Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology suggests the phrases, "strongly recommend" for strong evidence and "suggest" or "conditionally recommend" for weaker evidence.
Population, Intervention, Comparator, and Outcome (PICO) Question 1
Are car engineering advancements effective at preventing motor vehicle collision (MVC)-related injuries among the elderly?
The guideline committee suggests that ongoing engineering advancements in car safety restraint systems begin to take into account passenger-specific factors such as age, weight, and height.
As the United States (US) population proportionally ages, the number of elderly drivers can be expected to increase. The literature has demonstrated that elderly drivers are at significant risk of injury when involved in an MVC as a driver, passenger, or pedestrian. The current safety restraint standards for vehicles in the US do not take into account the vulnerability to injury of elderly vehicle occupants. In low-speed collisions, the very restraint systems designed to prevent injury may be contributing to chest/torso injuries in the elderly. An ideal solution would entail the development and implementation of sex-, height-, and weight-sensitive restraints to protect elderly occupants.
PICO Question 2
Are environmental or behavioral interventions effective at preventing MVC-related injuries among the elderly?
To answer this question, the committee found two subsets of data, one subset addressing reminder signs for seat belt use (2a) and the other subset addressing traffic-calming measures (2b).
The guideline committee recommends that seat belt reminder signs are placed at exit points in areas with significant numbers of senior drivers, such as senior centers or assisted living facilities.
Elderly drivers are more likely to be injured by similar velocity crashes. Based on prospective interventional data collected in multicentered trials, seniors successfully responded to seat belt reminders, and the effects were sustained with time.
The guideline committee suggests that pedestrian crosswalks be marked with stop signs or traffic lights and that traffic-calming measures be considered in areas of high pedestrian density.
The elderly are at high risk of injury as pedestrians struck by cars. However, it seems that unmarked crosswalks, that is, ones without stop signs or traffic lights, are associated with increased injury risk. Pedestrians may consider a crosswalk to be safe simply because it is a crosswalk, without considering driver cues or behaviors. In addition, lowering speeds and adding speed bumps or traffic circles in higher-trafficked areas was associated with fewer fatal pedestrian crashes. These should be considered but may also have important implications for businesses and residents.
PICO Question 3
Are risk screening strategies effective at preventing MVC-related injuries among the elderly?
The guideline committee suggests that elderly should be screened for alcohol abuse, frailty, significant diabetes, hearing impairments, severe visual impairments, and coronary artery disease (CAD) if they are continuing to drive because these conditions are known to increase the risk of MVC-related injuries.
Behavioral interventions to prevent MVC-related injury have been shown to be effective for elderly drivers. These types of programs aim to change elderly driver behaviors to enhance their safety and reduce injury. Seat belt awareness programs can be successful in changing the habits of a generation that did not have mandatory seat belt laws. However, the research on other behavioral interventions is lacking. There is a need for additional direct intervention investigations. Risk reduction strategies strive to identify key risk factors that place elderly drivers at higher risk for MVCs and injury. Several medical conditions such as arrhythmias, CAD, diabetes, and hearing impairment have been implicated. Universal screening for alcohol and drug abuse or use causing driving impairment, irrespective of age, should be a goal. Finally, frailty has been increasingly found to be associated with injury outcomes; frailty assessment may be a useful tool to help identify at-risk aging drivers, and its predictive ability should be prospectively studied.
It must be noted that the elderly driver population is heterogeneous; thus, any generalized limitation on driving privileges based on medical conditions is not indicated; individual patients should be screened for significant impairments that might affect their ability to drive safely.
GRADE Definition of Strong and Weak Recommendation
||Most patients would want the recommended course of action.
||Most patients would want the recommended course of action, but many would not.
||Most patients should receive the recommended course of action.
||Different choices will exist for different patients, and clinicians should help patients decide.
|For policy makers
||Recommended course should be adopted as policy.
||Considerable debate and stakeholder involvement needed to make policy.