Epilepsy and driving: current status of research.

In many parts of the world, licensing guidelines state that drivers with medical conditions such as epilepsy are restricted or prohibited from driving. These guidelines are sometimes subjective and not strongly evidence-based, rendering the task of assessing fitness to drive a complex one. Determining fitness to drive is not only essential for maintaining the safety of individual drivers but has implications for the community at large. It is therefore important to review the current state of knowledge regarding epilepsy and driving in order to aid health professionals required to assess fitness to drive and to guide future research directions. This review outlines the functional impairments related to epilepsy and driving, treatment and management issues, motor vehicle crash risk for drivers with epilepsy, estimates of predicted seizure occurrence and concludes with a discussion of the international licensing guidelines and relevant legal issues. More comprehensive research, including investigation into the effects of antiepileptic medication on driving, could aid in the development of policies and guidelines for assessing fitness to drive.

Older drivers, crashes and injuries.

OBJECTIVE: This article aimed to identify the main features of older driver casualty crashes, including detailed descriptions of injury outcomes. METHODS: Data were obtained from the Transport Accident Commission insurance claims database for 2 groups of drivers: aged 41 to 55 years (middle-aged drivers) and aged 65 years and older (older drivers). RESULTS: In terms of crash circumstances, the majority of crashes involved a collision with another vehicle (70.0% of middle-aged drivers and 68.7% of older drivers). The 2 main maneuvers at the time of crash were driving straight ahead (44.6% of middle-aged drivers and 42.8% of older drivers) and turning right (equivalent of left turn in North America; 15.2% of middle-aged drivers and 17.6% of older drivers). In terms of injury outcomes, older drivers sustained a significantly higher proportion of injuries to the thorax (30.9% compared to 18.5% of middle-aged drivers). Conversely, a significantly higher proportion of middle-aged drivers sustained some form of injury to the neck (30.6% compared to 12.1% of older drivers). CONCLUSION: These findings highlight the situations that are particularly risky for older drivers and provide important insights for developing solutions to reduce older driver crash and injury risk.

Licence restrictions as an under-used strategy in managing older driver safety.

While many older drivers remain unimpaired or otherwise effectively compensate for functional deficits, a minority are currently faced with two main options: either continue to drive with arguably an unacceptable crash risk; or cease driving, perhaps at the instigation of licensing authorities. Licence restrictions represent a possible third option for some older drivers, by better managing crash risk while still allowing acceptable levels of mobility. The present study has explored licence restrictions as applied to Victorian older drivers over a ten-year period. It has identified the types of restrictions and their extent of use in recent years, plus indications of potential safety benefits that may result from restricted licencing practices. Less than 10% of the older driver cohort had a licence restriction and in around 95% of instances, the restriction related to the need to wear corrective lenses; these numbers precluded a conclusive evaluation of safety benefits. However, two important findings emerged. First, the imposition of a licence restriction was usually associated with a reduction in absolute crash rates. Second, three restrictions were identified that most readily form the basis of a graduated driving reduction program.

Older female drivers: an emerging transport safety and mobility issue in Australia.

This paper describes an investigation of safety, mobility and travel patterns in a sample of older women drivers and former drivers aged 60 years and over. Participants provided information on general health and functional abilities, travel and driving patterns, driving experiences and confidence, difficulty with and avoidance of driving situations, self-assessment of driving ability, crash and infringement history, the process and experiences leading up to stopping driving, and satisfaction with current mobility. The sample was a fairly active group, travelling frequently and substantial distances, and generally satisfied with their level of mobility. Current drivers were strongly interested in keeping driving for as long as possible, expressed strong concerns about the prospect of stopping driving and reported little evidence of self-regulation. In contrast, former drivers were less negative about driving cessation and mostly reported successful retirement from driving with few negative mobility consequences. Further, a number of relationships between crash involvement and driving experience, confidence of being a safe driver, and problems in driving situations were found. These findings have added to our understanding of the issues concerning the safety and mobility of older women. Implications for the promotion of safe driving practices are discussed.

Child restraint system misuse and/or inappropriate use in Australia.

OBJECTIVE: Motor vehicle crashes are one of the leading causes of child death and acquired disability. Child restraint systems (CRS) for vehicles are designed to provide specialized protection for child occupants in the event of a crash. However, the effectiveness of a CRS is critically dependent on: correct installation of the CRS in the vehicle, the correct harnessing of the child in the CRS, and use of an appropriate CRS. The current study aimed to investigate the incidence misuse and/or inappropriate use of CRS through a CRS inspection program in the Australian states of New South Wales (NSW), Victoria (VIC), Queensland (QLD), South Australia (SA), Western Australia (WA), and Tasmania (TAS). METHODS: Participants were recruited through an advertisement for free CRS inspections displayed at childcare centers, kindergartens, community centers, hospitals, and child expos. At each inspection, the CRS fitting specialist inspected and reported to the owner of the CRS on the installation of the child restraint(s) and/or system(s) and any fitting faults and/or concerns with the fitting and/or use if the child restraint(s) and or system(s). RESULTS: The following results are based on the inspection of 1386 vehicles, in which there were 1995 restraints. Of all the restraints inspected, the majority (79%) were reported as having at least one instance of misuse. The most common forms of misuse included harness strap errors such as the straps being adjusted, faulty, twisted, and/or incorrectly positioned (38%); seat belt errors such as the seatbelt being incorrectly routed, twisted, and/or incorrectly adjusted (32%); missing or incorrect fitting of gated buckle/locking clip (23%); the need for a missing sash guide (8%); tether errors such as the tether being incorrectly routed and/or adjusted (7%); inappropriate use of a CRS for the size of the child (6%); anchor errors such as the anchor was fitted incorrectly or not the correct type (5%); and the H Harness(1) being used incorrectly (5%). In addition, there were significant differences across restraint types in terms of the proportion of restraints with CRS misuse or fitment errors, chi(2) (2) = 51.42, p < 0.001. The rate of misuse was highest for the forward-facing CRS (88%), compared to infant seats (67%) and booster seats or cushions (63%). DISCUSSION: The results show that CRS misuse and fitment errors are widespread in Australia. Based on the findings of this study, it is recommended that educational and awareness materials and programs that provide information on the safety benefits associated with correct CRS use (as well as the injury risk associated with CRS misuse) be developed for both parents and children.

Do age-based mandatory assessments reduce older drivers' risk to other road users?

To assess whether different licensing policies were associated with different fatality levels, the fatality outcomes of older drivers in Victoria and New South Wales (NSW) were compared. In Victoria, there is no age-based assessment required for re-licensing, while in NSW, drivers aged 80 years and older are required to provide annual medical certificates and from age 85, are required to pass on-road driving tests. Fatality rates associated with older drivers in each jurisdiction were calculated for the main categories of road users on two bases: per number of target drivers and per number of licensed drivers. When fatality outcomes were considered relative to the number of 80-plus year-olds in the Victorian and NSW populations, there was no significant difference in the overall fatality rate between the two groups. Similarly, there was no significant difference between the two groups in terms of the fatality rate for all other road users and for road users not in the older drivers' vehicles. When fatality outcomes were considered relative to the number of 80-plus year-old licensed drivers in either Victoria or NSW, Victorian older drivers were associated with a lower overall fatality rate and the difference was marginally statistically significant. Victorian older drivers were also associated significantly lower fatality rate for road users not in the older drivers' vehicles. Victorian older drivers represented a statistically significant higher risk in one major regard: to their passengers. Victorian drivers aged 80 years and older had between two and three times higher passenger fatality rates compared to NSW drivers. However it was also found that Victorian older drivers had a significantly higher passenger occupancy rate than their NSW equivalents. Once Victorian and NSW older drivers' different passenger occupancy rates were controlled for, there were no statistically significant differences across the two jurisdictions. These findings collectively suggested that age-based mandatory assessment programs do not have demonstrable safety benefits, in terms of either total fatalities or other road user fatalities--thereby broadly confirming the findings from previous research based on older driver crash involvement.

In defence of the 'low-mileage bias'.

There has been a long-recognised association between extent of driving and crash involvement: the lower the annual mileage driven, the higher the per-distance crash rate. Because older drivers generally drive less distance per year than others, this association has been used to explain much of their apparent over-involvement in crashes. Several studies from different countries around the world have demonstrated this 'low-mileage bias' and the relative safety of older drivers. However all studies have relied upon self-reported crash involvement and driving activity. Staplin et al. [Staplin, L., Gish, K., Joyce, J., 2008. 'Low mileage bias' and related policy implications-a cautionary note. Accident Analysis and Prevention 40, 1249-1252] have drawn attention to the discrepancy between self-reported and odometer-based driving distances and have argued against the credibility of the low-mileage bias. This paper has re-worked initial data from an early study which supported low-mileage bias, this time using odometer-based readings rather than self-reported mileage. Accepting the odometer readings at face value, the low-mileage bias remains evident, albeit at a reduced level.

An Australasian model license reassessment procedure for identifying potentially unsafe drivers.

Most licensing jurisdictions in Australia currently employ age-based assessment programs as a means to manage older driver safety, yet available evidence suggests that these programs have no safety benefits. This paper describes a community referral-based model license re assessment procedure for identifying and assessing potentially unsafe drivers. While the model was primarily developed for assessing older driver fitness to drive, it could be applicable to other forms of driver impairment associated with increased crash risk. It includes a three-tier process of assessment, involving the use of validated and relevant assessment instruments. A case is argued that this process is a more systematic, transparent and effective process for managing older driver safety and thus more likely to be widely acceptable to the target community and licensing authorities than age-based practices.

Do older drivers pose a risk to other road users?

OBJECTIVE: To investigate the extent to which older drivers pose a risk to other road users, relative to drivers of other ages, using Australian fatal crash data. METHOD: The principal data source was the Australian Transport Safety Bureau's National Fatalities Database, which has provided fatality numbers for the most recent available 10-year period (1988, 1990, 1992, 1994, and 1996-2001). For each driver age group ("target drivers"), fatality rates were calculated for the following categories of road users: target driver deaths, their passenger deaths, road users external to the target vehicle but killed in the crash involving the target driver, all road users killed other than target drivers, and all road users killed (including target drivers). Fatality rates were calculated on three bases: per population numbers in each age category, per licensed driver numbers in each age category, and per distance driven for each age category. The different road user fatality rates associated with drivers aged 80 years and older were compared to the rates associated with drivers from younger age categories. RESULTS: On a per population basis, older drivers had a significantly lower "all road users" fatality rate than all age groups bar one (RR for other age groups: 1.2-3.1) and these differences strengthened once target drivers were excluded (RR: 1.4-5.1), all differences significant. On a per licence basis, older drivers had significantly higher "all road users" fatality rate when compared to the rates for drivers aged 30-39 years through to 70-79 years (RR for these age groups: 0.5-0.7) but once the target drivers were excluded, older drivers' "all other road users & fatality rates for were significantly lower than for drivers aged 17-24 years to 30-39 (RR: 1.3-2.6) years. On a per-distance basis, older drivers had significantly higher all road users fatality rate when compared to the rates for all drivers aged 25-29 years through to 70-79 years (RR for these age groups: 0.1-0.4). Once the target drivers were excluded, older drivers' all other road users fatality rates remained significantly higher than for these other age groups (RR: 0.3-0.7) years. CONCLUSIONS: Based on two of the three bases (per population and per licence), it has been strongly asserted that overall, the older the driver, the less the threat to other road users--and particularly, the less the threat to road users external to the driver's vehicle. Drivers aged 80 years and older appeared to be the greatest threat to other road users only when per distance fatality rates were compared.

How important is vehicle safety in the new vehicle purchase process?

Whilst there has been a significant increase in the amount of consumer interest in the safety performance of privately owned vehicles, the role that it plays in consumers' purchase decisions is poorly understood. The aims of the current study were to determine: how important vehicle safety is in the new vehicle purchase process; what importance consumers place on safety options/features relative to other convenience and comfort features, and how consumers conceptualise vehicle safety. In addition, the study aimed to investigate the key parameters associated with ranking 'vehicle safety' as the most important consideration in the new vehicle purchase. Participants recruited in Sweden and Spain completed a questionnaire about their new vehicle purchase. The findings from the questionnaire indicated that participants ranked safety-related factors (e.g., EuroNCAP (or other) safety ratings) as more important in the new vehicle purchase process than other vehicle factors (e.g., price, reliability etc.). Similarly, participants ranked safety-related features (e.g., advanced braking systems, front passenger airbags etc.) as more important than non-safety-related features (e.g., route navigation systems, air-conditioning etc.). Consistent with previous research, most participants equated vehicle safety with the presence of specific vehicle safety features or technologies rather than vehicle crash safety/test results or crashworthiness. The key parameters associated with ranking 'vehicle safety' as the most important consideration in the new vehicle purchase were: use of EuroNCAP, gender and education level, age, drivers' concern about crash involvement, first vehicle purchase, annual driving distance, person for whom the vehicle was purchased, and traffic infringement history. The findings from this study are important for policy makers, manufacturers and other stakeholders to assist in setting priorities with regard to the promotion and publicity of vehicle safety features for particular consumer groups (such as younger consumers) in order to increase their knowledge regarding vehicle safety and to encourage them to place highest priority on safety in the new vehicle purchase process.

Factors associated with the premature graduation of children into seatbelts.

This study investigated the factors associated with the premature graduation into seatbelts for Australian children aged 4-11 years. From 699 child restraint use questionnaires, 195 children were identified as meeting the booster seat height-weight criteria (height: 100-145 cm and weight: 14-26 kg). Of these children, 44% were correctly traveling in a booster seat, while 56% had been moved prematurely into a seatbelt. A multivariable logistic regression model showed that there were a number of key predictors associated with the premature graduation to seatbelts. For example, children who were moved prematurely into a seatbelt were more likely to be older, have other children travelling in the vehicle and have younger parents compared to children appropriately restrained in a booster seat. In addition, there was a significant interaction between vehicle type and parent's household income. Based on the findings of this study, a number of recommendations are made for strategies to enhance appropriate restraint use for this age group, as well as for future research.

Booster seat use by children aged 4-11 years: evidence of the need to revise current Australasian standards to accommodate overweight children.

OBJECTIVE: To examine the relationship between child weight and vehicle booster seat usage in the context of current Australasian booster seat standards. DESIGN, SETTING AND PARTICIPANTS: Questionnaire survey conducted between February and April 2005. A convenience sample of parents with children aged 4-11 years in New South Wales and Victoria completed a questionnaire, reporting on the height and weight of their children and the nature of restraint devices used in the family vehicle. MAIN OUTCOME MEASURES: Proportion of children meeting standard-specified weight and height criteria who are not restrained in booster seats; proportion of children who meet the specified height criteria but whose weight exceeds the specified weight. RESULTS: 699 of 3959 questionnaires were returned (response rate, 18%), of which seven lacked essential details. The remaining 692 responses provided information on 1500 children. Of these children, 633 aged 4-11 years fell within the recommended height range for using booster seats, but only 29% were typically restrained in booster seats, the majority (70%) being restrained in normal seatbelts. A key finding was that 37% of the children who met the recommended height criteria exceeded the maximum weight for booster seats stipulated by the current Australasian safety standard. CONCLUSION: In view of increasing rates of overweight and obesity in children, it is important to reassess current Australasian standards for child restraints in vehicles. A concerted parental education campaign is also needed to raise awareness of which restraint types are appropriate for children of various heights and weights.

How important is vehicle safety in the new vehicle purchase/lease process for fleet vehicles?

OBJECTIVE: Despite the potential benefits that fleet vehicle purchase decisions could have on road safety, the role that vehicle safety plays in fleet managers' purchase decisions is poorly understood. METHODS: In this study, fleet managers from Sweden and Spain completed a questionnaire regarding the importance of vehicle safety in the new vehicle purchase/lease process and the importance that is placed on safety options/features relative to other convenience and comfort features. RESULTS: The findings of the current study suggest that vehicle safety is generally not the primary consideration in the vehicle purchase process and is consistently outranked by factors such as price and dependability/reliability. For example, when asked to indicate the vehicle factors that are included in their company's criteria for purchasing/leasing a new vehicle, fleet managers from both Sweden and Spain were more likely to list the vehicle's price, reliability, running costs, size, and fuel consumption than the vehicle's safety (defined as the vehicle's EuroNCAP rating/other safety reports). In addition, the findings of this study suggest that the importance of vehicle safety did not differ across the two countries. For example, there was no significant difference in the proportion of fleet managers who indicated that EuroNCAP ratings were part of their official policy across the two countries. CONCLUSION: The findings highlighted the need to educate fleet managers about vehicle safety in the new vehicle purchase/lease process. In addition, vehicle safety information, such as EuroNCAP results or other crash test results need to be promoted more widely and effectively so that they play a more prominent role in their new vehicle choices.

Driving responses of older and younger drivers in a driving simulator.

This paper reports the findings of a study of younger and older driver behaviour to hazardous traffic manoeuvres in a driving simulator. Hazardous situations on a highway and residential drive were studied and drivers' vision and vehicle performance responses were collected. While all drivers were able to avoid crashes, the finding that older drivers were consistently slower to fixate hazardous stimuli in the driving environment and were slower to respond presents a potentially serious road safety concern. Further research is warranted, especially under conditions of increasing traffic complexity.

Determining older driver crash responsibility from police and insurance data.

This study aimed to determine the extent to which older drivers can be considered responsible for their crashes, to identify key factors in those crashes for which older drivers have been judged responsible, and to assess the extent to which older drivers' extra crash responsibility contributes to the road toll. Insurance claims from the State of Tasmania, Australia, for 1998-2002 were linked with police records for crashes involving drivers aged either 41-55 years or 65 years or older. Insurance and police data sets contained independent judgments of crash responsibility. There was a high level of agreement between the two sets of judgments, with older drivers judged around 1.5 times more likely to be responsible for their crashes than middle-aged drivers and, conversely, older drivers were around 0.6 as likely to be absolved from crash responsibility. It was concluded that older drivers' additional crash responsibility while valuable in explaining "what went wrong," currently makes only a small contribution to the overall road toll.

Crash risk of older female drivers--contributing factors.

Using data from i) a self-administered survey of 673 older female drivers, and ii) a case-control study of 48 crash-involved and 44 non crash-involved older female drivers, some factors that may predict crash involvement were identified. Survey data gathered self-reported information on demographic characteristics, health status, travel patterns and driving practices. A battery of functional performance assessments were administered by trained experimenters in the case-control study, and participants completed a second detailed self-administered questionnaire. Factors found to predict crash involvement included driving characteristics such as being the main driver in the household, not highly confident of being a safe driver, experiencing difficulty driving in unfamiliar areas and having problems with the driving style of other drivers. In addition, low attentional, cognitive and motor skills and presence of multiple medical conditions were significant predictors of crash involvement.

Effectiveness of mandatory license testing for older drivers in reducing crash risk among urban older Australian drivers.

Most licensing jurisdictions in Australia maintain mandatory assessment programs targeting older drivers, whereby a driver reaching a specified age is required to prove his or her fitness to drive through medical assessment and/or on-road testing. Previous studies both in Australia and elsewhere have consistently failed to demonstrate that age-based mandatory assessment results in reduced crash involvement for older drivers. However studies that have based their results upon either per-population or per-driver crash rates fail to take into account possible differences in driving activity. Because some older people maintain their driving licenses but rarely if ever drive, the proportion of inactive license-holders might be higher in jurisdictions without mandatory assessment relative to jurisdictions with periodic license assessment, where inactive drivers may more readily either surrender or lose their licenses. The failure to control for possible differences in driving activity across jurisdictions may be disguising possible safety benefits associated with mandatory assessment. The current study compared the crash rates of drivers in Melbourne, Australia, where there is no mandatory assessment and Sydney, Australia, where there is regular mandatory assessment from 80 years of age onward. The crash rate comparisons were based on four exposure measures: per population, per licensed driver, per distance driven, and per time spent driving. Poisson regression analysis incorporating an offset to control for inter-jurisdictional road safety differences indicated that there was no difference in crash risk for older drivers based on population. However drivers aged 80 years and older in the Sydney region had statistically higher rates of casualty crash involvement than their Melbourne counterparts on a per license issued basis (RR: 1.15, 1.02-1.29, p=0.02) and time spent driving basis (RR: 1.19, 1.06-1.34, p=0.03). A similar trend was apparent based on distance travelled but was of borderline statistical significance (RR: 1.11, 0.99-1.25, p=0.07). Collectively, it can be inferred from these findings that mandatory license re-testing schemes of the type evaluated have no demonstrable road safety benefits overall. Further research to resolve this on-going policy debate is discussed and recommended.

Some consequences of different older driver licensing procedures in Australia.

Given both the expected growth in the number of older drivers and their over-involvement in fatal and serious injury crashes, there has been a world-wide call for improved licensing procedures to manage older driver safety. In particular, licensing authorities have been urged to move from mandatory assessment of all older drivers to assessment practices targeting only those at higher crash risk. The current study examined older driver fatal and serious injury crash involvement rates across all Australian States to determine a possible association with the different licensing procedures. In particular, older driver crash involvement rates in Victoria (where there is no age-based assessment program) have been compared with rates in other jurisdictions with assessment programs. Crash involvement rates have been calculated using two denominators: per population and per number of licensed drivers. Some data limitations notwithstanding, older drivers in jurisdictions with age-based mandatory assessment programs could not be shown to be safer than drivers in Victoria. Further, there is some indicative evidence that older drivers in Victoria may have a significantly safer record regarding overall involvement in serious casualty crashes.

Benefits of seat belt reminder systems.

This study sought to determine whether fitting a more aggressive seat belt reminder system to new vehicles would be cost-beneficial for Australia. While seat belt wearing rates have been observed around 95% in the front seat, non-wearing rates in casualty crashes are as high as 33% among persons killed and 19% among seriously injured occupants. Benefits were computed for three device options (simple, simple-2 and complex) and three introduction scenarios (driver-only, front seat occupants and all occupants). Four levels of effectiveness were assumed, from 10% to 40%, depending on the type of device fitted. Unit benefits were computed assuming a 5% discount rate and a 15yr fleet life. Various industry experts provided the costs. The findings showed that Benefit-Cost-Ratios ranged from 4.0:1 at best (simple device for the driver only) to 0.9:1 for all seating positions. These figures are conservative, given the assumptions made and the discounted human capital methods used.