Assessing Driving Risk in Patients with Sleep Apnea: Who’s Safe to Drive?

1. Assessing Driving Risk in Patients with Sleep Apnea: Who’s Safe to Drive? Charles F.P. George MD FRCPC University Of Western Ontario London, Canada

2. Objectives • Discuss the issue of drowsy driving as it relates to sleep apnea • Review current guidelines on fitness to drive • Describe the legal implications of physicians’ decisions about driving

3. “When I die, I want to go like my grandmother, who died peacefully in her sleep. Not screaming like all the passengers in her car.” --Author Unknown

5. Causes of Sleepiness/Drowsy Driving • Sleep loss or sleep restriction • Job-related sleep restriction • Personal demands and lifestyle choices. • Driving patterns (e.g. Night driving) • Use of sedating medications • Alcohol consumption • Untreated/Unrecognized sleep disorders

8. Stutts JC. Accid Anal Prev. 2003;35:321-331 Risk Factors in Sleep-Related Crashes • Holding multiple jobs • Working night shift • Less than 6 hrs sleep/night • Nighttime driving (2400-0600h) • Daytime sleepiness • Driving after awake >15hrs • Long duration driving • Past history of drowsy driving

9. Characteristics that may predict crash: • AHI • BMI • O2 Saturation • Sleepiness J Clin Sleep Med 2009; 6:573-581 Crash Risk among Individuals with OSA Compared to Controls (Random-effects Meta analysis)

10. Can you spot the sleepy, OSA driver?

11. Which Smoker will get emphysema, lung cancer?

12. Operating a Motor Vehicle • A Right or a privilege? • All rights include individual responsibilities. • Every motor vehicle operator is responsible for operating safely

13. Liability for Injuries When an Individual Falls Asleep • A motor vehicle driver has a duty to drive safely in order to avoid foreseeable harm to others • When that duty is breached by unreasonable unsafe, conduct, the driver may be held liable for the harm proximately caused.

14. A driver is not guilty of reckless or careless driving by reason of what he does when asleep; • But (s)he can be convicted of careless [or reckless] driving if he falls asleep at the wheel • – i.e. (s) he was guilty of the offence not at the moment when the crash occurred but at the prior moment when he should have realized that he was sleepy and should have stopped driving.

15. Case of Sleepy Driving • A university student driving home from studying for year-end exams. • Following an exam, the defendant had socialized, studied and napped until 6:00 the next morning, began driving home at about 6:00 a.m. • She failed to notice a highway diversion barricade and struck and killed a tow truck operator assisting at the scene of a previous accident.

16. R v. Gill 2005 BCPC 0665 • “ A reasonable driver, knowing that they had stayed awake for 24 hours and had already fallen asleep as a consequence, unexpectedly, during that time period, and feeling the need to take action while driving to prevent the onset of sleep, such as turning up a radio (or some other folk myth like opening windows for a blast of fresh air), is expected by law to exercise a standard of care by not driving until the impairment has been corrected.”

17. Case of OSA • 46 y.o. Obese male (BMI=36.3) is referred for snoring and breath-holding during sleep. His wife says he gets sleepy while driving long distances (2 hours). Both deny any collisions. • Sleep study reveals sleep apnea (AHI=32).

18. Case of OSA • Is the patient at risk for motor vehicle collisions? • How should the physician deal with the situation? • When is the physician liable for a patient’s action?

19. Should All OSA Patients Be Allowed To Drive? YES • Patients with OSA understand their sleepiness and respond to it appropriately. They are reliable . • It is inappropriate to punish all for the rare patient who has accidents. NO • Patients with OSA cannot accurately gauge their sleepiness and degree of impairment. • The benefit to society overrules the rights of the individual patient.

20. We don’t tolerate drunk drivers on our roads.Why should we tolerate drowsy (OSA) drivers?

24. Driving Recommendations For Patients With OSA • Patients with mild OSA without daytime somnolence who report no difficulty with driving are at low risk for motor vehicle crashes and should be safe to drive any type of motor vehicle. • Patients with OSA, documented by a sleep study, who are compliant with CPAP or who have had successful UPPP treatment, should be safe to drive any type of motor vehicle.

25. Patients with moderate to severe OSA, documented by sleep study, who are not compliant with treatment and are considered at increased risk for motor vehicle crashes by the treating physician, should not drive any type of motor vehicle.

26. Patients with OSA who are believed to be compliant with treatment but who are subsequently involved in a motor vehicle crash in which they were at fault should not drive for at least 1 month. • During this period, their compliance with therapy must be reassessed. After the 1-month period, they may or may not drive depending on the results of the reassessment.

27. I have sleep apnea but my Doctor said it was okay to drive!

33. Ontario Highway Traffic ActSection 203 203(1): Every legally qualified medical practitioner shall report to the Registrar (of Motor Vehicles) the name, address, and clinical condition of every person 16 years of age or over attending upon the medical practitioner for medical services who, in the opinion of the medical practitioner, is suffering from a condition that may make it dangerous for the person to operate a motor vehicle.

34. Gee, I didn’t know that. Ignorance of the law is no defence! CMPA

37. CMPA Medico-legal handbook p29.

38. At Risk Patients • Severe OSA • Defined by what metric? • Excessively sleepy • Objective or subjective measures? • Previous motor vehicle crash • How would you know if the patient doesn’t tell?

39. Not All OSA Patients Have Accidents OSA – on CPAP for 3 yrs OSA –no Rx Controls Controls 3 yrs later George CF. Thorax 2001;56:508–512

40. Sleep 2010; 33:745-752 MSLT is predictive of an increased risk of DMV documented automotive crashes in the general population

42. A diagnosis of obstructive sleep apnea precludes an individual from obtaining unconditional certification to drive a CMV for the purposes of interstate commerce. • An individual with a diagnosis of obstructive sleep apnea may be certified to drive a CMV if that individual meets the following criteria: • Has untreated obstructive sleep apnea with an AHI ≤ 20, AND • Has no daytime sleepiness, OR • Has obstructive sleep apnea that is being effectively treated.

43. Treatment with CPAP reduces MVC’s George C Thorax 2001; 56:508-512

44. Summary • Some but not all OSA patients are at risk for motor vehicle accidents. • MD’s must know their local reporting requirements and assess each patient. • Always document in your records. • Aggressively treat OSA • Educate all sleepy patients about drowsy driving.