If geriatricians had a pound for every time an adult child said that it wasn’t safe for their older parent to go home from hospital, their financial standing would improve enormously. It is an almost daily occurrence for geriatricians to mediate between older adults (who tend to value independence and embrace risk) and their adult children who seek security for their older parents while shunning risk. While in some ways this is a symbol of love by the adult children, it is hard to escape a feeling that a certain element relates to peace of mind, on their own terms, and a failure to imagine how they themselves might feel when their turn comes.
The solution lies in a diagnostic/therapeutic approach, engaging the older person in the discussion, and outlining the risks and benefits of the various options, whether this means being at home with support or considering a nursing home, and ensuring primacy of the patient’s voice – which often requires expertise, tact and planning.
A similar inter-generational dynamic was obvious in this BBC Scotland documentary on older drivers, but without the diagnostic/therapeutic approach, and a strong sprinkling of ageism. From the outset, the discredited statistic that older drivers have more accidents per mile set the tone. This is an artefact of low mileage, and disappears when low mileage is factored in: per year (the exposure measure used for the rest of us), older drivers are among the safest groups of drivers on the roads.
Overall the documentary stressed old age as the issue, when in fact it is age-related disease which is the problem. The documentary then followed an older couple, as well as an older woman with sleep apnoea, and one with a significant number of dings and scrapes on her car. We first met the lady with sleep aponoea playing Rameau on the piano with panache: it then evolved that apparently she had been failed on a road test due to her sleep apnoea, without an attempt to trial therapy for the condition and re-testing. She had sought a second opinion from a private sleep clinic, and as the documentary ended it was reported that she was pursuing treatment with a view to re-testing – why was this not offered to her in the first instance?
With regard to the lady with the multiple dings, unless this is a life-long pattern (and we all know people for whom this is the case!), this should have been a trigger for a specialist medical assessment. Was there some remediable medical illness, or medication affecting her driving, whereby intervention could have changed her circumstance? Instead, this was left to a driving assessment, and a family decision. The last we saw of her was waiting at a bus stop. The metaphor of abandonment is not inappropriate – not only are bus services rarely suited to those for whom driving is no longer possible, but they are also hazardous environments – non-collision bus injuries, due to acceleration/deceleration patterns on public transport are an increasingly recognised hazard for older people.
But it was not only the sense that these older people and their families were not supported by a medical system, which understood that there is a role for specialist diagnosis and treatment in improving mobility, that rankled in the film. Perhaps worse is the dichotomy between what is now the normal expectation of the flexibility and convenience of the private car for personal transport needs, and the chasm that separates this from the much less satisfactory public transport system.
This need not be the case. The documentary makers might consider a further episode on the remarkable ITNAmerica project (www.ITNAmerica.org), based in Portland, Maine, USA, and spreading elsewhere. This is an astonishing social economy model which has interacted with local and state government to provide an on-demand tailored driving service for those who can no longer drive. If you want a lift in one hour’s time, during rush-hour, you will get one but pay top dollar: as with budget airlines, book for two weeks time at off-peak and it is much cheaper. You, as a future older person who may need the service, can build up credits for your future by acting as a volunteer driver: the organisation can also sell your car for you, and use the proceeds for credits. They have also linked with shopping and health centres to co-fund trips, and your relatives can buy you credits as gifts.
So, this unnecessarily sad documentary is a wake-up call to family doctors and specialists to develop basic skills in traffic medicine when dealing with what is their main customer group – older adults – and to older people’s advocacy organisations to promote dignified, flexible, and useful alternatives to driving for those who can no longer drive. We will nearly all be fortunate enough to live into later life: let’s work on making sure that we will not have those mournful conversations with our adult children displayed in the documentary.
Desmond O’Neill is a consultant in geriatric and stroke medicine in Dublin, whose main research interest is transport, driving, and ageing.