GOTSU, Japan — Before Atsumu Yoshioka, 81, decided to give up driving, there were signs it might be time.
During a visit to a shrine in rural Shimane prefecture in western Japan, Yoshioka, a retired furniture maker, forgot to set the parking brake, spooking his wife, Kazuko, when the car drifted backward.
Then one morning as he backed out of the driveway, he rammed into a large urn in front of their home. Haunted by television news reports of fatal accidents caused by older drivers, Yoshioka called it quits.
"Before I caused any serious accidents," he said, "I decided to give up driving."
As Japan's population ages, so do its drivers. Japan has the oldest population in the world, with nearly 28 percent of its residents above 65 years old. One in 7 people are over 75. In the United States, by comparison, that figure is closer to 1 in 16.
According to data compiled by Japan's national police agency, drivers between 16 and 24 are more likely to cause traffic accidents than any other age group. But last year, drivers over 75 caused twice as many fatal accidents per 100,000 drivers as those under that age. Among drivers over 80 years old, the rate was three times as high as for drivers under that age. The news media regularly features grisly reports of deaths caused by older drivers, some of whom are later discovered to have Alzheimer's disease.
Since 2009, all drivers 75 and older must submit to a test of their cognitive functioning when they renew their licenses, typically once every three years. Under a new traffic law that took effect in March 2017, those who score poorly are sent to a doctor for examination, and if they are found to have dementia, police can revoke their licenses.
More than 33,000 drivers who took the cognitive test last year showed what police deemed to be signs of cognitive impairment and were ordered to see a doctor. The police revoked just over 1,350 licenses after doctors diagnosed dementia.
An additional 460,000 older drivers showed slight impairment of their cognitive functions, based on their performance on the test, but were allowed to keep their licenses if they took a three-hour traffic safety course.
Many more, for a variety of medical or psychological reasons, have voluntarily decided they are no longer safe to drive and have given up their licenses. Police and local governments, along with some businesses, encourage older drivers to surrender their licenses by offering incentives like restaurant coupons or discounts on buses and taxi rides. In the police station in the town of Gotsu, a poster showed an older man reclining on a porch surrounded by family members and the line: "Please consult with the station soon if you think something is wrong with your driving."
Over the last five years, the number of drivers over 65 who voluntarily gave up their licenses across Japan more than tripled, to nearly 405,000 last year.
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After a lifetime behind the wheel, the sense of loss can be profound. "It was like I lost my spouse," Yoshioka recalled of the early months after he and his wife got rid of their car.
Now he spends his days tinkering with wood and ceramics, filling up the living room with miniature statues, vases and dioramas. He relies on friends or taxi services to go shopping or visit the hot springs baths and karaoke bars that he enjoys.
Advocates for the aging say that in rural areas like Shimane, any measures urging the elderly to give up driving need to be balanced against the potential harm to their quality of life.
Unlike major urban areas like Tokyo or Kyoto, where public transit is plentiful and efficient, there are few options for getting around the countryside. The train line that connected Shimane's towns to neighboring Hiroshima prefecture ceased operating in April.
And unlike in the past, adult children no longer typically live with — or even near — their parents, leaving them to go grocery shopping or visit the doctor on their own.
"A lot of drivers in their late 70s or 80s need to drive to conduct their daily lives," said Masabumi Tokoro, a professor of psychology at Rissho University in Tokyo who has studied such drivers. "It's very difficult for them to give up their driver's licenses. This is becoming a social problem, especially in rural areas."
Those who favor imposing more restrictions on elderly drivers say the danger of accidents outweighs any concerns about lifestyle. What's more, they say, the new traffic law focuses too narrowly on cognitive abilities, when so many other factors, including loss of vision or deteriorating reflexes and motor skills, could affect performance.
"Isn't it necessary to introduce a system in which drivers are compelled to surrender their driver's licenses in cases where they lack various abilities?" read a January editorial in the newspaper Sankei. "It's too late to regret once an accident is caused."
As Japan's low birthrate and resistance to immigration have contributed to a steady decline in the population, rural areas have experienced the most drastic shrinkages. With fewer customers, local businesses and services have shut down, forcing residents who remain to go farther for a pint of milk.
An exodus of working-age people from rural areas like Shimane, which has the second lowest population of Japan's 47 prefectures, has left few people to drive buses, taxis or delivery trucks that could support residents who have given up their cars.
In Kawamoto, a town of 3,333 people, of whom 45 percent are older than 65 (and nine are over 100), there are only three taxis and the buses run just once every two hours. Many residents "feel like they have to be independent and protect their own lifestyles," said the mayor, Minoru Miyake.
Noboru Moriwaki, 90, said he had no imminent plans to give up driving.
He and his wife, Yukiko, 86, live up a curvy hill on the outskirts of Kawamoto. A few times a week, Moriwaki, a retired school principal with a corona of wispy white hair and a forehead festooned with liver spots, drives his 2002 stick-shift Toyota Corolla to the grocery store, bank or library. Once a month, he takes his wife to the hospital.
"If you can't drive," said Moriwaki, "you can't get on with your life." A history buff and avid gardener, Moriwaki said the cognitive tests that accompany driver's license renewal were "easy."
On a recent afternoon at a driving school in Hamada, one of 12 in Shimane that administer the cognitive assessments, officials demonstrated a sample test. Drivers look at various pictures and then recall and describe them several minutes later. Those who get less than half correct are referred to doctors.
Specialists in dementia say that some people may be forced to give up licenses even when they are still capable of driving.
"It is a misunderstanding of society that if someone has dementia, he becomes a totally different person," said Heii Arai, a professor of psychiatry and chairman of the Juntendo Graduate School of Medicine.
Arai said that instead of forcing older drivers to quit, the government should install infrastructure such as guard rails along the sides of roads and near schools to help prevent accidents.
Some doctors say they must consider how integral driving can be to an elderly person's emotional well-being.
"They feel as if they have no value after surrendering their licenses," said Naoto Kamimura, a psychiatrist and lecturer at Kochi University.