POSTED ON APRIL 4, 2012:
Waiting for Disaster
It's some of the toughest love imaginable. Finding a way to tell your aging parents or grandparents that things are not the way they used to be. Things could get worse.
During just one week in January of 2011, two serious accidents involved elderly Tulsans driving through the front of local businesses, causing personal injury and destruction of property. In another widely reported incident, on July 16, 2003, California man George Russell Weller, then 86, killed 10 pedestrians and injured 63 when he drove his 1992 Buick LeSabre through an open-air market, mistaking his gas pedal for the brake.
As Tulsa Baby Boomers edge into their golden years, the number of older citizens driving continues to rise. According to the National Transportation and Safety Board, one in five licensed drivers will be 65 and older by 2025, with that part of the population in Oklahoma rising by about 20 percent.
That's the good news. The old folks are with us longer and getting around in the mainstream, or just on Wednesdays, Sundays and go to meetings.
But with this increase of older drivers comes the bad news: increased risk, to themselves, but most importantly to innocent others who may be victims of an aged person's lack of judgment, impaired vision or physical disabilities or decreasing mental acuity.
Many are wondering -- perhaps more than ever -- how our respect for seniors' autonomy might be balanced with public safety. And they are wondering, too, how their families might best facilitate an elder member's transition from full independence to a safer and better-assisted life.
Especially since the 1950s, the car has meant much more than transportation to Americans -- it is a symbol of freedom and independence. "From the age of 17 or 18, or even 16, when these older people started driving, independence meant having a car and being able to go," said Dr. Chandini Sharma, director of geriatrics and palliative care programs at OSU Medical Center, and all-around advocate for senior citizens. "Families know, 'My kid is grown because now he can drive.' They may not be able to vote, but hey, they can go, they can get a job."
For most teens, receiving the keys at 16 is seen as a rite of passage from childhood to adulthood. And this freedom becomes such a part of everyday life that it is taken for granted, Sharma said. "And now suddenly when you turn 90, and because of your osteoarthritis because of which you can't move your neck; or because of your eye conditions such as macular degeneration or cataracts, because of which you cannot see; or because of the hearing deficits that develop," driving becomes dangerous both for the elderly person and for others.
"Imagine an osteoporotic little lady who can barely see above the wheel," Sharma said. "We've all seen that car driving by and have wondered, 'Was somebody driving it?' There are those two little eyes, but..."
Where are those little eyes going?
It is bad enough when the problems are only physical. "Dementia is the worst evil of them all, of course," Sharma said. "Because of dementia, the higher functions cannot be coordinated anymore, so they will not be able to remember simple things anymore -- like red means stop and green means go." Reaction time changes. Pedals can be mistaken.
Dr. Jeffrey McIlroy, founder of Strength of Mind psychiatric care centers in Broken Arrow and Claremore and former director of the geriatric psychiatry unit at Hillcrest's Claremore Regional Hospital, said that dementia "is a syndrome of loss of cognitive and behavioral function. It is not just a memory disorder, but it also makes one lose the ability to name things and to sort things out." And about two thirds of dementia is caused by Alzheimer's disease. "Most likely, the first sign is memory loss," McIlroy said.
Medications also play a part. "And of course let us not forget the medications -- the bunch of medications they're on," Sharma said. Half the time they're loopy because of the medications they're on."
But Sharma is quick to point out that she is speaking here not of all the elderly, but specifically the frail elderly. "Because the majority of the elderly may not have issues about driving until way towards the end," she said. "As a matter of fact, the majority of them are not frail. The majority of them, even in their 80s, are independent."
Some people think the solution is to enact stricter driving and licensing laws aimed specifically at older drivers. Several states, such as Arizona and Florida, require more frequent license renewal for older drivers, while these and others also restrict renewal by mail or internet. Oklahoma's laws make no distinction by age, except by charging reduced renewal fees for those 62 to 64 and waving fees for those 65 and older. Efforts to change these laws have failed.
According to a 2002 Oklahoma Law Review research report by James J. Fazzalaro, then principal research analyst for the review, 1985 saw heightened legislative activity on the subject, with six bills introduced, all of which failed. In 1990, a law requiring motorists of all ages to undergo a vision test at every other renewal was passed by the Oklahoma State Legislature, but the law was never implemented.
Advocacy groups, such as AARP, are firmly against such laws that would single out older citizens. "We want the road to be safe for all drivers, but it should be about ability, not age," said Craig E. Davis, associate director and spokesman for AARP Oklahoma. Davis said that laws like those in Arizona and Florida could not be supported by AARP in Oklahoma because they do not take into account the complexity of the situation, namely, that not all older drivers are frail and dangerous, while younger people may be unfit to drive.
AAA Oklahoma spokesman Chuck Mai said that AAA would support additional testing, "but only if it would include all ages," he said. "We feel that there are really good drivers who are 25 and really good drivers who are 85. Just because you reach a certain age it doesn't mean you are a bad driver."
Jim Camoriano, Oklahoma spokesman for State Farm Insurance, agrees. "We get behind any effort for safe driving," he said. A driver's age certainly is one concern among many, but "we can't make a blanket statement" concerning age, Camoriano said.
Also, some may think that getting insurance would be more difficult for mature drivers, but this is not necessarily the case. "A bunch of different factors go into it," said Mike Hefferman, a Tulsa AAA insurance agent. Usually if older drivers are seeking auto insurance with a company new to them, they have been receiving coverage elsewhere and therefore have an established driving record, which is taken into account when rates are offered, Hefferman said.
Camoriano said that State Farm "doesn't lump people into a certain category." They try to "match the right risk to the right price," he said. Age is taken into account, but so are many other factors such as the vehicle's type and age and a person's driving history.
Sharma also agrees that seniors should not be singled out. "We have all had tickets and accidents," she said. "Does that mean we are unfit to drive and our licenses should be taken away? No." She believes that a standardized test for drivers of all ages would be more appropriate, tests, "which would include the physical function, the mental function, and the overall individual's ability to handle the stress to say, 'Okay, this person failed the driving test, and this person is able to safely drive,'" she said.
And some are unfit to drive only temporarily, for example, because of surgery. Jennifer Perry, a physical therapist at St. John's Outpatient Rehab Department, works mostly with people over 60. They might be in her department for any number of reasons. "We see just about everything here," Perry said. "I see a lot of people with lower back pain and neck pain. We have patients who have had total hip replacements or hip fractures [needing] surgery, total knee replacements... and just about everything else," she said.
For something like a hip replacement, Perry said that it "usually takes about 16 weeks to really get back to what they want to do -- to have the strength to be truly safe with all the activities they want to do." And usually driving is not an issue. "Generally people are pretty good about wanting to be safe and not wanting to put themselves in harm's way," Perry said. "People are more on the cautious side than not." But she also said that patients with dementia, a small minority of cases, sometimes find it hard to understand why they should not be driving or living alone.
Knowing When to Stop
Just as getting the keys at 16 is full of emotion and symbolism, so is the moment when the keys have to be relinquished from a senior. And the transaction is usually difficult. Maria, who asked that her full name be withheld, is a single teacher, age 54, who along with her siblings recently moved her parents into an apartment adjoining her Tulsa home. "When my parents were living at home and able to drive, they would often just get out and go just to go. After the morning traffic died down, they would drive just to pass the time. They would go to the grocery store, or to Walgreens to see what was new on the 'As Seen on TV' rack," Maria said. "Getting them to quit driving wasn't easy. We knew it was time to get the car away, but they didn't want to quit."
The resistance of Maria's parents is not uncommon. "People will give up their apartments easier than they will give up their car," Sharma said. "So I'll move into the granny apartments -- no problem -- but my car's under my garage."
Dr. Gerard Clancy, psychiatrist and president of OU-Tulsa, explained that "for some, they see this as a total end to their independence and ability to choose what they do -- day in and day out. They see a higher level of care and supervision as a point of no return. Therefore, resisting as long as they can keeps the sense of freedom open."
And for those with beginning dementia, the problem is worse. For these, "there is some subtle memory and cognitive decline such that they do not have the brain power for the insight into how much they are struggling with their independence," Clancy said.
As with Maria's parents, many older people beginning to become frail fear having to give up life outside of their home. "We are very much dependent on daily reminders outside of the home of what is happening," Clancy said. "From the change in seasons noted by getting out daily, to talking with others about civic concerns and political activities -- the brain needs real interactive stimulation."
The issue, then, becomes identifying when a person should no longer be driving, and also when other life transitions, such as receiving daily living assistance or moving in with family, need to take place. Such decisions, according to Sharma, need to happen within the context of the family and the wider community.
"A lot of the time, those adults can come to those decisions eventually on their own," said Dr. Julie Miller-Cribbs, associate professor and the assistant director of the School of Social Work at OU-Tulsa. "Unfortunately, sometimes those decisions are precipitated by an event. Something catches fire, or they have an accident of some kind in the house where safety is involved."
For Maria's family, it was her mother's broken hip. "They would fall at home and not tell us. Once, mom was on the floor for maybe a day, and we only found out later," she said. "Mom fell out of bed and broke her hip but she didn't know it. And they didn't tell us they needed help. When we went to visit, she was there on the floor and we couldn't get her up. We had to call 911 and get her to the hospital."
After hip replacement surgery and rehab, Maria's mother moved in with her, while her father remained at home. "It took three or four months to convince Dad to move in too," Maria said. "He didn't want to give up the house."
In driving too, intervention often happens only when it is too late. "Exactly what most people wait for is an accident," Sharma said. "Either the family waits for a wreck, or the person waits for a wreck before they give up their ability." While such accidents are sometimes the first in a person's long history of driving, often clear warning signs, including past wrecks and accidents in the home, have been ignored.
What signs should the elderly and their families look for in order to decide when intervention needs to take place? Regarding driving, Sharma said that an important indicator is the inability of the person to accomplish other difficult daily tasks. "Driving is not, even though we take it as our second nature, as simple as we think it is," she said. If we think about all the steps it takes to drive, we see that it is a very technical task. "Put it up in that list of complex tasks instead of putting it in the list of, 'Oh, until you forget how to tie your shoe laces you can drive,'" Sharma said. "If your ability to handle complex tasks has been compromised, that should be an indicator that there is another complex task we should think about, and that is driving."
Some of those other complex daily tasks include banking and planning. "When the person is no longer able to bank because they cannot balance their checkbook, or when the person is no longer able to plan events for the family -- for example, Thanksgiving dinner -- where a fair amount of coordination and thinking are involved," those are the times when the family should start thinking of questions of driving and also of independent living, Sharma said.
Davis, of AARP, said that his organization works with seniors and their families to recognize when it is time to limit or stop driving. They offer a "We Need To Talk" online seminar on the topic and also list 10 signs to look for, including frequent "close calls," "finding dents and scrapes on the car," and "responding more slowly to unexpected situations." The seminar aims to help all family members understand the importance of independence to the older generation, and find the best ways to discuss the changes that need to happen.
AAA also offers programs to help drivers of all ages, especially mature drivers, be safe in their vehicles. Daniel Karnes, Tulsa based community relations specialist for AAA, spoke of their CarFit program, in which drivers can be properly fitted in their cars. During this free event, which takes about 15 minutes per person, a 12-point inspection takes place with the driver at the wheel, while the experts check for seat height, seat distance from the wheel, mirror placement, seat belt adjustment and other variables that help a person be ready to drive.
Camoriano, of State Farm, also said that Oklahoma is one of the states that requires insurance companies to grant a discount to people who have taken an in-class driver safety course, such as that offered by AARP.
Working along with the family doctor is also important, said Miller-Cribbs. "If you had a good physician who was working with his team, nurses and social workers, their intervention would be working with the family and working with the patient talking with them about these changes and supporting the family." Lilli Land, supervisor of senior and independent case management at Tulsa's LIFE Senior Services, agrees. "An older person will generally listen to their physician," she said. "And if the doctor's saying, 'You're a hazard; you really shouldn't drive anymore,' generally they will, although reluctantly, give up their keys." But often, a lot of firm convincing has to happen.
But what if a frail elderly parent flat-out refuses to quit driving? "That line is fine," said Miller-Cribbs, "and I think that's a big part of the caregiving dilemma -- always trying to preserve as much autonomy as possible while also making sure that the right decisions are being made in the best interest of that person even when they may not want to make them. I think that's one of the more heart wrenching ethical dilemmas that a lot of families find themselves in."
The last resort, unfortunately sometimes necessary, is government intervention. "If they refuse, you can always force the issue by making a report to the Department of Public Safety," Land said. "And then they call that person in and can give them a very intensive test -- and generally they will fail them -- so that if they drive, it is illegal."
Making Other Changes
Another fear seniors face, especially when health begins to decline, is the prospect of moving to a nursing home. Maria's father said, "I'd rather sleep under a bridge."
Naturally, most want to stay in their own home as long as possible, and those seniors with adult children would probably find moving in with family a difficult, but desirable, second alternative. Often, the decision depends on finances. "I hate that it boils down to that," Land said, "but it really does. It's how their choices really have to be made."
Many seniors who want to stay at home need help with daily activities such as cooking, doing the laundry, and bathing, while some need daily nursing care. Although home healthcare agencies can provide these services, not everyone can afford the expense. If younger family members cannot, or will not, step in to help, a nursing home is often the next step.
"We have a heavy emphasis, especially in the United States, of institutionalized care for our elderly, whereas in a lot of other cultures the elderly move in with family members," Miller-Cribbs said. "Most people would like to take care of their family members in their home, but there is a financial incentive, to some extent, and an insurance incentive, to place people in institutions. It's easier to get Medicare coverage for somebody in a nursing home than it is to provide care in-home."
Even if a parent moves in with adult children, or an adult child into the parent's home, finances can get in the way. "If I'm working, and I want my mom to live with me, but I can't leave her home by herself, it's really going to be harder for me to get Medicare to cover things for her in my house than it is for me to have her go to a nursing home," Miller-Cribbs said.
Land, however, does not believe insurance companies favor institutionalization over in-home care. "I would like to think that they don't," she said. "Maybe I'm being too 'pie in the sky,' but I think that sometimes a nursing home is the best place for somebody."
Also, she believes families can find ways to manage. "If they really don't want their parent to go to a nursing home, and their parent doesn't really want to go, with a little putting your head together and figuring it out, it can be figured out."
Land said that some people qualify for government assistance with in-home care. "There are federal programs that are handled by the state that can help people in that position that don't have a lot of income or resources." One of these is the Advantage Program, which Land said is a "state case management program" that helps people stay in their homes as long as possible. "It's a beautiful program," she said, but people must qualify both medically and financially to take part.
Sometimes, though, parents even resist this kind of help. Maria's family tried a home-health agency after her parents moved in. "I spoke to a very nice lady who was very understanding," Maria said. "They sent over two or three different ladies to check on them and do light housework. They said they would take them to the store. But Dad was unkind and told them they didn't need any help," Maria said. "Still, it's great that [our parents] are near us, and we do what we can -- whatever they let us do."
Although people reaching this stage in life do lose some of the independence they have enjoyed, there are nevertheless several Tulsa organizations dedicated to helping seniors remain as active as possible. "There is a whole range of services for the elderly in Tulsa, such as day centers where people are brought during the day," Miller-Cribbs said. "They take isolated people and bring them into a more social environment. Those are people who could probably otherwise live at home -- maybe they can't drive, but it would be nice to be somewhere where there's some socialization."
Land said that LIFE Senior Services exists for exactly this purpose. LIFE sponsors two adult day centers in Tulsa and one in Broken Arrow. They also have counselors who help families understand all the options they have in matters of health care, insurance and housing. They also operate 16 "senior housing communities" in Northeast Oklahoma.
Another option altogether, which is open to those who have the means and will to plan for retirement early, is a continuing care retirement community such as Montereau, 6800 S. Granite Ave. Jamie Townsend, director of marketing for Montereau, describes it as a "resort-type lifestyle for one's retirement years," where a person can enjoy an active life without worry about future health care. Residents -- who must be at least 55 and living independently when they begin the plan -- pay a one-time entrance fee and then a monthly fee to live in one of the many apartments or cottages on the property and take advantage of the community's activities and services -- including gourmet restaurants, a fitness center, a theater, and many common areas. "This is as far away as can be from a nursing home," Townsend said. "A lot of people don't know we have something of this caliber in Tulsa. It's like something you would find in Florida or Arizona."
According to Clancy, continued activity is a must. "There is strong evidence that healthy diet, vitamins, exercise and stimulating conversation and study can slow the progression of cognitive decline that comes with aging," Clancy said. "I have seen several times that after retirement from a stimulating job, some decline quickly regarding cognitive function. Sometimes this is because of the loss of the stimulating environment that good work can bring. So, stay active physically and cognitively."
And even if driving oneself is no longer possible, Tulsa Public Transit offers reduced rates on their fixed-route system for adults 62 an over (75 cents -- half the regular price), and adults 75 and over get free rides.
Above all, families should not wait for disaster before taking action and planning for the future, said Miller-Cribbs. Neither should they wait until the elderly cannot make these decisions alone. "Ideally, families would have these conversations earlier while both sets of people are in sound mind -- so that you are proactive -- so that when you meet this point you've already had a discussion about what they wanted." Whether with the issue of driving or with seeking extra daily care, when the need arises, often families are unprepared. "They don't have those discussions early on and then a big event happens and they're not sure what to do," Miller-Cribbs said.
There is too often a resistance -- not only by the elder member, but also by adult children -- to discussing these life-changing issues. Why? According to Miller-Cribbs, people generally don't want to talk about death. And death is the natural end of aging. "People don't like to talk about it, so they put it aside; they don't think about it," she said.
"It's always great when you see families working together," Land said.
But when they don't, the already hard transitions of later life become all the more difficult.
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