Transcript Older Drivers - Pan Pacific Research

Older Drivers
A Perspective for Malaysian Consideration
Michael Hull
Research Director
Pan Pacific Research Pty Ltd
Objectives
• To establish the demographic case for taking
prompt action in anticipation of an ageing
population.
• 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 Malaysia
Wong Chay Nee, Policy Response for the Aging in Malaysia,
Malaysian Institute of Economic Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s2_02.pdf
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 - Malaysia
Wong Chay Nee, Policy Response for the Aging in Malaysia,
Malaysian Institute of Economic Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s2_02.pdf
Growth in Nuclear Family Homes:
Malaysia
[= decrease in extended family homes]
Growth of Nuclear Family Households Malaysia 1980 - 2020
Percent Nuclear Households
100
90
80
70
60
50
40
30
20
10
0
1980
1990
1994
2000
2010
Year
Adapted from: NDFBP Malaysia,
Malaysian Population & Family Survey, 1994
2020
Quantifying Household Change Malaysia
Income Growth - Malaysia
Mean Monthly Income (RM)
Malaysia
6000
National
Rural
5000
Urban
Ringgit
4000
3000
2000
1000
0
1970 1976 1979 1984 1987 1990 1995 1997 1999 2005 2010 2015 2020
Year
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
Malaysia
Wong Chay Nee, Policy Response for the Aging In Malaysia,
Malaysian Institute of Economic Research. www.mof.go.jp/jouhou/soken/kenkyu/h18/s2_02.pdf
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
elsewhere
• Increasing demand for personal mobility
• Increasing capacity to pay for personal mobility
• Increasing political and economic power to get
what they want
• Additionally an increasing number of ageing
Malaysians who have been driving for many
years will not want to stop driving
The Bad News
Australia
• 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
Malaysia
The blue line
represents fatal
and serious
injuries to drivers
in car crashes
casualties/1000 population
Fatal & Serious Injuries
Malaysia 2007
0.7
0.6
0.5
0.4
0.3
Motorcycles
0.2
0.1
Cars
0.0
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
Age Group
Derived from official Malaysian statistics by Jenny Oxley, and adapted by me.
Why?
The pink line
represents fatal
and serious
injuries to riders
of motorcycles.
Only the motorcycle
curve shows the
U-shaped curve
seen in Australia.
Time differences in
Vehicle Ownership
The increasing demand, in both countries, for
private motor vehicles can be seen in the graph.
But a much larger proportion of Malaysian vehicle
ownership is of motorcycles, rather than cars.
700
Motor Vehicles per 1000
population
It is obvious that the gap in vehicle ownership is
getting smaller.
Motor Vehicle Ownership 1975 - 2005 Malaysia & Australia
600
500
400
300
200
Australia
Malaysia
100
0
Motorcycles are a great deal less safe than cars for
those using them.
But the main point of this graph for our
discussion here, is the higher level of vehicle
ownership in Australia 40 years ago (1975). A
higher proportion of people who are now old
have been driving all their adult lives and will resist
any attempt to stop them now!
Malaysia is just beginning to encounter this
problem.
1975
1980
1985
1990
1995
2000
2005
Year
Australian data does not include motorcycles, but
these are a very small proportion of motor vehicles in
Australia. Malaysian data does include motorcycles.
2005 data for Malaysian is based on my regression of
official statistics for previous years.
Malaysian Source: (1999) Malaysian Roads General
Information, Malaysian Road Transport Dept
Australian Source (number of cars only): Australian
Bureau of Statistics (2005), Year Book of Australia,
ABS Canberra
Normal Changes in Ageing People
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•
•
•
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
• INCREASE IN DISEASES AND MEDICATIONS.
–
–
–
–
At least 30% over age 75 have significant vision impairment
50% over age 75 have significant hearing impairment.
Nearly all elderly have some degenerative joint disease.
Because of the increase in disease, the average number of medications also rises
with age, further increasing the likelihood for negative effects on driving safety.
• INCREASED FRAGILITY AND MORTALITY.
– crash rates increase with age, but mortality rates are even more impressive. Drivers
over age 85 are nine times more likely to die in a crash than drivers age 25 to 69
– Even when controlling for crash severity, older drivers are four times more likely
to die than a 20-year-old driver.
• INADEQUATE COMPENSATORY BEHAVIORS.
• Crash and mortality statistics become more significant when noting that older
drivers tend to drive less, slower, and avoid high-risk situations (eg, driving at
night, in bad weather, and on unfamiliar roads).
Odenheimer G (2006),. “Driver safety in older adults. The physician’s role in assessing driving capabilities of
older patients”. Geriatrics 61(Oct):14-21.
Increasing Life Expectancy
With increasing life expectancy
• Normal changes
– Normal changes accompanying ageing will become more
common
– As people live to be older, normal changes will become more
severe
• Diseases associated with ageing
– There will become more common
– As people live to be older
• these diseases will become more severe
• These diseases will require more medical attention & medication
How Safe will Older
Malaysian Drivers Be?
• Increasing life
expectancy increases
Life Expectancy at Birth - Malaysia 1990 - 2020
$82
$80
$78
Age
$76
$74
– the probability of
multiple medical
conditions
Adapted from World Bank Indicators, 2003.
– The probability of
Data beyond 2002 are my regressions
• Increasing
efficiencymedications
of health services and better diagnosis of diseases offers increased
multiple
$72
$70
$68
$66
1988
1992
1996
2000
2004
2010
2015
2020
Year
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
safety.
Speechley, C & Bridges-Webb, C, undated, The Pathway to Dementia Diagnosis, Research & Development Unit Project, Royal
Australian College of General Practitioners,
http://www.racgp.org.au/Content/NavigationMenu/News/Conferencesandevents/asc20071/Abstracts07/Mentalhealth07/ASC2007S
peechly.pdf
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.
http://www.racgp.org.au/Content/NavigationMenu/News/Conferencesandevents/asc20071/Abstracts07/Mentalhealth07/ASC2007S
peechly.pdf
AD - A Malaysian Problem?
• In Malaysia an estimated 50,000 people suffer from
dementia “Very few private nursing homes are dedicated to
the care of the AD sufferer although some homes will
accept a few AD sufferers if they are not behaviourally
challenged ” said Philip Poi head of geriatric medicine at
Universiti Malaya
• “Malaysia is starting to appreciate there is a problem but
currently caregiving is provided mainly by the informal
carers such as the spouse or child ”
• China has up to eight million dementia patients but very
few hospitals in the country have independent dementia
units By 2030 one in every four Chinese will be over 60.
Source: The Malaysian Insider, 3 September 2010
http://www.themalaysianinsider.com/features/article/alzheimers-scourge-hangs-over-ill-prepared-asia/
Reliable Assessment of Incidence of
Alzheimer’s in Malaysia
Reliable data is not readily available because
of the relative recent concern about
Alzheimer’s Disease and because of
diagnosis difficulties.
%
These data come from a scientific study of
522 elderly Malays living in a Malay urban
settlement in Kuala Lumpur.
The authors report that prevalence rates are
similar to those reported for similar
populations in Singapore.
As numbers of the elderly increase and
as life expectancy increases the absolute
number of cases and the prevalence rate
will both increase
Source: Krishnaswami, S, Kadir, K, Ali, R
& Mathews, S, (1997) “Prevalence of
dementia among elderly Malays in an
urban settlement in Malaysia”, Neurol J
Southest Asia, 2:159-162
What Malaysian experts say
• Although dementia has always been somewhat common, it has
become even more common among the elderly in recent history.
It is not clear if this increased frequency of dementia reflects a
greater awareness of the symptoms, or if people simply are
living longer and thus are more likely to develop dementia in
their older age.
Dementia caused by nervous system disease, especially
Alzheimer's disease, is increasing in frequency more than most
other types of dementia. Some researchers suspect that as many
as half of all people over 80 years old develop Alzheimer's
disease.
Source: Malaysian Psychiatric Association, Statement on Dementia, July 2006
http://www.psychiatry-malaysia.org/article.php?aid=80
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
conditions
• Multiple medical conditions may each be at an early
stage and difficult to diagnose.
• Multiple medical conditions may be at a more advanced
stage in people who don’t attend doctors regularly
• For example:
– Reduced vision can be overcome, to some extent by scanning
the road ahead and to the sides by moving the head from side
to side
– But if the patient has arthritic conditions and cannot move
the neck, what then?
Polypharmacy
• People with multiple diagnosed medical
conditions may be taking medicines, prescribed
by different medical specialists.
• Medical specialists are not good at reporting to
each other or to GPs about a shared patient.
• Who knows about ALL the medicines that one
patient takes?
What to do about increasing
numbers of older drivers?
• Require all persons over age ___ (60?) to have a driving
or medical test before they can renew their licence
– The problem will be an increasing demand for alternative
transport services; more time off work by family members to
transport older relatives
– Older drivers may go “doctor shopping” for a health
professional who will say they are OK to drive.
• Danger of corruption
• Danger that people won’t go to see doctors out of fear of losing
licence
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
work?
• No one is quite sure.
• Some possible explanations suggested by
researchers:
– If doctors are legally required to report, then people
simply don’t go to the doctor – not good for
national health!
– If licence tests are required when you reach a set
age, less confident drivers simply don’t attempt to
renew their licence – only the determined and those
without insight attempt to renew their licences.
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