2. What will the Candrive program do to make roads safer?

3. When should an older person stop driving (or at what age)?

4. What driving restrictions should be placed on older drivers?

5. Will Candrive limit the rights and freedom of older drivers?

6. Should older drivers be tested on an annual basis?

7. What immediate recommendations do you have to improve road safety?

8. Can families request that a person's driving privileges be revoked?

9. Should all people with Alzheimer's (dementia) have their license revoked?

10. Will seniors' groups or government will support your driving rules? What support have you obtained from these groups at this point?

11. Why is age 65 (or 70) identified as the age to become concerned about driving ability? ( What happens when people get older that makes them unsafe drivers?)

12. If you are tracking crashes through a government database, isn't that like a “Big Brother” scenario involving an invasion of privacy?

13. What kind of screening test are you looking for? Shouldn't the Ministry of Transportation be doing those tests instead of doctors?

14. Don't several driving assessment programs already exist? How is yours different?

15. By revoking a senior's driving license are they not at risk of being isolated? What can family members and the community do to prevent isolation in seniors who lose their license?

16. Some places allow drivers with disabilities to drive under restricted conditions. Is that a good idea?

17. What is the long term goal of Candrive?

18. If this is a research grant, is there a particular project?

19. How can you make any decisions about driving ability in the doctor‘s office, without watching someone drive?

20. How do physicians presently decide when someone should stop driving? What training do doctor‘s have to assess the ability to drive of the elderly?

1. Why are physicians not adequately protecting the public by preventing dangerous older drivers from driving? What should physicians be doing differently?

Many Canadian physicians have been given the legal responsibility of determining if their patients are safe to drive from a health-related perspective. Such a responsibility is not universal, as many jurisdictions in the U.S and Europe do not require their physicians to make such judgements . Unfortunately, even though most Canadian physicians have been delegated this role, the valid and reliable tools to assist them in assessing who is & who is not safe to drive have never been developed. Many physicians do not even know whether their older patients are drivers, and often by the time a physician is made aware of driving safety concerns the patient may have already had a collision. This is one of the primary reasons why the Candrive research program exists – to delevop tools front-line physicians need to assess driving risk in an accurate, fair and just manner.

•  Physicians across Canada need a scientifically valid, reliable and easy to administer screening test to evaluate patients' medical fitness to drive.

2. What will the Candrive program do to make roads safer?

The Candrive program is looking at alternatives to loss of driving privileges such as retraining and de-graduated licensing. The ultimate goal is ‘ to help keep safe older drivers driving' . Regrettably, there will always be a small minority of older drivers whose medical and functional conditions have progressed to the point where they can no longer drive safely and where they can no longer benefit from retraining or customized (de-graduated) licensing. By developing screening tools that identify this minority at the earliest possible time, we hope to prevent collisions and improve the safety record of all older drivers.

•  Customized licensing is a way to extend the safe driving period.

•  Retraining provides refresher information and information on adapting driving style.

3. When should an older person stop driving (or at what age)?

There is no specific age at which a person should stop driving. A person should stop driving when their physical, functional and mental abilities have declined to the point that they are unsafe. It is really a question of function and ability rather than age. Many people remain safe drivers throughout their life and, consequently, the ability to drive should be evaluated on an individual case by case basis.

•  This decision needs to be based on individual evaluation.

4. What driving restrictions should be placed on older drivers?

No driving restrictions whatsoever should be applied to seniors as a group. We need to always remember that the majority of older drivers are safe and represent the most experienced drivers on the road. It is really a question of function or ability rather than age. Many people remain safe drivers throughout their life and, consequently, the ability to drive should be evaluated on an individual case by case basis.

5. Will Candrive limit the rights and freedom of older drivers?

The philosophy of Candrive is to enhance the driving ability and protect the driving privileges of safe older drivers. The best way of protecting these driving privileges is to minimize the number of car crashes involving drivers who are medically unfit to drive, and thus minimizing the negative publicity that these unfortunate events create. This can be done in two complementary ways:

[1] by identifying drivers with early evidence of increasing risk who can benefit from retraining or customized licensing and directing them to such programs and

[2] by identifying those unfortunate few who have medical and functional impairments that preclude them from safe driving and helping them obtain alternate means of transportation. These two approaches will minimize the number of avoidable car crashes involving older drivers, will decrease the frequency with which such tragic events appear in the news and therefore will help protect the driving privileges of the majority of safe older drivers. In other words our goal is to ‘ keep safe older drivers driving '.

6. Should older drivers be tested on an annual basis?

That is a very important question which has been asked by a number of medical associations, governmental agencies and researchers. The studies done to date do not provide any convincing answers. It is likely that the question cannot be answered until we have the accurate and fair in-office screening tools which Candrive will develop over the next few years.

7. What immediate recommendations do you have to improve road safety?

There are some warning signs that indicate that drivers should seek their doctor's opinion regarding their driving safety;

•  If a driver finds that they are getting lost or needing more directions from passengers

•  If a driver is causing other drivers to drive defensively or other drivers are demonstrating frequent signs of irritation with a driver (e.g. horn honking).

•  Recent motor vehicle crashes, minor fender-benders in parking lots, increased near-misses or traffic citations.

•  Unwillingness of family or friends to be passengers

•  The driver's loss of confidence in their own driving ability and increasing discomfort on the road

More details regarding such warning signs can be found in the Driving Toolkit (http://www.candrive.ca/En/Physician_Resources/toolkit.asp)

8. Can families request that a person's driving privileges be revoked?

Family members cannot request that driving privileges be revoked but if they have concerns they should discuss these with the older driver's primary care physician. This information is often extremely valuable to the physician as it may indicate an untreated or inadequately treated medical problem. By notifying the physician as early as possible, car crashes may be prevented. Remember that while a physician may only see an older driver for relatively short periods of time each year, the driver's family may see them every day, may sit in the car with them when they are driving and may notice symptoms that fluctuate and are only present from time to time. Such fluctuating symptoms can easily be missed if they are not present on the day that the driver sees the doctor. The driving-related information available to families is often much more detailed than that available to physicians.

•  Families can express their concerns to the physician but cannot demand that a license to be taken away. The physician will then assess the patient's capacity to drive.

9. Should all people with Alzheimer's (dementia) have their license revoked?

No. We must keep in mind that it is not merely the presence of medical problems but rather the severity of medical problems and their effect on function that impacts on driving. People with mild or early Alzheimer's disease and strong baseline driving skills may remain safe drivers for a period of time. Loss of one's driver's license can lead to social isolation, decreased quality of life and depression. Consequently, we must not revoke licenses prematurely or when there are safe alternatives. We must have a fair and flexible approach that focuses on actual driving ability rather than on a diagnostic label.

Nevertheless, Alzheimer's disease always progresses and gets worse. Consequently, persons with Alzheimer's will have to stop driving when their disease progresses to the moderate to severe range. Thus, even if someone with early Alzheimer's is initially a safe driver, their ability to drive should be tested on a frequent basis (i.e. every 6 months) and their families must plan for the day when they can no longer drive.

•  Needs to be case by case. Routine evaluation needs to take place as most dementias (including Alzheimer's) are progressive diseases.

•  It is not presence of disease but rather severity that needs to be looked at.

10. Will seniors' groups or government support your driving rules? What support has Candrive obtained from these groups?

We recognize that research related to older drivers will only be possible with the support of seniors' groups, medical associations, individual health professionals and government.

The various levels of government in Canada are clearly concerned about road safety and recognize that as our population continues to age, there will be many more drivers with medical and functional impairments on the road.

The Canadian Council of Motor Transportation Administrators (CCMTA), an organization of federal and provincial driving safety researchers and administrators, has called for precisely the type of research that Candrive is performing.

Both federal and provincial transportation authorities have been extremely supportive and have indicated their willingness to partner with Candrive to achieve the goals of improving the front-line assessment of drivers with medical and functional conditions and thereby ‘keeping safe older drivers driving'.

We recognize that the Candrive research program is enhanced by the support and assistance of seniors' groups. Candrive partners include seniors' groups including CARP (www.carp.ca) and the Federal Superannuates National Association (FSNA).

•  Seniors' group support is vital to achieving the research goals of Candrive.

11. Why is age 65 (or 70) identified as the age to become concerned about driving ability? ( What happens when people get older that makes them unsafe drivers?)

Unfortunately, as people grow older they often accumulate a number of medical and functional conditions that may affect one's ability to drive. Numerous studies have demonstrated that by age 70 the risk of crash per km driven has doubled. This is likely due to the accumulation of such medical and functional problems. Research also very clearly shows that the rate of serious injury and death due to car crashes rises dramatically in persons over the age of 70. This is not only an issue of public safety but is also important from the perspective of maximizing the health and independence of seniors.

•  Medical and functional problems become more common as we age

•  Need to decrease morbidity and mortality

12. Why are you targeting seniors when there are many young people who should not be allowed to drive?

Older and younger drivers have high crash rates for very different reasons. Younger drivers usually become involved in crashes due to on-road risk-taking behaviour and inexperience. There continues to be extensive work on the road safety of younger drivers and graduated licensing programs have already had a positive impact in terms of decreasing collisions.

Seniors represent the most rapidly growing segment of the driving population. Risk-taking behaviour is not a major problem in older drivers. The rate of crashes per km driven is higher in older drivers due to the accumulation of medical and functional conditions that impact on driving ability becoming more common as one ages. The impact of medical and functional conditions on driving ability is precisely the focus of the Candrive research program.

We also know that the rate of serious injury and death due to car crashes rises dramatically in persons over the age of 70. Consequently, this is also an issue that affects the health and independence of seniors.

In other words, Candrive is responding to an identified need to develop more fair assessments of older drivers, and to explore methods to ‘keep safe older drivers driving' . This, in turn, will help improve the health and independence of older persons.

13. If you are tracking crashes through a government database, isn't that like a “Big Brother” scenario involving an invasion of privacy?

All participants in Candrive research studies give explicit informed consent to allow their ministry of transportation driving record to be released to the Candrive program. These data are currently tracked by provincial ministries of transportation across Canada. All ministry protocols ensure that privacy & confidentiality of the data will be followed. Published research will not include data identifying any individual. Any person who does not want Candrive to access their driving record are not included in the research studies. The bottom line is that Candrive will not access driving records of individuals without the full understanding and agreement of individual participants.

•  Upfront permission of participants

•  Follow privacy and confidentiality legislation

14. What kind of screening test are you looking for? Shouldn't the Ministry of Transportation be doing those tests instead of doctors?

In many provinces, such as Ontario , physicians are required by law to report when they feel a driver has a medical problem that may impact on driving safety. Unfortunately, even though they have been given this responsibility, physicians have never had access to screening tools to make this evaluation accurately, fairly and as early as possible. Physicians need a test or series of tests that can be used in their offices to identify which drivers may be unsafe or may require more in-depth testing. Given the fact that at least part of the evaluation of driving safety is based on a detailed understanding of an individual's changing medical conditions, at least part of the assessment must be done by their physician.

• In most provinces, Physicians are legally required to report patients that are medically unfit to drive to the ministry of transportation.

15. Don't several on-road driving assessment programs already exist? How is yours different?

The assessment programs to which you are referring are very different from the screening tools that Candrive are developing. Specialized assessment programs involve computerized tests and on-road evaluations Candrive is developing a rapid screening test that can be done in the family physician's office and which will help the physician determine who is safe, who is unsafe and who needs to go to these specialized on-road assessment programs for more in-depth evaluation.

16. By revoking a senior's driving license are they not at risk of becoming socially isolated? What can family members and the community do to prevent isolation in seniors who lose their license?

When persons lose the privilege to drive, they are losing some of their independence and may become isolated from family, friends and their community. Family and friends can prevent this social isolation by helping the older person remain involved in community activities. This may be accomplished by driving them to appointments and leisure activities and by helping find alternative transportation modes.

Communities can also become involved by encouraging the development of alternative transportation services as well as other programs and support services to help fill the gap.

• Families and community need to work to prevent isolation
• Look for alternative forms of transportation

17. Some places allow drivers with disabilities to drive under restricted conditions. Is that a good idea?

Restricted or de-graduated licensing means that persons with specific medical and functional conditions are only licensed to drive under certain conditions such as during day-light hours, on certain low traffic roads or within a limited distance from their home. The evaluation of the type of restriction to apply is made on a case-by-case basis. Almost every province except Ontario has some form of restricted/customized licensing, however there is a great deal of variation in the rules and in how they are applied. Seniors' groups, the Ontario Ministry of Transportation and the Ontario Medical Association are all keenly interested in the idea of ‘de-graduated' licensing. Clearly, de-graduated licensing offers more independence than complete loss of driving privileges It would also lessen the possible strain on the physician-patient relationship if de-graduated licensing were an alternative to complete cessation of driving.

The concept of de-graduated licensing is supported by evidence in the younger driver age group. There is evolving evidence that the graduated licensing program in Ontario has decreased the crash risk in younger drivers.

One of the Candrive researchers, Dr. Shawn Marshall, has published data regarding the positive experience of de-graduated licensing for persons with medical problems in Saskatchewan (CMAJ Oct 1, 2002). The Candrive program will be examining the different de-graduated licensing programs across Canada & in other countries in order to develop a better understanding of how they differ and which approach is best.

•  Customized licensing helps extend the length of time people can drive

•  Customized licensing helps to meet the need to the individual

•  Not used in all jurisdictions plus there are varying degrees of implementation

18. What is the long term goal of Candrive?

Candrive is an interdisciplinary health-related research program that is studying the effect of medical and functional conditions on the ability to drive in older persons. Candrive's long-term goal is to work on improving the safety of older drivers or, put simply, ‘to keep safe older drivers driving '. Part of this goal will be accomplished through the development of screening tools which can be used in physicians' offices and by evaluating methods to extend the safe driving period through driver retraining or customized (de-graduated) licensing programs. Ultimately, these approaches will improve the health and independence of persons with medical and functional limitations. High rates of serious injury and death in older drivers who are involved in motor vehicle crashes seriously diminish health and independence.

•  Keep safe drivers driving

•  Decrease morbidity and mortality of older drivers and passengers

19. If this is a research grant, is there a particular study?

The Candrive program of research includes a number of studies.

The major Candrive study is following a selected group of older drivers from across Canada over 5 years. During this time they will undergo a number of annual clinical screening tests. The results of the tests will be compared to actual driving performance recorded in ministry of transportation databases. The goal of this specific project is to develop driving screening tools which clinicians can use in their offices to help identify older drivers who are safe and not safe to drive.

Complementary research studies will look at initiatives such as retraining and de-graduated licensing in an effort to prevent loss of driving privileges and thereby extend the safe driving period for as long as possible.

The ultimate goal of all of these projects is to improve the safety record of older drivers as a group, to ‘keep safe older drivers driving' and to maximize the health and independence of seniors.

•  Large study following a group of older drivers from across Canada

•  Studies on retraining programs

•  Studies on de-graduated licensing its effectiveness

20. How can you make any decisions about driving ability in the doctor‘s office, without watching someone drive?

Presently, there is no simple paper and pencil test (including such tests as the Mini-Mental State Examination, Trailmaking A and B tests, SIMARD-MD) available that is accurate enough to be used alone or in combination when determining fitness to drive in older persons. 

Development of a scientifically valid, reliable and easy-to-use, in-office screening tool will help identify those persons that clearly should not be driving, those that appear to be safe to continue driving, and those that require more in-depth and possibly on-road testing. Nevertheless, since it would be unfair to seniors (i.e. cost, time, stress) and since we neither have the numbers of on-road testers to send every driver with medical and functional conditions for annual on-road testing, we must be practical and use the medical resources that we do have. With the proper tools physicians will be better able to make many of these evaluations.

•  Preliminary evaluation that will help determine the need for further assessment and possible on road testing

21. How do physicians presently decide when someone should stop driving? What training do doctor‘s have to assess the ability to drive of the elderly?

This is not well known. Despite the fact that they are legally mandated to report patients who have medical problems that may affect driving, few physicians receive training specific to the assessment of driving safety. The medical history and physical examination were developed to detect disease not to evaluate driving safety. Physicians have never been given good office-based tools to assess driving safety.

As a result, people who are medically and functionally unfit to drive remain on the road while other drivers may have their licenses unfairly or prematurely revoked.

This lack of tools and training and the resultant unfair and dangerous situation clearly highlights the pressing / urgent need for precisely the type of research Candrive is undertaking.