Older Adult Drivers Living in Residential Care Facilities
Residential care facilities (RCFs) provide assistance to older adults who cannot live independently, but the extent to which residents of these facilities have retired from driving is unknown. The authors identified a population of older adults who still drive from a national cross-sectional survey (2010 National Survey of Residential Care Facilities) of 733,000 residents of RCFs, such as assisted living facilities and personal care homes, in the US. Demographic information and indicators of health, functioning, mobility, and community activity involvement, all of which could be associated with increased risk of automobile accident involvement, unsafe driving, or retirement from driving, were evaluated for each resident. Of 8087 residents, 4.5% (95% CI: 3.9–5.1) were current drivers. The drivers were mostly older than 80 years of age (74%; 95% CI: 67–79), tended to be 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 drivers (78%; 95% CI: 72–83) were independent with activities of daily living, though some needed assistance with walking and used gait devices such as a cane or a walker. RCF staff and healthcare providers should be aware of factors associated with driving risk to promote the safety of older drivers and to provide resources for the eventual transition to other modes of transportation.
Key words: Residential facility, assisted living facility, geriatric, driving
Many individuals experience changes in health, functioning, and mobility as they age that can adversely affect their driving ability. The risk of automobile accident fatality increases with age,1 and the biggest risk of harm posed by older drivers is to themselves and their passengers, rather than to other drivers or pedestrians.2,3 Factors that contribute to driving difficulties and increased automobile accident risk include increased age; medical conditions; impairments in cognitive, mental, physical and sensory functioning; and the use of medications to treat these conditions and impairments.4–7 Although there is not a particular age at which adults are encouraged to “retire” from driving, most older men and women will outlive their ability to drive safely by 6 years and 10 years, respectively, and thus should prepare for a transition from driving to other modes of transportation.8
The same factors that can affect driving ability also impact an individual’s ability to live independently; thus, some older adults may choose or be required to live in residential care facilities (RCFs). RCFs provide long-term housing and supportive services, including assistance with functioning, mobility, and transportation. These facilities are state-regulated and include assisted living facilities, personal care homes, and other residences. RCFs offer a range of personal care services (eg, bathing, dressing) or health-related services (eg, medication assistance); room and board with at least two meals per day; and on-site supervision.9,10 In 2010, there were approximately 733,000 residents who live in RCFs in the United States, 54% of whom were older than 85 years of age.11
Because of their advanced age, RCF residents are likely to have functional limitations that may increase their risk of being involved in automobile accidents if they are still driving. Direct care providers and staff who work at RCFs may be aware of information about these individuals that may enable them to identify 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 (iADL), especially those that involve cognitive and sensorimotor skills, may be predictive of difficulty with driving.14,15 Additionally, RCFs may help support the transition to driving cessation by providing accessible alternatives to residents who no longer drive, such as volunteer ride services and shuttles.16
To date, there are no regional or national studies that provide information about RCF residents who continue to drive. The 2010 National Survey of Residential Care Facilities (NSRCF) from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics presents a unique opportunity to characterize residents of US long-term facilities other than nursing homes, such as assisted living residences and board and care homes.9,17 Specifically, the objectives of the survey were to provide national estimates of the number of US RCFs and residents receiving care, and to determine characteristics of facilities and their residents.
The goal of this study is to characterize RCF residents who drive using the NSRCF survey. We evaluated demographic information and indicators of health, function, mobility, and community activity involvement, because these factors tend to be associated with increased driving risk in older drivers. This contemporary description of drivers living in RCFs may help identify opportunities for supporting safe driving practices among RCF residents and for supporting the transition to alternative modes of transportation as needed.
Methods
Study Design
We performed a secondary analysis of the resident data file from the 2010 NSRCF of the National Center for Health Statistics.17 The Colorado Multiple Institutional Review Board reviewed and approved the study protocol as an exempt study. Full details of survey methodology, including sampling, questionnaire, and interview processes, are described elsewhere.9 Briefly, RCFs included in the survey were 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; within these sampling strata, 3650 RCFs were systematically and randomly sampled with probability proportional to size.9
Study Participants
Surveys were collected via in-person interviews with facility directors or their designated staff (registered nurses [RNs], licensed practical nurses [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. Interviews were completed with 2302 facilities and 8094 current residents. We included in our analysis residents for whom an affirmative answer was given to the question: “Does [resident] still drive?” There were 8087 residents for whom data on driving status was available; for 7 residents, driving status was unknown. There were 287 residents who were identified as still driving by the survey respondents.
Descriptive Variables
Variables analyzed for each RCF resident identified as still driving were selected on the basis of previous studies that identified factors associated with potentially impaired driving ability or with increased risk of automobile accident involvement for older drivers.4,15 Demographic information and indicators of health, functioning, mobility, and community activity involvement were assessed. The demographic indicators included age, gender, length of stay in the RCF, and residence prior to living in the RCF. Indicators of health included health status; the presence of sensory limitations such as hearing or vision loss; diagnosis with one of the 10 medical conditions most common among RCF residents (eg, stroke, Alzheimer’s disease/other dementias);11 diagnoses associated with motor or cognitive impairment (ie, arthritis, dementia, stroke); mental status; and healthcare utilization. Mental status was determined on the basis of responses of the interviewee (ie, facility director or other knowledgeable staff) to the following questions: (1) “Is [resident] limited in any way because of difficulty remembering or because [resident] experiences periods of confusion?”; and (2) “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?” Indicators of functional ability included the need for assistance with activities of daily living (ADLs) and use of gait devices. Mobility was determined on the basis of the responses of the interviewee to the following questions: “Without assistance and without equipment, how difficult is it for [resident] to (1) walk a quarter mile, about three city blocks; (2) walk 10 steps without resting; (3) stand or be on feet for about two hours; or (4) go out to do things like shopping, movies, or sporting events?” Indicators of community activity involvement included the response of the interviewee regarding whether the resident participates in activities such as “shopping or trips”; “leaving facility grounds”; or “going out to the movies, dining out, or other social activities” “at least twice a month, regardless of whether or not it is arranged by the facility.” Use of transportation assistance was assessed for RCF residents who still drove as well as for RCF residents who did not drive (n=7800). This variable was assessed on the basis of the interviewee’s responses to the questions of whether the resident “received any assistance going outside of the facility grounds”, “used transportation to medical appointments”, or “used transportation to stores and elsewhere”. Full details of the NSRCF resident questionnaire are available on the CDC website.18
Statistical Analysis
Variables were categorized based on clinically meaningful thresholds. Statistical analyses were performed using Stata 12.1 (StataCorp, College Station, TX). For each variable, <1% of subjects had 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). Weighted results were not calculated for groups with fewer than 30 residents, in accordance with NSRCF directions, due to unreliability of weighted estimates.
Results
Of 8087 residents surveyed in the 2010 NSRCF, 287 were identified as still driving (4.5% of 732,419 residents surveyed; 95% CI: 3.9–5.1). For reference, in 2011, 16% of all licensed drivers (35 million individuals) were older adults.1 Of the RCF residents who still drove, 74% (95% CI: 67–79) were aged 80 years and older, and 50% were women (95% CI: 44–57; Table 1). Most had lived in an RCF for <5 years (82%) and had moved there from a private residence (90%; 95% CI: 85–94). Their overall health status ranged from excellent to fair/poor, with a large number of individuals having very good health (31%; 95% CI: 25–38) or good health (35%; 95% CI: 29–42). The median number of chronic medical conditions per individual was 2, with a range of 1–6. Only a small number of RCF residents who still drove had a diagnosis of Alzheimer’s disease or other dementias, had a history of stroke, used oxygen therapy, or had difficulty seeing. However, confusion (7.9%, 95% CI: 5.3–12) or short-term memory problems (7.5%, 95% CI: 4.9–11) were more commonly reported for RCF residents who still drove.
Table 2 presents the functioning, mobility, and community activity involvement of RCF residents who still drove. The majority of these individuals were completely independent with ADLs (78%), and 21% (95% CI: 16–26) only required assistance with one or two ADLs. One in four RCF residents who still drove (25% [95% CI: 20–32]) required assistance with walking, and similar percentages reportedly required the use of a cane (24%; 95% CI: 19–31) or a walker (25%; 95% CI: 20–31). Many RCF residents who still drove had limited mobility, as measured by reported difficulty walking ¼ mile, walking 10 steps without resting, or standing for 2 hours. Among RCF residents who still drove, the vast majority had no or little difficulty participating in community activities (82%, 95% CI: 76–86). These individuals regularly left the RCF, went shopping or on other trips, and went out for social activities (Table 2).
The NSRCF survey asked all residents about their use of transportation assistance—modes of transportation offered by facility staff or provided at the facility by non-facility staff—for community activities. A smaller percentage of residents who still drove (n=287) used transportation assistance than did residents who did drive (n=7800) for leaving the RCF grounds, attending medical appointments, and running other errands (Figure 1).
Discussion
This study provides the first national estimate of the number of RCF residents in the United States who continue to drive. In 2010, 4.5% of RCF residents reportedly still drove. Most of these individuals were older than 80 years of age and were in very good or good health. Although most were able to carry out ADLs independently, a substantial minority required assistance with walking and experienced various limitations in their personal mobility and levels of community activity involvement.
In this analysis, we described the prevalences of several identifiable demographic, health, mental, and cognitive characteristics among older adult residents of RCFs who still drive; these may be indicators of increased driving risk.13 Although the older adult drivers who live in RCFs comprise a small percentage of the total number of older adult drivers in the United States, the rate of automobile accident fatalities increases after age 75 and even more notably after age 80, suggesting that older adults may need improved screening and counseling regarding their ability to drive safely.19,20
Although the percentages of drivers with diagnoses of dementia or stroke were relatively small, larger proportions of residents were described as having difficulty remembering, experiencing confusion or having short-term memory problems. These results are unsurprising considering that dementia is often underdiagnosed and that mild cognitive impairment and delirium are prevalent in older adults.21 However, the high prevalence of cognitive and mental status issues among this population of older drivers is concerning, because cognitive impairment is the primary risk factor for driving-related injuries and crashes.4,12 The discrepancy between the proportion of residents with a known diagnosis of dementia or stroke and the proportion for whom cognitive or mental status impairments were reported by RCF staff on the survey suggests that there is a need for improved awareness among RCF staff of their residents’ driving status, of strategies for reducing risk of automobile accident involvement, and of opportunities to provide critical insights regarding driving ability to residents, their loved ones, and healthcare providers.22
The description of this population of older drivers highlights the functioning, mobility, and community activity levels of RCF residents who continue to drive. Approximately 21% of RCF residents who still drove required assistance with one or two ADLs, including walking, and approximately 25% used a cane or walker. With regard to mobility, walking a distance of ¼ mile, walking 10 steps, or standing for 2 hours were frequently reported as being 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.23
The findings support a need for heightened awareness of how residents’ mobility can affect their ability to drive safely. Healthcare providers can integrate the input of RCF staff regarding a resident’s mobility with the resident’s own perspective as well as their performance on functional screening questionnaires and physical screening tests, such as the Get-up-and-Go test, as part of personalized mobility counseling.24 The American Occupational Therapy Organization suggests that general occupational therapists, many of whom serve older adults living in RCFs, can also be involved in driving assessments.15,25,26 An iADL assessment can provide information about driving activity and can thus be used to identify individuals who might benefit from further evaluation or a driving rehabilitation program.14,25,27
This study has several limitations. The responses were provided by staff members from each facility (including directors, RNs, LPNs, or personal care aides), who knew the residents well through direct care and interactions, but these responses were not directly verified with residents and may have been inaccurate or biased. In seven instances, the respondent did not know the resident’s driving status. Future work will need to verify the accuracy of our findings through direct surveys of older adult RCF residents regarding their driving patterns and abilities. Furthermore, this analysis did not include a comparison of the physical and cognitive abilities of drivers and non-drivers living in RCFs, because we were most interested in describing the population of RCF residents who still drove.
Although the NSRCF includes information on several medical conditions, it does not include information on medication use, including the use of sedating agents (eg, anticholinergic medications, CNS depressants such as benzodiazepines) that can impair driving ability.7 The available NSRCF data also does not include information about driving frequency and patterns, which influence the risk of automobile accident involvement.
This study has several potential applications. Residents who drive, RCF staff and healthcare providers involved in their care, and family members and friends should be aware of methods for maintaining safe driving capacity, such as maximizing mental alertness, engaging in regular physical activity and exercise, and maintaining an optimal driving position. Furthermore, residents who drive should consider planning for eventual retirement from driving, and their care providers and family members should support them in this process.28 Given our findings that most RCF residents who still drove had recently moved to the RCF (within the previous few years), we hypothesize that driving cessation may happen relatively soon after relocating to an RCF. RCF staff and healthcare providers should consider the best approach for discussing with RCF residents changes in their driving patterns in order to effectively assist residents and their loved ones with the transition towards driving cessation.28,29 This study also showed that RCF residents who still drove concurrently used alternative means of transportation provided by the RCF in order to attend activities off of the RCF grounds, attend medical appointments, and run other errands, suggesting that some of these residents are open to using alternative modes of transportation. The extent to which the transportation needs of RCF residents are being met is another topic for further study. Given the association between driving cessation and negative outcomes like depression,30 the provision of resources to support quality of life and well-being of older adults who cease driving is an important need for older adult residents of RCFs.
Conclusion
This is the first national, contemporary description of RCF residents who continue to drive. Although only a minority of RCF residents still drove, many of these older adults had multiple health, cognitive, functional, and mobility impairments that suggested an increased risk of experiencing driving-related accidents and injuries. The findings highlight the need to support increased awareness and counseling regarding safe driving in RCFs, an expanding sector of the continuum of care for the aging US population. We identified characteristics that were observed by RCF staff such as memory difficulty or confusion, limitations with ADLs or iADLs, and limitations in mobility that could trigger discussions about improving driving safety or transitioning to driving cessation. Future research is needed to understand the perspectives of residents on their driving patterns and abilities and to determine the best approaches for supporting eventual driving cessation. RCFs should ensure that they are providing adequate transportation alternatives for this population as their health and functional needs change.
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