Health Status and Activity Discomfort among Elderly Drivers: Reality of Health Awareness

As the number of elderly drivers rapidly increases worldwide, interest in the dangers of driving is growing as accidents rise. The purpose of this study was to conduct a statistical analysis of the driving risk factors of elderly drivers. In this analysis, data from the government organization’s open data were used for the secondary processing of 10,097 people. Of the 9990 respondents, 2168 were current drivers, 1552 were past drivers but were not driving presently, and 6270 did not have a driver’s license; the participants were divided into groups accordingly. The elderly drivers who were current drivers had a better subjective health status than those who were not. Visual and hearing aids were used in the current driving group, and their depression symptoms reduced as they drove. The elderly who were current drivers experienced difficulties while driving in terms of decreased vision, hearing loss, reduced arm/leg reaction speed, decreased judgment of the road conditions such as signals and intersections, and a decreased sense of speed. The results suggest that elderly drivers are unaware of the medical conditions that can negatively affect their driving. This study contributes to the safety management of elderly drivers by understanding their mental and physical status.


Introduction
Globally, the number of elderly drivers aged 65 and over was 7685 million in 2019, accounting for 14.9% of the total population [1]. This number is rapidly and continuously increasing. Therefore, as many accidents occur among elderly drivers, interest in the dangers of driving is increasing [2]. One study reported that elderly people with a driver's license can improve their independence by self-driving: thus, increasing their autonomy in participating in old-age activities [3]. Among the elderly, driving is considered an essential action that expands the scope of activities, such as leisure activities, visits to hospitals, and shopping, and provides opportunities for independence in their daily lives [4]. In this way, elderly drivers have positive emotional and social functions, given the increasing opportunities for social activities [5]. Thus, elderly people who drive themselves are considered to have a relatively high level of life satisfaction [6]. Approximately 30,000 cases were reported in 2018 in the Republic of Korea, and this number is continuously increasing [7,8]. When accidents occur, the elderly suffer serious injuries and have a slow recovery rate compared to young people [2,4]. As such, elderly drivers have a high risk of traffic accidents, and their anxiety about accidents is severe compared to the other age groups [5,9].
The ability of elderly drivers to self-regulate changes in their driving ability by becoming more aware of and managing their health status is naturally strengthened with increasing age [10]. Nevertheless, the reliability of elderly drivers' awareness of their health status and driving ability is controversial [11]. In countries such as the United States, the United Kingdom, Canada, and Australia, a self-reporting evaluation method was used to investigate the characteristics of elderly drivers [12,13]. Although they tend to avoid certain driving situations, such as night driving, long-distance driving, and driving when the roads are congested [8,14,15], they are affected by society and the culture to which they belong [16]. Some studies analyzed changes in behavior, cognition, perception, and physical function of elderly drivers while driving using the Self-report Assessment Forecasting Elderly Driving Risk (SAFE-DR), which was developed to assess the situation in the Republic of Korea [15,17,18].
Owing to medical advances and changes in the social environment, the proportion of elderly drivers is rapidly increasing and will continue to increase [1]. If elderly drivers are not aware of their physical changes and do not avail themselves of treatment in a timely manner, it interferes with their driving ability [5] and, consequently, increases the risk of accidents. This study aimed to analyze the physical characteristics, underlying diseases, and health consciousness of elderly drivers to identify their mental and physical conditions and help prevent traffic accidents. In addition, the researchers provide basic data for related research.

Study Design and Sampling
The data for this study were obtained from the Health and Welfare Data Portal of the Korea Institute of Health and Social Affairs and included the data of 10,097 elderly people in the Republic of Korea aged 65 years and over (National Statistics approval no. 117071). A total of 10,097 people were surveyed; 107 people who did not drive were excluded from the total, and the remaining 9990 people were divided into three groups: 2168 people who were currently driving, 1552 people who were past drivers but were not currently driving at the time of the survey, and 6270 people who had no driver's license. Those with the highest age of elderly drivers at the time of the survey were selected and further classified as those without a driver's license, past drivers, or not current drivers, who were at the time of the survey. The participants' ages ranged from 65-90 years ( Figure 1). hearing (talking on the phone, talking to the person next to you), chewing (chewing meat or hard things), and determining muscle strength (active movement (running about one lap (400 m) on the playground), walking around the playground (400 m), climbing 10 steps without a break, bending over, squatting, or kneeling, and reaching out for something higher than one's head). Physical functioning was divided into lifting, moving, and disability determination. (4) Depressive symptoms were measured using the shortened geriatric depression scale (SGDS)-K15, which is a Korean translation of the SGDS developed by [19] to evaluate depressive symptoms in the elderly population (out of a total score of 15, individuals with a score of 8 or higher were classified as having depressive symptoms). (5) Social activities and discomfort in social activities were classified into two categories, namely, difficulty in using the information necessary for life and the inconvenience caused by using information technology in everyday life. (6) Economic activity was classified into current income, work, and desired work. (7) Precognitive function: cognitive function was confirmed and measured using the Mini-Mental State Examination for Dementia Screening (MMSE-DS) test tool. A representative screening test developed by [20] is widely used for simple and rapid measurement as well as screening for any cognitive impairment; the standardized Korean version of the mini-mental state examination (MMSE-K) [21], the Korean mini-mental state examination (K-MMSE) [22], and the mini-mental state examination-Korean children (MMSE-KC) [23] have been used in the Republic of Korea. A total mini-mental state examination (MMSE) score of 30 points is considered the cutoff point for cognitive impairment; a score of 0-10 indicates severe cognitive impairment, 10-20 indicates moderate cognitive impairment, 20-24 indicates mild cognitive impairment, and 24-30 indicates no cognitive impairment [14]. (8) General characteristics, such as gender, height (cm), weight (kg), body mass index (kg/m²), drinking, smoking, education level, subjective age of the elderly, suicidal ideation, and health-type factors, were obtained.

Data Variables
The data description of the variables used in this study is as follows: (1) Driving status, which was divided into two groups: past drivers (not currently driving) and not having a driver's license. (2) Health status and health behavior, which included thoughts on health in general; presence of chronic diseases (diseases lasting for more than 3 months as diagnosed by a doctor, namely circulatory diseases: high blood pressure, stroke (stroke, cerebral infarction), hyperlipidemia (dyslipidemia), angina pectoris, and myocardial infarction (heart failure and arrhythmia); endocrinal disease: diabetes and thyroid disease; musculoskeletal diseases: osteoarthritis (degenerative arthritis), rheumatoid arthritis, osteoporosis, low back pain, sciatica, fracture, dislocation, and after effects of accidents; respiratory diseases: chronic bronchitis, emphysema, asthma, pulmonary tuberculosis, and tuberculosis, neuropsychiatric diseases: depression, dementia, Parkinson's disease, and insomnia; sensory diseases: cataract, glaucoma, chronic otitis media, senile deafness, skin disease, and cancer (malignant neoplasm); digestive diseases: gastroduodenal ulcer, hepatitis, and liver cirrhosis; genitourinary diseases: chronic kidney disease, prostatic hyperplasia, urinary incontinence, and anemia, etc. (3) State of physical function, including eyesight (watching TV, reading newspapers), hearing (talking on the phone, talking to the person next to you), chewing (chewing meat or hard things), and determining muscle strength (active movement (running about one lap (400 m) on the playground), walking around the playground (400 m), climbing 10 steps without a break, bending over, squatting, or kneeling, and reaching out for something higher than one's head). Physical functioning was divided into lifting, moving, and disability determination. (4) Depressive symptoms were measured using the shortened geriatric depression scale (SGDS)-K15, which is a Korean translation of the SGDS developed by [19] to evaluate depressive symptoms in the elderly population (out of a total score of 15, individuals with a score of 8 or higher were classified as having depressive symptoms). (5) Social activities and discomfort in social activities were classified into two categories, namely, difficulty in using the information necessary for life and the inconvenience caused by using information technology in everyday life. (6) Economic activity was classified into current income, work, and desired work. (7) Precognitive function: cognitive function was confirmed and measured using the Mini-Mental State Examination for Dementia Screening (MMSE-DS) test tool. A representative screening test developed by [20] is widely used for simple and rapid measurement as well as screening for any cognitive impairment; the standardized Korean version of the mini-mental state examination (MMSE-K) [21], the Korean mini-mental state examination (K-MMSE) [22], and the mini-mental state examination-Korean children (MMSE-KC) [23] have been used in the Republic of Korea. A total mini-mental state examination (MMSE) score of 30 points is considered the cut-off point for cognitive impairment; a score of 0-10 indicates severe cognitive impairment, 10-20 indicates moderate cognitive impairment, 20-24 indicates mild cognitive impairment, and 24-30 indicates no cognitive impairment [14]. (8) General characteristics, such as gender, height (cm), weight (kg), body mass index (kg/m 2 ), drinking, smoking, education level, subjective age of the elderly, suicidal ideation, and health-type factors, were obtained.

Data Analysis
All continuous variables in this study are expressed as standard deviation mean (SD), and categorical variables are expressed as percentages (%) in their respective groups. A normality test was performed, and the significance of Kolmogorov-Smirnov and Shapiro-Wilk was lower than the p-value of 0.05, so it was judged to be non-normal. The difference between all dependent variables, according to the presence or absence of driving, was verified using the Kruskal-Wallis test and the Chi-square test (frequency was 20.0% over performing a Fisher's exact test). For the analysis, we used IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY, USA), and the statistical significance level was set at p < 0.05.

Results
The elderly who currently drive had a better subjective health status than those who did not. Among the current drivers, seven people had severe disabilities (grades 1-3), 44 had moderate disabilities (grades 4-6), 32 had physical disabilities, 11 had hearing impairments, three had visual impairments, and two had respiratory problems. At the time of the data investigation, most of the diseases had been cured, but there were differences between the groups in the treatment status of diabetes and chronic diseases, such as back pain, sciatica, pulmonary tuberculosis, and tuberculosis. The people who were not driving had more chronic diseases. In the currently driving group, the use of visual and hearing aids was 52.7% and 7.7%, respectively. Among the participants, 25.9% had discomfort due to bad eyesight, 15.1% had a hearing discomfort, and 28.0% experienced discomfort due to bending, squatting, kneeling, or reaching out for something higher than their heads. Of the respondents, 19.5% reported that it was difficult to perform touch movements. Depression symptoms decreased as they drove, and cognitive function was better in the driving group than in the other groups; however, it was also lower than the cut-off points for those over the age of 80. Among the elderly who were current drivers, 12.0% said that they experienced difficulties while driving in terms of decreased vision, hearing loss, decreased arm/leg reaction speed, decreased judgment (understanding of road conditions such as signals and intersections), and sense of speed. In other words, to prevent accidents due to aging, it is necessary to contribute to the safety management of elderly drivers by identifying their mental and physical conditions through precise identification of their mental and physical conditions.

General Characteristics
The general characteristics of the study participants were as follows: "current drivers" included 1729 men and 439 women; "past drivers but not current drivers" included 1237 men and 315 women; and 1045 men and 5225 women had "no driver's license". There was a difference between the groups with regard to age: "current drivers" 69.3(4.22), "past drivers but not current drivers" 74.08(5.74), and "no driver's license" 74.58(6.54) (p < 0.001). Regarding the subjectively considered age of the elderly, there was a difference between the groups: 71.32(4.60) were "current drivers", 69.72(4.14) were "past drivers but not current drivers", and 70.02(4.04) had "no driver's license" (p < 0.001). There was a difference in the presence or absence of disability determination as follows: 51 people were "current drivers", 92 were "past drivers but not current drivers", and 301 people had "no driver's license" (p < 0.001). Regarding the degree of disability, "current drivers" comprised 7 people with severe disability (grades 1-3) and 44 people with moderate disability (grades 4-6); "past drivers but not current drivers" comprised 29 people with severe disability (grades 1-3) and 63 people with moderate disability (4-6); those with "no driver's license" comprised 68 people with severe disability (1-3) and 233 people with moderate disability (4-6), exhibiting a group difference of p = 0.046. As for the usual subjective health status, 1598 people said they were "current drivers", 749 people stated they were "past drivers but not current drivers", and 2576 people stated they had "no driver's license"; the perceived health difference was p < 0.001 (Table 1).

Current Disease Status and Their Treatment
The results of the current disease status and whether there were patients receiving treatment are as follows: although there were differences in most diseases, treatment was completed at the time of investigation; however, there was a difference between the groups in the presence or absence of treatment for diabetes (p = 0.01), musculoskeletal diseases (back pain, sciatica) (p < 0.001), and respiratory diseases (pulmonary tuberculosis, tuberculosis) (p = 0.037). The total number of chronic diseases diagnosed by doctors was 1.37 (1.24) for "current drivers", 1.78 (1.50) for "past drivers but not current drivers", and 2.02 (1.50) for "no driver's license" exhibiting differences between the groups (p < 0.001). The number of prescription drugs being taken for more than 3 months was 1.31 (1.20) for "current drivers", 1.78 (1.74) for "past drivers but not current drivers", and 1.94 (1.55) for "no driver's license" (p < 0.001) ( Table 2).

Physical Function Status and Discomfort in Daily Life
The following were the outcomes of the physical function status and discomfort in daily living: For those who answered "yes" regarding the use of a vision aid, 1142 people were "current drivers", 890 people were "past drivers but not current drivers", and 3247 people had "no driver's license"; there was a difference between the groups (p < 0.001). As for those who answered "yes" in relation to the use of hearing aids, 1676 people were "current drivers", 199 people were " past drivers but not current drivers", and 747 people had "no driver's license"; there was a difference between the groups (p < 0.001). Those who were "uncomfortable" in their daily lives as a result of bad vision were as follows: "current drivers" consisted of 560 people, "past drivers but not current drivers" consisted of 508 people, and "no driver's license" consisted of 2165 people; there was a difference between groups (p < 0.001). For discomfort due to hearing in daily life, "current drivers" consisted of 327 people, "past drivers but not current drivers" consisted of 383 people, and "no driver's license" consisted of 1534 people who were "uncomfortable"; there was a difference between the groups (p < 0.001). Regarding the difficulty in performing motions (such as bending, squatting, or kneeling), "current drivers" consisted of 608 people, "past drivers but not current drivers" consisted of 770 people, and "no driver's license" consisted of 3506 people who stated that it was "slightly or very difficult"; there was a difference between the groups (p < 0.001). For difficulty in performing movements (such as reaching out for something higher than their head), "current drivers" consisted of 423 people, "past drivers but not current drivers" consisted of 616 people, and "no driver's license" consisted of 2911 people who stated that it was "slightly or very difficult"; there was a difference between groups (p < 0.001) ( Table 3).

Depressive Symptom
As a result of examining the depressive symptoms, the score was 10.08 (2.21) for "current drivers", 10.40 (2.20) for "past drivers but not current drivers", and 10.34 (2.28) for "no driver's license", with a cut-off point of 8. The "current drivers" group exhibited a lower depression score than the "no driver's license" (p < 0.001) group. Despite this, all groups were found to have high levels of depression.

Economic Activity
The results related to economic activity were as follows: In relation to current economic activity, 1432 people were from the "current drivers" group, 448 people from the "past drivers but not current drivers" group, and 1898 people from the "no driver's license" group were "currently working". There were 676 "current drivers", 1041 "past drivers but not current drivers", and 3116 having "no driver's license" who had "previously worked but not currently working". The "never worked" people who were "current drivers" were 60 people, "previously a driver but not currently" were 63 people, and 1256 people had "no driver's license"; there was a difference between the groups (p < 0.001). As for the participants who would like to work in the future, there were 804 people who "didn't want to work" who were "current drivers" and 1006 people who had "no driver's license"; 4298 people indicated wanting to "continue their current work" of which 1135 people were "current drivers" and 334 people had "no driver's license"; 1339 people wanted to "continue with current job", of which 82 people were "current drivers", 53 people were "past drivers but not current drivers", and 130 people had "no driver's license. There were 141 "current drivers", 130 "past drivers but not current drivers", and 379"having no driver's license"; there was a difference between groups (p < 0.001) ( Table 4).

Recognition Function
The results reflecting age and educational level that affect cognitive impairment are as follows: Looking at overall cognitive impairment, the elderly who were in the "current drivers" group had less precognitive impairment than the "past drivers but not current drivers" and "no driver's license" groups. However, in the driving group, there were participants with lower than the recognition function cut-off points of 30 in the age group of 80 years or older (Table 5).

Current Drivers
The degree of difficulty in driving was as follows: 24 people found it to be very difficult; 238 people stated that it was somewhat difficult; 352 people stated that it was just so; 859 people stated that it was not difficult at all; and 689 people stated that it was not at all. The difficulties experienced while driving were "eyesight impairment" in 236 people, "hearing impairment" in 22 people, "decreased reaction speed in arms and legs" in 82 people, "decreased judgment" (understanding road conditions such as intersections) in 151 people, and "slow speed" in 123 people.

Discussion and Conclusions
The data for this study were obtained from the health and welfare data portal of the Korea Institute for Health and Social Affairs to identify the physical and mental status of the elderly who are currently driving. A total of 9,990 people took part in the survey in 2020. Choi stated that elderly drivers experiencing difficulties adapting to changes in driving conditions are aware of the driving risks, including deterioration in sight and hearing [11]. It has been shown that many elderly drivers choose to drive despite the deterioration in their sight and hearing, which is a result of their natural aging and can cause serious accidents. Lee also stated that elderly drivers' ability to adapt to driving situations is related to the risk of traffic accidents, which means that the physical health of the elderly is highly correlated with their driving performance [19].
Aging is natural, but the deterioration of vision inevitably increases the risk of accidents associated with driving; hence, elderly drivers must accurately recognize their mental and physical conditions. Health status is highly correlated with the safety perception of driving. If the elderly are rewarded for good health status, [5] they will drive more cautiously. Previous studies also reported that elderly drivers become distracted while driving owing to the increased auditory processing load, which increases the risk of driving accidents owing to increased driving speed variability [11,12]. It has been recognized that the driving risk increases when the elderly drive [11]. In addition, complications that can lead to accidents and, consequently, cause social problems are also important when psychotic or cognitive impairment occurs in elderly drivers [5,11]. In reality, it is impossible to unconditionally ban the elderly from driving, but in particular, the elderly who have vision and hearing impairments should receive driving assistance through orthoses and treatment.
It was reported that the elderly who currently drive had a better subjective health status than those who did not. Among the "current drivers", seven people had severe disabilities (grades 1-3), 44 had moderate disabilities (grades 4-6), 32 had physical disabilities, 11 had hearing impairments, three had visual impairments, and two had respiratory problems. At the time of the data investigation, most of the current diseases had been cured, but there were differences between the groups in the treatment status of diabetes and chronic diseases such as back pain, sciatica, pulmonary tuberculosis, and tuberculosis. The number of chronic diseases increased, resulting in the elderly not driving. In addition, for 28.0% of the respondents, bending, squatting, and kneeling movements were difficult, and for 19.5%, reaching for something higher than their head was difficult. Depression symptoms decreased as they drove, and cognitive function was better in the driving group than in the other groups, but it was also lower than the cut-off point for those over the age of 80. Among the elderly who are currently drivers, 12.0% said that they experienced difficulties while driving in terms of decreased vision, hearing loss, decreased arm/leg reaction speed, decreased judgment (understanding of road conditions, such as signals and intersections), and decreased sense of speed. In a study by Choi, elderly drivers were found to take drugs for hypertension, diabetes, and hyperlipidemia [11]. Also, regarding the economic activity results of elderly drivers, there is a significant difference between groups according to current drivers, drivers who have driven in the past, and those without a driver's license. This means that driving and economic activities are significantly correlated, and drivers have a strong correlation with economic activity. In this study, diseases such as diabetes, lower back pain, and sciatica were significantly different from those in the other groups. These results suggest that elderly drivers are unaware of medical conditions that can negatively affect their driving. The findings of this study can facilitate the safety management of elderly drivers by better understanding their mental and physical status.
This study has some limitations. The results must be interpreted with caution, as the findings do not represent all elderly drivers in the Republic of Korea. Further, the findings do not reflect the actual driving situation. In addition, it was impossible to directly discuss the risk of driving due to neurological symptoms.