More mad and more wise

Refashioning the uneasy relationship between older people and geriatric medicine

A notable feature of most medical specialties is close joint working between patient advocacy groups and specialist societies in furthering improvements in policy and services. While growing old is not a disease, nor too is being a child, and the engagement of advocacy and international bodies such as UNICEF with paediatricians is well established and recognised. Yet almost eight decades after the founding of geriatric medicine, it is clear that this type of relationship does not hold for the advocacy bodies representing those we serve, as well as the wider constituency of older people. Geriatricians are an extraordinary resourceful and imaginative group, and a more effective promotion of our role as guardians of the longevity dividend is vital to a more positive and mutually beneficial relationship with older people and society. This will require a redirection of our focus to a more critical stance on our origins as a discipline, our relationship with ageing across the lifespan and with older people and a fuller engagement with the broader concepts of gerontology in training and research to develop a refreshed articulacy for, the opportunities arising from gerontologically attuned healthcare.

Transport, driving and ageing

Transport is the invisible glue that holds our lives together, an under-recognized contributor to economic, social and personal well-being. In public health terms, the medical profession had previously allowed itself to focus almost exclusively on the downsides of transport. However, the research basis for transport, driving and ageing is steadily evolving and has important academic and practical considerations for gerontologists and geriatricians. For gerontologists, teasing out the critical role of transport in the health and well-being of older people is an imperative, as well as the key challenges inherent in transitioning from driving to not driving. The safe crash record of a group with significant multi-morbidity allows us to focus on the remarkable strategic and adaptive skills of older people. From a policy perspective, strictures on older drivers are an exemplar of institutionalized ageism. For geriatricians, a key challenge is to develop strategies for including transportation in our clinical assessments, formulating effective strategies for assessment of medical fitness to drive, incorporating enabling techniques, giving due consideration to ethical and legal aspects, and developing and promoting multi-modality and alternative transportation options.

Family reports of medically impaired drivers in Missouri: cognitive concerns and licensing outcomes

This study investigated reasons why older adults (n=689) were reported to the Driver License Bureau, Missouri Department of Revenue, by family members as potentially unfit to drive with an emphasis on cognitive concerns and associated licensing outcomes. A total of 448 drivers were reported to have some cognitive issue; common symptoms included confusion, memory loss, and becoming lost while driving. Diagnostic labels (Alzheimer's disease (AD), cognitive impairment/dementia, brain injury/insult) were listed for 365 cases. A physician evaluation is required for license review. Of those with a diagnostic label, half (51%, n=187) failed to submit this evaluation and almost all were de-licensed immediately. Of those evaluated by a physician, diagnostic agreement between family members and physicians was high for specific conditions (100% for AD, 97% for acute brain injury), and less so for cognitive impairment/dementia (75%). This latter finding suggests that physicians and family members may understand cognitive symptoms differently. Whether cognitively impaired or not, few family reported drivers in this sample (∼2%) retained a valid license. Family members may be in the best position to recognize when medical-functional deficits impact on driving safety, and physicians and driver licensing authorities would do well to take their observations into account with respect to older driver fitness.

What are the impacts of giving up the driving licence?

Driving cessation is a gradual process, where driver's self-regulation plays an important role. Age-based licence renewal may interfere with this process and trigger premature driving cessation. The present study compares Danish drivers (aged 69 years at the baseline) who either renewed or gave up their driving licence. Data were collected in 2009 (N=1,792) and in 2012 (N=863). The standardised interviews covered respondents' background information, health and wellbeing, and transportation patterns. Non-renewers had poorer health already at baseline but did become more dependent on others in their activities after giving up their licence. In travel frequency, neither the differences between renewers and non-renewers nor the changes over time within the groups were pronounced. The groups differed in their use of transport modes already at the baseline: the renewers drove, while non-renewers travelled as passengers, used public transport, walked or cycled. Not renewing the licence was a strong predictor of unmet mobility needs, especially in relation to leisure activities. The present study indicates that younger seniors' mobility is not likely to be affected by the strict renewal policies. However, given the positive economic and safety consequences of independent mobility in old age, society should try to prevent unwarranted mobility loss. Having restrictive, ageist policies that moreover fail as societal investments may work against this goal.

Driving Cessation Anno 2010

This study focuses on the decision to either stop or continue driving among a cohort of Danish seniors whose driving licenses expire, for the first time, at the age of 70. Based on 1,537 standardized telephone interviews with licensed drivers, we compared persons who intended to renew or not to renew their licenses. The results partly recapture the findings of earlier studies. However, in contrast to former cohorts, a much higher percentage of older drivers intended to keep their licenses. The strongest factors predicting the intention to renew were active car use, feeling safe as a driver, and not having illnesses that impaired driving ability. Three of these factors were strongly correlated with gender, indicating that efforts to prevent premature driving cessation should especially focus on increasing women’s confidence and experience in driving.