THE DROWSY DRIVER. David Y. Huang, M.D. February 27, Tallahassee Pulmonary Clinic Tallahassee Memorial Sleep Center

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1 THE DROWSY DRIVER David Y. Huang, M.D. February 27, 2016 Tallahassee Pulmonary Clinic Tallahassee Memorial Sleep Center

2 Disclosures I have no conflicts of interest

3 Goals: The Drowsy Driver To become aware of the national problem of drowsy driving To become familiar with the risk factors for drowsy driving car crashes To understand some measures that may reduce drowsy driving car crashes

4 WHAT REALLY SCARES US ANNUAL RISK OF DYING Shark attack 1 in 281,000,000 Dog bite 1 in 19,000,000 Plane crash 1 in 9,000,000 Lightning 1 in 3,000,000 West nile virus 1 in 1,000,000 Influenza virus 1 in 130,000 Gunshot 1 in 28,000 Car crash/mva 1 in 6,700 Pulmonary embolism 1 in 6,000 Heart disease 1 in 300 (Ropeik, 2002)

5 Drowsy Driving Personal Experience 1999: Driving at night to TN from 9 pm - 5 am Dan Davis, M.D s Medical Intern: Driving home after 36 hour shift Bill Potts, M.D. 2002: Driving on the highway in Montana Ronshay Dugans 2008: 8 yr old killed by drowsy driver, which generated FL legislation PT 2013: College Freshman driving late at night

6 Life is Short. Stay Awake!

7 How Big is The Problem of Drowsy Driving?

8 Crash Statistics are Conservative Only half of drowsy driving crashes are reported Most police not trained to detect driver drowsiness There is no objective measurement of drowsiness (e.g. Breathalyzer or blood alcohol) Self-reporting tends to be inaccurate because people don t accurately recognize when they nodded off Fall-asleep crashes often filed incorrectly because they can look like alcohol- or drug-related crashes

9 Drowsy Driving Crash Statistics 1995: US Dept of Transportation 100,000 police-reported crashes annually 71,000 injuries annually 1,550 deaths = 4.4% of all fatal car crashes annually 2013: AAA Foundation for Traffic Safety 328,000 (estimated) = 1.4% of all crashes 109,000 injuries = 7% of crashes resulting in injuries 6,400 deaths = 21% of all fatal car crashes

10 Other Statistics NSF s 2014 Sleep in America Poll found: Over 50% reported driving drowsy in past year 25% actually dozed off at the wheel in past year 1% had a car accident or near-miss accident during the last year due to drowsiness

11 Video #1 Video clip of drowsy driver crash

12 Video #2 Video clip of drowsy driver crash Q&ebc=ANyPxKpFACAtCxdjjcCIz7gHgMOJmFAkr_RnZ8tgvaeaBn8JOEAd LbVqZPqzPr65huPi0CFDy7bb3QyBjN3r_pxPLJu 7du1Xw

13 What are The Characteristics of Drowsy Driving Crashes?

14 Characteristics of Drowsy Driving Crashes Most happen between midnight 6:00am; or in the midafternoon (circadian dip) The driver is alone and likely to be a young male There is usually no evidence of braking or evasive maneuvers Many involve serious injuries or fatalities

15 Characteristics of Drowsy Driving Crashes? A single vehicle drifts off the road, often a high speed roadway, and hits a tree/stationary object Crashes are often rear-end or head-on collisions

16 Video #3 Video clip of drowsy driver crashing

17 Jane Stutts, PhD next 7 slides

18 Drowsy Driving Crashes AAAFTS and University of North Carolina: Jane Stutts, et al (November 1999) Epidemiology of drowsy driving crashes Scientific case-controlled report 3 categories of drivers Drowsy driver crashes All other crashes (control crash drivers) Drivers renewing license (non-crash controls)

19 Factors Perceived as Important in Causing Crashes _ All Car Crashes Alcohol 96% Driver drowsiness 80% Aggressive driving 79% Poor weather 77% Inattention 72% Speeding 71% Inexperience 58%

10 BAC (1)(2) People with moderate untreated sleep apnea performed worse than those with a.

20 Sleep Deprivation = Alcohol Impairment 18 hours sustained wakefulness produces performance impairment =.05 BAC (1) 24 hours of being awake =.10 BAC (1)(2) People with moderate untreated sleep apnea performed worse than those with a.06 BAC (3) On 4 hours sleep, 1 beer can have same impact as a six-pack of beer for a NL person (4) (1) Dawson & Reid, 1997 (2) Williamson & Feyer, 2000 (3) Powell, 1999 (4) Roehrs et al, 1994

Who is at Risk for Drowsy Driving Crashes? Category Slide of various faces Sleep disorder 1.9 2 jobs 2.

21 Who is at Risk for Drowsy Driving Crashes? Category Slide of various faces Sleep disorder jobs 2.1 Sleeps 5-6 hours 3.8 Sleeps < 5 hours 7.0 Poor sleeper 12.1 Night shift worker 13.6 *Odds ratio *Compared to Non-crash controls

22 Who is at Risk for Drowsy Driving Crashes? Category Sleep disorder jobs 2.1 Sleeps 5-6 hours 3.8 Sleeps < 5 hours 7.0 Poor sleeper 12.1 Night shift worker 13.6 *Odds ratio *Compared to Non-crash controls

23 Epworth Sleepiness Scale (ESS) How likely are you to doze off (Scale 0-3) (Mild chance 1; Moderate chance 2; Severe chance 3) (Normal score < 10 and Maximum score = 24) Sitting and reading Watching television Sitting in a public place (theater or meeting) As a passenger in a car for an hour Lying down to rest in the afternoons Sitting and talking with someone Sitting quietly after lunch (no alcohol) In a car, stopped for a few minutes in traffic

24 Who is at Risk for Drowsy Driving Crashes? Category *Odds ratio ESS score ESS score 16 or higher 15.2 Driving late at night 6.5 Slept < 4 hours the night 19.2 before the crash Awake for hours 10.4 Awake for > 20 hours 56.6 *Compared to Non-crash controls

25 Are You At Risk? Before you drive, check to see if you: Are sleep-deprived or fatigued Are suffering from insomnia, poor sleep, and chronic sleep debt Will be driving long distances, greater than 4 hours, without proper rest breaks Will be driving through the night, midafternoon, or when you would normally be asleep

26 Are You At Risk? (cont.) Taking sedating medications during the day Working night shift from 11 pm - 7am Working more than 60 hours a week Working more than one job and your main job involves shift work Drinking even small amounts of alcohol Driving alone on a highway or on a long, dark, boring rural road

27 How To Reduce Your Risk DON T DRIVE! Take public transportation Hire a taxi or a chauffeur Buy a self-driving car

28 Video #4 Video clip of drowsy driver crashing

29 Recognize The Warning Signs of Fatigue Trouble focusing, keeping your eyes open, or keeping your head up Daydreaming; wandering thoughts Yawning or rubbing your eyes repeatedly Drifting from your lane, tailgating, and missing signs or exits Feeling restless and irritable

30 Before A Trip Get a good night s sleep, preferably 7-8 hrs Drink 2 cups of coffee before leaving on your trip Travel with a companion to help share driving Avoid alcohol and sedating medications Schedule 10 minute breaks every 100 miles or every 2 hours during long trips Consult your physician or a sleep physician if you are experiencing frequent daytime sleepiness

take a short nap Drink 1 or 2 cups of coffee before you start driving again Don t

31 Countermeasures While Driving If you get sleepy, STOP DRIVING!!! Let someone else take over the driving Pull off the road at a safe place and take a short nap Drink 1 or 2 cups of coffee before you start driving again Don t rely on drowsy driving devices Roadside rumble strips have been shown to reduce fall asleep car crashes

32 New Developments in Cars ALERTNESS MONITORING: Mercedes (Attention Assist) Subaru (Eyesight/Lane Keep Assist) Saab (Driver Attention Warning System) All car manufacturers SELF-DRIVING or AUTONOMOUS DRIVING Mercedes Benz S550 Self-driving car Audi A-7 prototype Autonomous driving car Tesla Model S Autonomous software Almost all car manufacturers

33 Video #5 Video Clip of Self-driving Tesla Model S

34 Can Legislation Deter Drowsy Driving? Maggie s Law in New Jersey in 2003 Rob s Law in Massachusetts in 2005 Florida Statute 2010 re Ronshay Dugans death: Drowsy Driving Awareness Week in September

35 Summary Drowsy driving is a major problem Drowsiness and Fatigue are impairments like alcohol or drugs Anyone can be at risk There are simple ways to combat drowsy driving get enough good sleep Practice good sleep habits and remember Drive Alert Arrive Alive

36 Who is at Risk for Drowsy Driving Crashes? Patients with sleep loss, especially < 5 hrs sleep qhs Acute sleep deprivation you or me after being on call Special At-Risk Groups: Young people, especially adolescent males Shift workers e.g. Nurses or Medical/Surgical interns Commercial (CMV) truck drivers People taking sedating medications during the day People with undiagnosed OSA or other untreated sleep disorders such as Narcolepsy

37 Young man, that car is a loaded 3000 lb WEAPON!

Adolescent Drivers 16-19 yrs Comprise 6-8% of drivers, but involved in 16% of

38 Adolescent Drivers yrs Comprise 6-8% of drivers, but involved in 16% of car crashes, involved in 21% of automobile deaths Males are at higher risk Risk of MVA is increased 1.3X due to drowsiness if sleep deprived (< 6 hr/night) Driving late at night (MN to 6 am) increases risk 2X Martiniuk JAMA Pediatr 2013 DRIVING

39 Adolescent Drivers yrs Alcohol often involved Speeding and also inexperience often quoted Not wearing seat belts increases mortality

40 Other At Risk Drivers Shift workers Increased # of health problems, decreased quality of life, decreased lifespan, chronic sleep deprivation Increased risk for drowsy driving crashes at 7-8 am, when getting off their night shift Nurses working nightshift > 12.5 hours had 2X higher risk of drowsy driving car crash, even worse if getting < 6.4 hours sleep daily Dinges Sleep 2007

41 Medical Shiftworkers Pediatric Housestaff 49% fallen asleep at wheel, almost always post-call 44% fallen asleep stopped at red light 23% fallen asleep driving 20 MVA total Med School Faculty 13% fallen asleep at the wheel (P < 0.001) 12.5% fallen asleep stopped at red light 8% fallen asleep driving 11 MVA total Marcus - Sleep 1996

42 Medical Shiftworkers Large survey of 2737 Medical/Surgical Interns Risk of MVA among Interns working several extended work shifts per month (EWS > 24 hrs, with ave 32 hrs) Ave 70 hours of work/week with ave of 4 EWS/month Results: 2.3X higher risk of MVA after an EWS 5.9X higher risk of a near-miss car accident after EWS Every extra EWS/month increased risk of MVA by 9% Worked 5 or more EWS/mo, 2.4X risk of falling asleep Led to new ACGME guidelines Barger - NEJM 2005

43 Commercial Truck Drivers Increased risk of crashes, but not clear how high, probably 2X or higher, range 1.3X 5X Comprise 4% of drivers but involved in 12% of mortalities Truckers are usually male and more obese than general population; more likely to have OSA Truckers may also be sleepier since many only get 5-6 hours of sleep each night FMCSA Evidence Report 2007 Collop JCSM 2016

44 Video #6 Clip of two truck drivers and near miss crash due to driver drowsiness

45 Commercial Truck Drivers Truckers have been documented to have microsleeps (30 seconds) based on continuous EEG testing while driving (Mitler - NEJM 1997) Implications of driver drowsiness in the trucking industry are mind-boggling The first lawsuit that claims a trucker was negligent in a crash due to self-imposed chronic sleep deprivation may set a precedent Tracy Morgan 2014

46 Patients on Sedating Medications Sedating antihistamines (Benadryl) Benzodiazepines (Klonopin and others) Narcotics (Oxycodone/Oxycontin and others) Anticonvulsants (Tegretol and others) Tricyclic antidepressants (Elavil and others) Antipsychotics (Seroquel, Saphris, and others) Some SSRI s (Paxil, Luvox; also Remeron) Some BP medications (Clonidine) High dose dopamine agonists (Requip/Mirapex)

47 Patients on Sedating Medications Zolpidem (Ambien) (Farkas NEJM 2013) Hazardous, particularly the 10 mg or 12.5 mg CR dose when written for women May result in hangover effect, especially if taken too late at night (< 8 hours before desired wake up time) Same concerns for other Z-drugs as well as BZD sleep aids such as Restoril or Klonopin

48 Driving and Obstructive Sleep Apnea Does OSA impair driving performance? Do OSA patients have increased car crash rates? Does treatment of OSA with CPAP/APAP reduce crash rates? >50% of OSA patients remain undiagnosed

49 Car Crashes in Sleep Apnea Patients Patients with OSA have about a 2.5 times higher risk for a car crash Higher ESS, more severe OSA, lower oxygen desaturations on PSG, and higher BMI may all be associated with higher risk for a car crash Alcohol increases the risk even more Even men with mild OSA may have 3 times higher risk (not women) AHI > 40 results in higher risk of MVA Philips - JCSM 2009

50 CPAP Reduces Crash Rates Crash rate before CPAP (per 100,000 km) Crash rate after CPAP (per 100,000 km) All crashes (p<0.01) Crashes from falling asleep or fatigue (p<0.05)

51 CPAP Reduces Crash Rates Incidence 1yr before CPAP Incidence 1yr after CPAP Car crashes (p<0.01) Near-miss accidents (p<0.01)

52 Wear Your CPAP!

53 Legal Implications of the Sleepy Patient Obstructive Sleep Apnea Patient

54 Mandatory Categorical Reporting Reporting every patient with OSA to the Florida Dept of HS and Motor Vehicles Already done for tuberculosis, HIV disease, and Legionella pneumonia - PHD A major problem is defining what is significant OSA (who determines this) Florida and most states don t advocate this

55 Mandatory Reporting for OSA Pros Impaired patients are not allowed to drive Protects the patient, you, and me Cons Difficult to precisely determine who is at risk for car crashes Some patients with OSA may avoid medical evaluation/treatment Patients with OSA may seek disability

56 OSA and Driving - American Thoracic Society ATS Guidelines recommend reporting highrisk OSA patients to Department of Motor Vehicles under the following circumstances (Pack s view): Patient with OSA and previous car crash due to falling asleep at the wheel Patient with OSA, excessive daytime sleepiness, and near miss car crash who continues to drive and refuses adequate treatment (e.g. CPAP)

57 OSA and Driving - A Practical Approach Warn patient of increased risk of car crashes due to untreated OSA and document it High risk patients who have fallen asleep driving or are having microsleeps should not drive until OSA has been adequately treated Try to get PSG (split-night study) ASAP Consider therapy with autopap until PSG Be vigilant for bus drivers and truck drivers

58 OSA and Driving - A Practical Approach General Recommendations for OSA patients: Warn the patient not to drive if they get drowsy (verbal and written brochure) If a long drive can not be avoided, consume caffeine in preparation for the long drive Stop driving if falling asleep or very drowsy. Let someone else drive or pull over and take a short nap Take frequent breaks while driving (10 min/2 hr)

59 OSA and Driving - A Practical Approach General Recommendations for OSA patients: Avoid alcohol prior to driving Also avoid any sedating medications such as Benadryl, benzodiazepines, narcotics, etc Avoid sleep deprivation before long trips Adequate therapy e.g. CPAP > 6 hours qhs Also avoid operating heavy equipment if sleepy

60 Reporting to Dept of HSMV Follow ATS guidelines for reporting highrisk OSA patients to DHSMV (Medical Reporting Form 72190) Most drivers who have OSA have not had car crashes and it is not reasonable to prevent all people with OSA from driving Physicians should be given immunity from tort liability when they, in good faith, report appropriate drivers to DHSMV

61 GG UPS Driver of the Year 2014 Severe OSA with AHI of 70 per hour CPAP 7 hrs qhs Awarded plaque for his 28 year history of Driving Excellence Zero MVA!!!

62 DOT Physical Exam and OSA CMV truck drivers with OSA may have a 1.3X - 5X higher risk of a car crash compared to controls Higher ESS, more severe OSA, lower oxygen desaturations on PSG, and higher BMI may all be associated with higher risk for car crashes Truckers with OSA may not be aware of the extent to which they are negatively affected by their EDS Adequate CPAP therapy (optimum pressure for at least 6 hours/night) reduces the crash risk for pts with moderate-to-severe OSA (1 day? 2 weeks?) FMCSA Evidence Report 2007

63 When is it Safe to Drive or Fly? If Epworth sleepiness scale score is NL < 10? If the patient is compliant with an appropriate level of CPAP? (pt uses it > 6 hours qhs by sleep log in machine) If Multiple Sleep Latency Test is NL > 10 min? If Maintenance of Wakefulness Test is > 20 or > 33 min? If patient performs normally on Driving Simulator or Divided Attention Task? The answer is not clear, probably MWT

64 Who Can Drive or Fly? In Australia, you can not be a commercial truck driver if you have severe OSA In U.S. no consistent requirements regarding the screening, evaluation, or treatment of OSA in commercial truck drivers in process by FMCSA Federal Aviation Administration may be the most avante garde a pilot can fly if OSA is adequately treated (uses CPAP > 6 hr/night based on annual download or UPPP surgery followed by NL PSG) and exam by certified physician. In the past, normal MWT alone would qualify.

65 Other At Risk Drivers Untreated narcolepsy patients No good data due to rarity of this disorder (.05% prevalence in the general population) 75% of narcolepsy patients remain undiagnosed Impaired driving due to EDS and increased car crashes have been documented

66 Other At Risk Drivers Untreated RLS patients May affect up to 3-4% of population Symptoms in the evening and bedtime, as well as leg jerking while sleeping 80% have PLMS which disrupts sleep Impaired driving due to daytime fatigue and sleepiness has been postulated

67 Any Questions?

68 Case Presentation Dr. GP Morbidly obese 55 yo man with severe OSA RDI > 80 events per hour, longest apnea 50 seconds, and lowest SaO2 of 70% Poor compliance with CPAP therapy and F/U with Dr. Admitted to TMH with severe daytime sleepiness and symptoms of biventrivular CHF Noted by family to fall asleep at red lights No family or friends would ride with him because he almost crashed several times Epworth sleepiness scale score of 19 (NL<10)

69 Patient GP Reported to Florida DHSMV as impaired driver Patient warned of this reporting Patient told not to drive until his OSA was adequately treated Agreed to use CPAP/BiPAP after adjustments BiPAP titration study: started BiPAP 15/10 MWT done: average sleep latency 23 min Epworth sleepiness scale score fell from 19 to 8

THE DANGERS OF DROWSY DRIVING. The Costs, Risks, and Prevention of Driver Fatigue

THE DANGERS OF DROWSY DRIVING. The Costs, Risks, and Prevention of Driver Fatigue THE DANGERS OF DROWSY DRIVING The Costs, Risks, and Prevention of Driver Fatigue Presented on behalf of Texas Department of Transportation This presentation is a modification of one created and copyrighted