Aging, Transportation and Health

November 6, 2013

Witness: Grant Baldwin, PhD, MPH

Testimony - Testimony before the Special Committee on Aging, U.S. Senate

Good afternoon Chairman Nelson, Ranking Member Collins and members of the committee. Thank you for the opportunity to testify before you today. My name is Dr. Grant Baldwin, and I am the Director of the Division of Unintentional Injury Prevention in the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention (CDC). In this role, I am responsible for the leadership and implementation of CDC’s programs that prevent death and injury due to motor vehicle-related crashes, older adult falls, prescription drug overdoses, and traumatic brain injury.

I am pleased to be here today to speak with you about the intersection of transportation and public health and how transportation affects the health of older adults. I will also discuss what can be done to help older adults remain safe, active, mobile, independent, and healthy as they age.

Health and Transportation

In recent years, public health and transportation officials have been identifying how transportation influences public health and collaborating to incorporate consideration of health outcomes into the transportation decision-making process. This partnership recognizes that many factors outside of the traditional public health sector influence health and that addressing difficult health challenges effectively requires working collaboratively across sectors. For example, in 2010, CDC released the document, “Recommendations for Improving Health through Transportation Policy,”¹ which includes a range of recommendations to reduce injuries associated with motor vehicle crashes, improve air quality, expand public transportation, promote active transportation, and encourage healthy community design. In 2011, the National Prevention Strategy (NPS) recommended that agencies consider health across multiple sectors, including transportation. CDC has participated in the Transportation Research Board’s (TRB) Health and Transportation Subcommittee,² which was established in 2011 to develop a research agenda to improve our understanding of the effects of transportation on health. CDC also has participated on other TRB committees that develop future research needs relating to the safety and mobility of older adults. In August 2012, CDC, the Department of Health and Human Services (HHS) and the U.S. Department of Transportation (DOT) co-sponsored a White House roundtable on Health and Transportation in the Built Environment, which brought together representatives of the health and transportation sectors from federal, state and local governments and non-profit organizations to share information and discuss possible future collaborations on public health and transportation.

CDC collaborates with DOT to promote health in transportation. Specifically, CDC has a Memorandum of Understanding (MOU) and an action plan for coordination with the National Highway Traffic Safety Administration (NHTSA) through which we work together to reduce motor vehicle injuries. This partnership facilitates work together within the public health and transportation sectors to improve data, strengthen policy, synergize research, and translate evidence-based interventions into real-world settings. One example of this collaboration is an appraisal of state-based ignition interlock program features that are related to higher usage of interlocks. In addition to the MOU with NHTSA, CDC is partnering with DOT to develop a simple-to-use transportation and health tool that will help state transportation agencies and Metropolitan Planning Organizations (MPOs) assess how their transportation systems affect the health of the people they serve and how these systems could better promote health. The importance of the MPO planning process to key health outcomes was highlighted in the National Prevention Strategy case example of the Nashville Area MPO’s 2035 Regional Transportation Plan,³ which commits to devoting a minimum of 25 percent of its Federal Surface Transportation Program dollars for active transportation and public transit. CDC also is working with the Federal Highway Administration (FHWA) to assess the Nonmotorized Transportation Pilot Program’s (NTPP) impact on health through investment in walking and bicycling infrastructure, such as walking trails, bicycle paths, and other enhancements, in four communities to make active transportation safer and easier. In addition, CDC will be participating with FHWA at upcoming peer exchanges and conferences to discuss how health can be incorporated into transportation planning at the regional level.

Mobility Benefits Older Adults’ Health

Mobility – whether by car, foot, bicycle, public transit, or other transportation options, such as ride sharing, shuttles, or volunteer driver services – enables older adults to remain independent, active and socially connected. Mobility concurrently helps older adults obtain needed health care and preventive care services, and access other health-promoting goods and services. Ease of mobility also may enable older adults to pursue volunteer or paid work opportunities, further connecting them with their communities, helping bring meaning and a sense of fulfillment to their lives and benefiting their communities as well.

In addition, the opportunity to walk to a destination, or combining walking with another form of transportation – like public transit – enables, facilitates, and encourages older adults to be physically active, thus reducing their risk for obesity, diabetes, heart disease, stroke, depression and other chronic health conditions.⁴ Communities need to be safe for older adults and all pedestrians to walk throughout the community, and CDC supports evidence-based interventions that encourage healthy lifestyles while promoting safety.

Aging Population Faces Transportation Challenges

As the U.S. population continues to age in the coming decades, many older adults face safety concerns and challenges to their mobility. In 2012, 14 percent of the U.S. population was 65 years or older, and by 2030, it is projected to reach 20 percent. The vast majority of older adults prefer to “age in place” by continuing to live in their current homes and communities. As of 2000, 80 percent of people aged 65 and older lived in metropolitan areas, with two-third of those living in suburbs. Based on population projections, as the baby boomers continue turning 65, between 2010 and 2020, the suburbs will see a 50 percent increase in people aged 65-74. In addition, the fastest-growing segment of the older U.S. population is those aged 85 or older, and this group is at greatest risk for experiencing frailty and needing mobility assistance. Transportation issues will be of major concern.

Many older adults are dependent on cars, particularly in suburban or rural areas, which typically developed around the motor vehicle as the primary mode of transportation. This is reflected by the fact that about 9 out of 10 trips by older adults are made in personal vehicles. The built environment – the human-made physical characteristics of a community – such as wide roads with high volume, fast traffic, long walking distances, and the absence of infrastructure like sidewalks, safe street crossings or public transportation often presents obstacles to other forms of transportation like walking, bicycling and public transit. Poor street conditions and fear of crime and victimization can also be significant deterrents to walking for older adults. These obstacles can limit older adults’ mobility and thus their ability to remain active, mobile, socially connected and healthy.

Motor vehicle travel has become safer over time, but motor vehicle crashes continue to be a leading cause of injury-related death for older adults, who are disproportionately affected by motor vehicle fatalities. They have higher rates of motor vehicle occupant deaths, pedestrian deaths, and overall motor vehicle deaths than younger adults. Earlier this year, CDC published findings in a Morbidity and Mortality Weekly Report (MMWR) article indicating that pedestrian death rates generally increase with age and that the highest death rate for both sexes is among those aged 75 and older.⁵ Older adults take fewer walking trips than younger adults; however, when struck while walking, they are more likely than younger adults to die from their injuries.

As they age, some older adults will face limitations in their ability to drive (e.g., inability to drive at night), and some will have to stop driving altogether, due to age-related declines in vision, cognitive functioning (the ability to reason and remember), and physical changes (such as arthritis or reduced strength). When driving is no longer an option, other transportation options may be limited. In rural or suburban areas where public transportation may not be available, other options should be considered to help with mobility, such as ride sharing and volunteer ride programs. CDC research that is pending publication, has found that many older adults anticipate driving for years to come and do not plan for future alternative mobility needs. Therefore, more work is needed to ease the transition from driving to not driving and to help older adults find other ways to stay mobile in their communities. This transition is very challenging, and more research is needed to understand the factors that enable older adults to successfully and safely manage this transition.

Helping Older Adults Remain Mobile and Healthy

Public health can play an important role in working with transportation officials and those with expertise in healthy community design and age-friendly communities to create environments that promote health and address the mobility challenges facing older adults.

Healthy Communities

Designing communities that meet the needs of all road users can help older adults remain active, mobile and healthy. Healthy community design encourages streetscapes that promote opportunities for walking, bicycling and wheelchair access by incorporating safe sidewalks and street crossings, accessible transit and slower traffic speeds. It is also important that exterior walkways and signage are accessible to a population with a proportionately higher prevalence of impairments in hearing, vision, and mobility.

Older adults interact with their communities in ways that reflect changing lifestyles and changing physical capabilities. For instance, after retirement, people have more time to volunteer in their community and enjoy parks, recreational activities, libraries and other community facilities. Local planners can enhance communities by considering the design of neighborhoods so that older adults and others in the community whose mobility may be limited can engage with and participate fully in their communities. At the same time, conditions such as chronic diseases leading to disabilities such as limited vision, hearing or cognition may present barriers to mobility and require strategies to overcome those barriers. An older adult who is no longer able to drive but lives in a community with a safe and secure pedestrian environment that is near destinations such as libraries, stores, and places of worship, and is served by transit and other transportation options has the ability to remain mobile, active and healthy. Affordable, accessible, and suitable housing options can allow older adults and others living with disabilities to age in place and remain in their communities. Housing that is convenient to community destinations can provide opportunities for physical activity and social interaction.

One tool available to aid communities in making informed choices about improving public health through community design is Health Impact Assessment (HIA), which evaluates the potential health effects of a plan, project, or policy before it is built or implemented and provides recommendations. This information about potential health impacts can inform the decision-making process for plans, projects, and policies that fall outside the traditional public health arenas, such as transportation and land use.

Motor Vehicle Safety and Older Adult Mobility

For those older adults who are able to drive, we must continue to find ways to improve motor vehicle safety and reduce the disproportionate number of fatalities and injuries suffered by older adults whether they are drivers, vehicle passengers or pedestrians. This requires partnerships with organizations like AARP to help improve older adult driver safety. CDC, together with our colleagues at NHTSA, also will continue to identify effective, evidence-based interventions to prevent motor vehicle crashes.

We also must understand the various stages of transition for older drivers from driving independently to relying on other means of transportation. To this end, CDC worked with the Centers for Medicare & Medicaid Services (CMS) to include new questions about older adults’ use of various transportation options in its Medicare Current Beneficiary Survey (MCBS), a nationally representative survey of the Medicare population. CDC also is developing a tool to help older adults quickly assess their own mobility and receive individualized feedback based on their assessment. Currently, we are researching national prevalence estimates of U.S. older adult views on driving cessation, including when older adults predict that they will stop driving. In light of the growing population of older adults, we have recently identified older adult mobility as a new priority area for our motor vehicle injury prevention work, and we expect to undertake additional projects in the future.

Community-Based Transportation Services

The HHS Administration for Community Living provides funding to states, territories and tribes under the Older Americans Act (OAA) to support a variety of home- and community-based services that can be tailored to meet the individual needs of persons aged 60 and older so that they are better able to live independently in their homes and communities. In Fiscal Year 2011, this funding provided nearly 25 million rides to older adults across the country. National surveys indicate that these transportation services play a key role in helping older adults – particularly those who are frail and vulnerable and most in need of this assistance – maintain their independence:

• 62 percent are age 75 or older, and nearly 30 percent are age 85 or older;
• 64 percent live alone;
• More than half rely on these services for the majority of their transportation needs;
• Seven out of ten use these transportation services to get to the doctor and other health care appointments;
• One-third have been hospitalized in the past year;
• 45 percent are mobility impaired, meaning they either do not own a car, or they are unable to drive and do not live near public transportation;
• Three out of four have chronic illnesses that may impair the safety of their driving or prevent them from driving (e.g., stroke, macular degeneration, etc);
• Two-thirds had a doctor tell them they have vision problems (including glaucoma, macular degeneration or cataracts);
• 95 percent take at least one daily medication, and 14 percent take ten or more medications, many of which interfere with safe driving;
• Over one-third use the services to shop for necessities like groceries; and
• 97 percent of these transportation clients rate OAA-funded transportation services as good or excellent.

These transportation services, in combination with other community-based supports tailored to meet individual needs, serve as a vital lifeline for many older adults, allowing them to maintain mobility while safely remaining in their homes and communities as they age.

Conclusion

We recognize that transportation influences public health in a variety of ways and that it is important for public health and many critical sectors, including transportation officials, to work together to ensure that our transportation system, like our entire community, supports health, which is why these relationships and collaborations are so important for our agency. By helping older adults remain active, mobile and independent as they age, we also have an opportunity to help them remain healthier. We look forward to continuing to collaborate with our colleagues at DOT and other organizations to make progress toward this goal.

Thank you again for the opportunity to be here with you today, and thank you for your continued support of CDC’s essential public health work. I look forward to answering any questions you may have.