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unless they receive treatment (Mets et al. 2012). According to these specialists,
excessive daytime sleepiness was the biggest limiting factor for driving (Mets et al.
2012). Nevertheless, physicians do not seem to assess their patients’ driving history
and eligibility adequately (Alkharboush et al. 2017).
170 A. S. BaHammam et al.
Fig. 11.2 A histogram of a split-night study of a patient with obstructive sleep apnea. The first part
of the study is diagnostic, and in the second part, continuous positive airway pressure (CPAP)
therapy was titrated. Obstructive events were eliminated when the optimal pressure was reached
Table 11.2 summarizes the data for the management
of sleep disorders and
driving performance.
11.2.6 Hypersomnolence Monitoring
Several techniques for assessing hypersomnolence have been developed. Below are
some of the commonly used tools in brief.
1.
Questionnaires on sleep: Several questionnaires, including the ESS, the Stanford
Sleepiness Scale, the Pittsburgh Sleep Qualit y Index, and the Karolinska Sleep-
iness Scale, have been developed to assess hypersomnolence (Buysse et al.
1989;
Johns 1991; Kaida et al. 2006). Unfortunately, subjective drowsiness ratings do
not correspond with objective sleepiness tests. Furthermore, none of those tools
have been validated for MVA risk.
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11 Traffic Safety in Sleep Deprivation, Sleepiness, and Sleep Disorders 171
Table 11.2 A summary of major studies that assessed the effects of treatment on the risk of motor
vehicle accidents in patients with hypersomnolence
Authors Type of study Intervention Study population Results
Philip et al.
(
2006)
Randomized,
crossover,
double-blind
placebo-con-
trolled trial
Modafinil
400 mg/day or
placebo for
5 days before a
driving test
13 patients with nar-
colepsy and 14 with
idiopathic
hypersomnia
Modafinil improved
wakefulness and
reduced inappropri-
ate line crossing and
the standard devia-
tion of the lateral
position of the
vehicle
Hirshkowitz
et al. (
2007)
Randomized
double-blind
study
Armodafinil
150 mg/day
Patients with OSA on
nCPAP having resid-
ual EDS
Armodafinil
improved wakeful-
ness and reduced
fatigue
Hack et al.
(
2001)
Case-control
study
nCPAP for
OSA and sleep
for sleep-
deprived
patients
26 patients with OSA
before and after
nCPAP; 12 healthy
subjects after sleep
deprivation and after
normal sleep or before
and after alcohol
intoxication
nCPAP for OSA,
normal sleep in sleep-
deprived subjects,
and removal of alco-
hol reversed impaired
driving. The effects
of OSA are related to
sleep fragmentation/
sleep deprivation,
while alcohol induces
impairment through
impaired cognitive
performance
Cassel et al.
(Hack et al.
2001; Cassel
et al.
1996)
Cohort study nCPAP for
OSA patients
59 patients using
nCPAP for 1 year
Spells of sleepiness,
sleep onset latency,
fatigue, and attention
are reduced with
nCPAP, thus reduc-
ing the number of
MVAs
Horstmann
et al. (2000)
Cohort study nCPAP for
OSA
85 patients with
OSAHS using nCPAP
nCPAP reduced the
number of accidents
from 10.6 to 2.7 per
million kilometers
2. OPTALERT (System of Infrared Reflectance Oculography): OPTALERT is a
new infrared reflectance oculography method for monitoring eye and eyelid
movements (Krahn et al. 2021). During driving operations, transducers are
connected to a glass frame and continually monitor drowsiness using a new
scale (Johns Drowsiness Scale-JDS) (Johns et al. 2007, 2008).
3.
The Multiple Sleep Latency Test (MLST) (Krahn et al.
2021): This test examines
a person’s proclivity to sleep in a comfortable position, a criterion widely
employed in diagnosing narcolepsy. Patients with mean sleep latencies of
5 min or less are deemed pathologically sleepy and should be advised about
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172 A. S. BaHammam et al.
their elevated risk of industrial or motor vehicle accidents (Richardson et al.
1978).
4. The Maintenance of Wakefulness Test (MWT) (Krahn et al. 2021) evaluates a
person’s capacity to remain awak e. According to one study, an MWT mean sleep
latency of 0–19 min is connected with simulated driving impairment (Sagaspe
et al.
2007b). More research is needed to confirm that abnormal MWT scores are
linked to actual driving impairment.
5. The Oxford Sleep Resistance Test (OSLER) (74 points): This test incorporates
aspects of the MWT as well as psychomotor testing.
6. Pupillography: This test assesses the diameter and variability of the pupil, as well
as their association with subjective sleepiness complaints (Balkin et al.
2004).
7. Actigraphy: This instrument analyses shift workers’ sleep duration and circadian
rhythm abnormalities, and it can be used to detect hypersomnia (Smith et al.
2018).
8. The most generally used test to measure sleep and associated abnormalities is
polysomnography (PSG), also referred to as the benchmark or the most reliable
method for diagnosing OSA (Caples et al.
2021).
These survey instruments and physiological tests are critical for effectively
diagnosing sleep problems and their symptoms, thereby avoiding driver errors and
accidents that may negatively impact public health. Nonetheless, none of the
methods mentioned above can reliably predict the degree of impairment and the
probability of MVAs (George et al. 1996; Kotterba et al. 2004). Furthermore, present
methods of simulated driving cannot reliably estimate the likelihood of accidents,
but they may predict who is unlikely to be involved in an MVA (Turkington et al.
2001; Vakulin et al. 2014).
11.3 The Treatment: Physician’s Role
Several studies have demonstrated that daytime sleepiness is connected with an
increased risk of MVAs (Gupta et al.
2017). Drivers are frequently unable to forecast
their degree of awareness prior to driving or their performance while driving (Verster
and Roth 2012). MVAs impose a high economic and social cost. As a result, routine
health examinations should be performed prior to obtaining or renewing a driver’s
license, especially in patients with sleep disor ders. Physicians should consider this
risk when evaluating patients with sleep disorders, medical illnesses, or drugs that
may cause excessive daytime sleepiness (Alkharboush et al. 2017). It is debatable
whether physicians have a legal obligation to evaluate their patients’ medical fitness
to drive (Adams 2010; Laycock 2010). While some nations hold doctors legally
responsible for failing to notify specific medical issues local traffic authorities
(Berger et al. 2000; Reuben and St George 1996), others do not (Alkharboush
et al. 2017). Furthermore, physicians in some countries have a high level of
awareness about the relevance of this issue, but physicians in other nations have a
https://t.me/medicina_free
Funding This work was partially supported by a grant from the National Plan for Science and
Technology Program by the King Saud University Project in Saudi Arabia. The sponsor had no role
in the design or conduct of this research.
lack of felt responsibility. According to a Canadian survey, 72% of family physi-
cians say they should be held legally accountable for alerting traffic authorities about
patients who are unable to drive (Jang et al. 2007). In contrast, a study in Saudi
Arabia found that just 15% of those polled thought it was their responsibility to
report patients who were unable to drive to local traffic authorities (Jang et al.
2007).
11 Traffic Safety in Sleep Deprivation, Sleepiness, and Sleep Disorders 173
11.3.1 Legislative Concerns
Numerous European countries, as well as Canada, Australia, and several US states,
have detailed traffic rules that restrict persons suffering from sleep disorders such as
OSA and narcolepsy from driving or acquiring a driver’s license until the disease is
medically treated (de Mello et al.
2013; Krieger 2007; Masullo et al. 2014). Several
European nations (Belgium, the Netherlands, Finland, Spain, Sweden, France, and
the United Kingdom) have placed legislative restrictions on the issuance of a driving
license to patients suffering from OSA and narcolepsy (Masullo et al.
2014).
However, in other nations (particularly developing countries), no traffic laws govern
sleepy driving. To limit the risk of sleepy driving, regulations must be put in place.
Sleepy drivers should be held liable for the dangers they take and the damage they
create if they do not seek medical attention (Powell and Chau
2011; National
Conference of State Legislatures
2018). Furthermore, clear regulations are required
to identify the legal duties of treating physicians in the case of hypersomnolence
patients.
11.4 Conclusions
Given that evidence worldwide show s hypersomnolence, sleep deprivation, and
sleep disorders as major causes of industrial and road accidents, sleep-related
measures should be included in screening at least commercial drivers (if not all
drivers). This screening should be part of the first medical work-up before a
commercial driver is issued a license. Furthermore, these drivers’ health should be
monitored on an annual basis. Drivers should be encouraged to seek the advice of a
sleep physician and follow that advice. Additionally, drivers should be informed of
the necessity of getting enough sleep before driving and employing effective sleep-
related countermeasures. Furthermore, physicians, particularly family physicians
and general practitioners, should be educated about the dangers of sleepy driving
and the significance of routine fitness-to-drive exams.
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174
A. S. BaHammam et al.
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