Fitness to drive
When is it time to give up the car keys and let someone else sit behind the wheel? It's a question that is coming to the forefront of public debate and government legislation

     Life can be measured by a series of defining moments. Many are age-related. Sixteen, for example, is often remembered as "the year I got my driver's licence," a marker of maturity and independence that usually lasts for a lifetime.
But with increasing frequency, there's a corresponding – and often traumatic – marker at the other end of the timeline. It's the moment when a doctor, transportation official or family member says: "Time to hand over the car keys."
The issue of safety and the aging driver is one that has surged to the forefront of public discussion and legislative debate in recent years. While seniors organizations expound on the need for mobility as an aging population demands the right to independence, extreme incidents – an elderly woman confidently driving against the traffic in the wrong lane on Hwy. 401 in Ontario, or an unfortunate Toronto woman killed after being run over by an older driver – underline the need for controls.
It's a tough situation for those who must give up the independence and tough for the physician who often must make the decision, says Dr. David Walter Irving, of Edmonton.
"Many older people feel that a driver's licence is incredibly important to them," says Irving, chairman of a committee that last year produced the sixth edition of the Canadian Medical Association doctor's guide, Determining Medical Fitness to Drive. "It gives them mobility; it gives them independence; it gives them the ability to do things and not have to rely on friends or relatives. As a physician, it's often difficult to say 'I think you'd better stop driving.' However, that's sometimes a very necessary thing to do."
It's also often a judgment call.
Physical factors – vision, hearing, restricted movement and reduced strength due to arthritis, potential problems from medications, cardiovascular conditions or progressive diseases – are fairly obvious and easily evaluated, Irving says.
Cognitive assessment poses the greater problem since the symptoms are more subtle. It's also more dangerous, he notes, since those with cognitive dysfunction who do make an error tends to become rattled, potentially leading to other, more serious, errors.
Doctors have strategies to test memory and judgment but there are grey areas and patients in early stages of cognitive failure or dementia are often skilled at bluffing and covering up minor slips. Now, however, there's a relatively new assessment tool  gaining recognition and popularity across the country and sparking interest in the U.S. as well.
Based on scientific research, the DriveABLE evaluation, developed by another Edmonton doctor, Allen Dobbs, offers a definitive answer to the question "when it is time to stop driving?" Dobbs maintains it's purpose is as much to keep safe drivers on the road as it is to take away licences.
"The reason people decline in their driving abilities is because they have some health problem. Otherwise there's no reason for any decline," says the former director of the Centre for Gerontology at the University of Alberta. "It isn't really a matter of age. It really is a matter of having a medical condition that can affect your driving."
Dobbs's research involved driving tests on a standardized road course with hundreds of drivers, including those with "ample empirical evidence of unsafe driving" and corresponding age-matched healthy drivers. The errors made were categorized into those exclusive to unsafe drivers and others which do not signal a decline in competence. These formed the basis for scoring and pass/fail criterion.
Many errors made by the unsafe group were extremely dangerous, he says, citing examples like going the wrong way on a freeway, attempting to merge directly into cars in an adjacent lane, not seeing a pedestrian in a crosswalk and head-on collisions avoided only by the evaluator taking control. This made road testing for all clients too risky.
The result is a user-friendly computer test. Successful performance requires memory, judgment, decision-making, attention and motor speed abilities and the integration or shifting among these abilities. Failure of this portion signals that the person is "out of normal range and shouldn't be driving," Dobbs says.
For clients who achieve a borderline score, it's supplemented by a 40-minute road test. The maneuvers and road conditions have been shown in the research to reveal errors of medically compromised drivers and penalties are not given for errors characteristic of healthy drivers. Dobbs says about two-thirds of those tested do not pass.
This test offers a consistent standard that was not previously available, says Deb LeBlanc, of Toronto's Saint Elizabeth Health Centre, where the assessment had its Ontario launch in 1999. "It's a research-based method of fairly and objectively assessing a driver's competence … It focuses on ability and judgment, not basic driving skills."
"The more this kind of testing is available the better," Irving says. He also sees an advantage in the ability to clearly show clients how they are performing so that the ultimate decision is not a subjective one by doctors. "All of us think we are the best drivers ever but this kind of test can sometimes show people, Look, sorry but you're not quite as good as you thought you were."
The issues are also being examined by governments across the country in an effort to come up with appropriate guidelines. A Task Force on the Aging Driver was formed in 1998 under the auspices of the Canadian Council of Motor Transport Administrators (CCMTA), a non-profit organization comprising representatives of provincial, territorial and federal governments who consult on and standardize policies and regulations dealing with transportation and highway safety.
The group released its Aging Driver Strategy last fall, a framework for future initiatives. Members concluded that setting an age, such as 50 or 55, for mandatory testing was unrealistic, particularly given the sensitivity of the topic, says Ian Tomlinson, CCMTA programs manager. Emphasis will rather be given to awareness and education aimed at the medical community and the public and provision of practices guidelines.
Future initiatives could include restrictive licenses that specify when and where driving is allowed. This would give senior drivers, particularly in rural areas where alternative transportation is a problem, some mobility for necessary tasks such as banking and grocery shopping while limiting access to problem areas like busy freeways.
Many seniors, Irving says, already self-regulate themselves in this way. Realizing their abilities have decreased they opt not to drive in certain conditions – at night, during rush hour or in bad weather.