education of older Malaysians
• Increasing proportion of older Malaysians
  Implications for Malaysia’s Future
All these things suggest the same changes seen
• Increasing demand for personal mobility
• Increasing capacity to pay for personal mobility
• Increasing political and economic power to get
  what they want
• Additionally an increasing number of ageing
  Malaysians who have been driving for many
  years will not want to stop driving
                         The Bad News
• There is an increased serious injury
  crash risk amongst older drivers,
  starting from about age 60.
    – The black line shows the
      unadjusted crash risk
    – The red line shows the crash risk
      adjusted for vulnerabity – Older
      drivers are more frail and therefore
      more easily injured
• Research suggests that a significant
  proportion of the remaining risk
  after allowing for frailty rests from
  older people driving more
  frequently on local roads with
  many intersections, mostly without
  traffic lights.                            Langford, J, Andrea, D, Fildes, B, Williams, T & Hull, M (2006),
                                             Assessing Responsibility for Older Drivers’ Crashes, Austroads Project No.
                                             SS1111, Austroads, Sydney
                                                                      The Bad News
                                                                   Fatal & Serious Injuries                                          The blue line
                                                                         Malaysia 2007                                                    represents fatal
                                                                                                                                          and serious
                                                                                                                                          injuries to drivers
casualties/1000 population

                                                                                                                                          in car crashes
                                                                                                                                     The pink line
                             0.2                                                                           Motorcycles                    represents fatal
                             0.1                                                                                                          and serious
                             0.0                                                   Cars                                                   injuries to riders
                                    0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
                                   years years years years years years years years years years years years years years years years
                                                                                                                                          of motorcycles.
                                                                              Age Group                                              Only the motorcycle
                       Derived from official Malaysian statistics by Jenny Oxley, and adapted by me.
                                                                                                                                           curve shows the
                                                                                                                                           U-shaped curve
                                                                                                                                           seen in Australia.
                          Time differences in
                          Vehicle Ownership
The increasing demand, in both countries, for                                             Motor Vehicle Ownership 1975 - 2005 Malaysia & Australia

private motor vehicles can be seen in the graph.                                    700

It is obvious that the gap in vehicle ownership is

                                                          Motor Vehicles per 1000
getting smaller.



But a much larger proportion of Malaysian vehicle                                   200

ownership is of motorcycles, rather than cars.                                      100


Motorcycles are a great deal less safe than cars for
                                                                                            1975     1980      1985      1990     1995      2000     2005

those using them.
But the main point of this graph for our                  Australian data does not include motorcycles, but
discussion here, is the higher level of vehicle           these are a very small proportion of motor vehicles in
ownership in Australia 40 years ago (1975). A             Australia. Malaysian data does include motorcycles.
higher proportion of people who are now old               2005 data for Malaysian is based on my regression of
have been driving all their adult lives and will resist   official statistics for previous years.
any attempt to stop them now!
                                                          Malaysian Source: (1999) Malaysian Roads General
Malaysia is just beginning to encounter this              Information, Malaysian Road Transport Dept
problem.                                                  Australian Source (number of cars only): Australian
                                                          Bureau of Statistics (2005), Year Book of Australia,
                                                          ABS Canberra
     Normal Changes in Ageing People
• Slowing reaction time, taking longer to make complex decisions.
• Difficulty with multi-tasking and selective attention.
• Less accurate in judging speed and distance.
• Pupils become smaller and slower to adapt to sudden changes in light
  intensity, such as headlights.
• Driving issues correlate with measures of frailty, falls, and dementia.
• However:
        – older drivers do tend to curb night driving;
        – often choose not to drive at peak traffic periods;
        – often choose not to drive in rain.
• With the great heterogeneity in older populations in health and function, age
  should not be the determining factor for driver licensing.
• Driving is already considered one of the most dangerous activities at any age.
  So when is the risk unacceptable? This is a societal and political question…
    Odenheimer G (2006),. “Driver safety in older adults. The physician’s role in assessing driving capabilities of
    older patients”. Geriatrics 61(Oct):14-21.
    Increasing Morbidity in Older People
     –   At least 30% over age 75 have significant vision impairment
     –   50% over age 75 have significant hearing impairment.
     –   Nearly all elderly have some degenerative joint disease.
     –   Because of the increase in disease, the average number of medications also rises
         with age, further increasing the likelihood for negative effects on driving safety.
     – crash rates increase with age, but mortality rates are even more impressive.
       Drivers over age 85 are nine times more likely to die in a crash than drivers age 25
       to 69
     – Even when controlling for crash severity, older drivers are four times more likely
       to die than a 20-year-old driver.
• Crash and mortality statistics become more significant when noting that older
  drivers tend to drive less, slower, and avoid high-risk situations (eg, driving at
  night, in bad weather, and on unfamiliar roads).
 Odenheimer G (2006),. “Driver safety in older adults. The physician’s role in assessing driving capabilities of
 older patients”. Geriatrics 61(Oct):14-21.
     Increasing Life Expectancy
With increasing life expectancy
• Normal changes
   – Normal changes accompanying ageing will become more
   – As people live to be older, normal changes will become more
• Diseases associated with ageing
   – There will become more common
   – As people live to be older
      • these diseases will become more severe
      • These diseases will require more medical attention & medication
                    How Safe will Older
                   Malaysian Drivers Be?
• Increasing life
                                                                          Life Expectancy at Birth - Malaysia 1990 - 2020



  expectancy increases                                   $78



      – the probability of multiple                      $72


        medical conditions

                                                               1988       1992     1996       2000          2004   2010     2015   2020

      – The probability of

                                                                      Adapted from World Bank Indicators, 2003.
        multiple medications                                             Data beyond 2002 are my regressions
• Increasing efficiency of health services and better diagnosis of diseases offers increased
detection of many common diseases
•Increasing age brings increasing risk of disease and multiple disease.
• The cumulative effect of multiple conditions, each of which may not, by itself, be
significant, and the medications used to treat them, may combine to create an unsafe driver.
                     Example: Alzheimer’s
                     First Problems Noticed
•   Confusion with everyday tasks
•   Cooking/housekeeping
•   Forgetting people/names
•   Repetitive behaviour or speech
•   Losing things or getting lost
•   Problems managing money
•   Personality or behaviour changes
•   INSIGHT: Patients may be unaware that they have
    these symptoms and not understand the impact on road
    Speechley, C & Bridges-Webb, C, undated, The Pathway to Dementia Diagnosis, Research & Development Unit Project, Royal
    Australian College of General Practitioners,
   Alzheimers: Anecdotal Driving Issues

• Gets lost whilst driving. Stops in middle of busy road
  to work out where to go.
• “Talking through” a driving assessment: Patient says,
  “there is a Stop Sign ahead. That means I have to stop and look
  both ways before driving through”. Then drives through
  without stopping.
• Patient with no previous convictions, drives
  unroadworthy car to shops, twice in one day, despite
  having had licence cancelled for health reasons.
               Alzeimer’s Disease
            The Australian Experience
• Time to diagnosis
  – Retrospective: 2 to 2.5 years
  – Prospective: up to 5 years
• In one study, GPs referred only 23% of those
  they suspected might have dementia
• On average, carers and family members delayed
  2 – 2.5 years before taking concerns to doctor
  Speechley, C & Bridges-Webb, C, undated, The Pathway to Dementia Diagnosis, Research & Development Unit Project, Royal
  Australian College of General Practitioners.
     AD - A Malaysian Problem?
• In Malaysia an estimated 50,000 people suffer from
  dementia “Very few private nursing homes are dedicated to
  the care of the AD sufferer although some homes will
  accept a few AD sufferers if they are not behaviourally
  challenged ” said Philip Poi head of geriatric medicine at
  Universiti Malaya
• “Malaysia is starting to appreciate there is a problem but
  currently caregiving is provided mainly by the informal
  carers such as the spouse or child ”
• China has up to eight million dementia patients but very
  few hospitals in the country have independent dementia
  units By 2030 one in every four Chinese will be over 60.
    Source: The Malaysian Insider, 3 September 2010
 Reliable Assessment of Incidence of
       Alzheimer’s in Malaysia
Reliable data is not readily available because
of the relative recent concern about
Alzheimer’s Disease and because of
diagnosis difficulties.                                                          %
These data come from a scientific study of
522 elderly Malays living in a Malay urban
settlement in Kuala Lumpur.
The authors report that prevalence rates are
similar to those reported for similar
populations in Singapore.                        Source: Krishnaswami, S, Kadir, K, Ali, R
                                                 & Mathews, S, (1997) “Prevalence of
As numbers of the elderly increase and           dementia among elderly Malays in an
as life expectancy increases the absolute        urban settlement in Malaysia”, Neurol J
number of cases and the prevalence rate          Southest Asia, 2:159-162
will both increase
        What Malaysian experts say
• Although dementia has always been somewhat common, it has
  become even more common among the elderly in recent history.
  It is not clear if this increased frequency of dementia reflects a
  greater awareness of the symptoms, or if people simply are living
  longer and thus are more likely to develop dementia in their
  older age.

  Dementia caused by nervous system disease, especially
  Alzheimer's disease, is increasing in frequency more than most
  other types of dementia. Some researchers suspect that as many
  as half of all people over 80 years old develop Alzheimer's
   Source: Malaysian Psychiatric Association, Statement on Dementia, July 2006
    Health conditions: a concern
• The elderly, in both Australia and Malaysia,
  often go to a health professional as a last resort.
   – One result is that health conditions that could be
     treated are not diagnosed until late in the
     progression of the disease.
   – In Australia, and probably in Malaysia, this is
     especially true for men.
• Unless family and friends speak to older people
  about their driving, they may not be aware of
  the danger they create for other road users
          Multiple conditions
• Diagnosed multiple conditions
  – Some multiple conditions commonly go together –
    like diabetes and cardiovascular illness, but both
    require separate medications. Safe driving concerns
    may be quite different however. Each condition,
    considered separately may not be at a severe enough
    stage to prevent driving. But what are the
    cummulative effects, each treated by a separate
    medical specialist?
  Sub-clinical undiagnosed multiple
• Multiple medical conditions may each be at an early
  stage and difficult to diagnose.
• Multiple medical conditions may be at a more advanced
  stage in people who don’t attend doctors regularly
• For example:
   – Reduced vision can be overcome, to some extent by scanning
     the road ahead and to the sides by moving the head from side
     to side
   – But if the patient has arthritic conditions and cannot move
     the neck, what then?
• People with multiple diagnosed medical
  conditions may be taking medicines, prescribed
  by different medical specialists.
• Medical specialists are not good at reporting to
  each other or to GPs about a shared patient.
• Who knows about ALL the medicines that one
  patient takes?
       What to do about increasing
        numbers of older drivers?
• Require all persons over age ___ (60?) to have a driving
  or medical test before they can renew their licence
   – The problem will be an increasing demand for alternative
     transport services; more time off work by family members to
     transport older relatives
   – Older drivers may go “doctor shopping” for a health
     professional who will say they are OK to drive.
      • Danger of corruption
      • Danger that people won’t go to see doctors out of fear of losing
 Older Driver Testing in Australia
• The 8 different driver licence authorities in Australia (States &
  Territories) have different rules about testing older drivers to
  determine if they are still able to drive.
• Only the State of Victoria does not impose any tests on drivers
  because of their age. Victoria relies on self-reporting, the
  reporting of family, Police and Health Professionals instead.
• Langford and his colleagues found, in 2004, that older drivers in
  Victoria were no more likely to be involved in casualty crashes
  than older drivers in States & Territories that require mandatory,
  age-based testing. In some States & Territories the older driver
  crash rate was higher than Victoria, where there are no
  mandatory tests.
 Langford, J, Fitzharris, M, Koppel, S. & Newstead, S (2004), “Effectiveness of Mandatory License Testing for Older Drivers in Reducing Crash Risk Among
                                          Urban Older Australian Drivers”, Traffic Injury Prevention, Volume 5:4 pp 326 - 335
  Why doesn’t Older Driver Testing
• No one is quite sure.
• Some possible explanations suggested by
  – If doctors are legally required to report, then people
    simply don’t go to the doctor – not good for
    national health!
  – If licence tests are required when you reach a set age,
    less confident drivers simply don’t attempt to renew
    their licence – only the determined and those
    without insight attempt to renew their licences.
                 A Possible Answer
• Education of older drivers and their families and friends
• Continuing medical education of health practitioners to alert
  them to additional responsibilities in an ageing – and driving –
  population (this includes optometrists).
• A requirement for older drivers to report health conditions to
  JPJ by way of a legal declaration
• Enabling families, friends, health professionals and maybe Police
  to report older drivers whose driving is dangerous
    – Legally protect anonymity of those reporting and protect them from all
      possible legal action.
• The answer is not simple because older people will be at greater
  risk of serious injury if they are walking than if they are driving!
                                              Finally …
• The Malaysian answer to this emerging problem of
  ageing drivers must be a Malaysian answer, carefully
  tuned to Malaysian culture and expectations.
• But it must also act to keep older people, and the rest
  of the community safe.
• Asking appropriate questions is a logical first step
    – You might like to consider Malaysian answers to the
      questions at the end of each Chapter in the Discussion Paper
      of the Victorian Parliament’s Road Safety Committee
      Discussion Paper.
 Hull, M (principal author) (2000), Improving Safety for Older Road Users, Road Safety Committee, Parliament of Victoria, Melbourne

To top