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Drivers with the sleep disorder sleep apnoea are more likely to nod off at the wheel and fail simulated driving tests than motorists without the condition, new research finds. Scientists from the University Hospital in Leeds, England, conducted two studies involving sleep apnoea and driving performance.

In one study, they tested the driving ability of 133 patients with untreated sleep apnea and 89 people without the condition using a simulated driving test. As they navigated the roughly 56-mile course, the “drivers” were assessed on completion, time spent in the middle lane, unprovoked crashes and crashes caused by veering off the road.

Twice as many people with untreated sleep apnoea (24%) failed the driving test, compared to 12% of those who didn’t have the condition. The researchers noted many of the sleep apnea patients couldn’t complete the test. They also had more crashes and had difficulty following a clear set of directions given at the start of the test.

“Driving simulators can be a good way of checking the effects that a condition like sleep apnoea can have on driving ability,” said the study’s chief investigator, Dr Mark Elliott, in a news release from the European Lung Foundation. “Our research suggests that people with the condition are more likely to fail the test.”

In another study, 118 people with untreated sleep apnea completed a survey about their driving behaviour and also took the simulated driving test. Their results were compared to those of 69 people who didn’t have sleep apnoea. More than one-third (35%) of those with sleep apnoea admitted to nodding off while driving. The researchers noted 38% of this group also failed the driving test. In contrast, only 11% of those without sleep apnoea admitted falling asleep while driving. And none of the motorists without sleep apnoea failed the driving test.

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People who drive commercial vehicles, such as buses, taxis, trucks and aeroplanes, could be incorrectly reporting their symptoms of sleep apnoea due to their fears of endangering their employment, according to a new study. The research will be presented on 1 September 2012 at the European Respiratory Society’s (ERS) Annual Congress in Vienna.
Researchers examined 37 commercial vehicle drivers with sleep apnoea and compared them with a control group of 74 patients. Both groups had similar characteristics of age, body mass index (BMI) and similar numbers of disturbances suffered on average during the night. Both groups also underwent treatment using CPAP. Levels of sleepiness were then analysed using the Epworth Sleepiness Score; a well-established short questionnaire used to give levels of sleepiness during the day time. The survey provides a score, which is the sum of 8 items and can range between 0 and 24.The higher the score, the higher the person’s level of daytime sleepiness.
At the start of the study, commercial drivers reported an average score of 8.1 on the sleepiness scale, compared with an average of 11.0 reported by non-commercial drivers, despite a similar number of disturbances at night between the two groups. The difference was also seen after 6 months of treatment using CPAP therapy with the drivers reporting an average sleepiness score of 4.8 and non-drivers reporting an average of 7.7. The results also showed that drivers received less treatment (only receiving CPAP for an average of 75% of days, compared with 83%) and also had more unscheduled visits to the clinic, which suggests they were struggling with their symptoms.
The authors speculate that the lower scores reported by the commercial drivers could be due to drivers under-scoring their sleepiness levels for fear of losing their licence permissions. Lead author, Dr. Werner Strobel from University Hospital, Switzerland, said: “Our study suggests that commercial drivers are playing down their levels of sleepiness for fear of losing their jobs. Although this is very difficult to prove, both the group of drivers and the group of non-drivers began the study with a similar number of disturbances during the night. You would therefore expect their reports of sleepiness to be similar to begin with, however the drivers estimated their levels of sleepiness as lower than the non-drivers. This pattern continued throughout the course of the study, with drivers reporting lower symptoms, yet receiving less treatment and making more unscheduled visits to the clinic. “We can assume from these results that commercial drivers with sleep apnoea symptoms could be under-reporting their sleepiness in order to protect their job. These results should be taken into account by healthcare professionals who are treating this group of people.”

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According to a new study in the journal Archives of Internal Medicine on car accident factors in southwest France, there was little difference between driving sleepy or drunk. Both doubled the risk of causing a car accident. This information is largely significant for drivers and the public to be aware because it can save lives.

The study included 679 people who were hospitalized because of a car accident between 2007 and 2009 in France. According to the study, men and younger adults were more likely to drive while sleepy.

The researchers wrote: In conclusion, the main factors associated with being responsible for a crash resulting in serious injury were younger age and driving cars, but more important were alcohol ingestion and sleepiness at the wheel, which are synergic.

In terms of possible action to reduce accidents the researchers wrote: “If alcohol use while driving can be reduced by legal interdictions and punishment correlated with BAC, the fight against sleepiness at the wheel can be addressed only by information and education. Coercion might be difficult to implement: could, for instance, a Stanford sleepiness test be administered by police forces and drivers fined or forbidden to drive if they fail?”

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A new Australian study published in Sleep Journal has highlighted the dangers of sleep apnoea in commercial drivers:

As obstructive sleep apnea (OSA) is associated with a higher risk of motor vehicle crashes, there is increasing regulatory interest in the identification of commercial motor vehicle (CMV) drivers with this condition. This study aimed to determine the relationship between subjective versus objective assessment of OSA in CMV drivers.

Drivers were interviewed regarding their driving experience, personal health, shift schedules, payments, and various questions on sleep and tiredness in order to describe their sleep health across a range of variables. In addition, home recordings using a flow monitor were used during one night of sleep. Only 4.4% of drivers reported a previous diagnosis of sleep apnea, while our at home diagnostic test found a further 41% of long-distance heavy vehicle drivers likely to have sleep apnea. The multivariable apnea prediction index, based on self-report measures, showed poor agreement with the home-monitor detected sleep apnea (AUC 0.58, 95%CI = 0.49-0.62), and only 12% of drivers reported daytime sleepiness (Epworth Sleepiness Scale score > 10). Thirty-six percent of drivers were overweight and a further 50% obese; 49% of drivers were cigarette smokers.

The study concluded:

Sleep apnea remains a significant and unrecognized problem in CMV drivers, who we found to have multiple health risks. Objective testing for this sleep disorder needs to be considered, as symptom reports and self-identification appear insufficient to accurately identify those at risk.

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The Charlotte Observer reports that a five-month investigation by NewsChannel 36 finds that one factor in the increasing number of trucking deaths is seldom reported and largely unregulated: sleep apnoea.

Drowsy driving kills more people on America’s highways than distracted driving, a top sleep expert recently told a motor carrier safety advisory panel. Dr. Charles Czeisler of Harvard University Medical School says sleep apnoea gets a lot less attention than other factors in deadly accidents involving tractor-trailers, but accounts for one in five crashes.

The number of Americans who died in commercial truck crashes grew slightly to about 4,000 last year, the Federal Motor Carrier Safety Administrator recently told Congress.

“I would argue that fatigue as a causal factor in truck-involved crashes is underreported, not over-reported,” said Don Osterberg, vice president of Safety for Schneider National Trucking. “Absent the commercial driver acknowledging that he or she fell asleep, law enforcement doesn’t record the crash as fatigue-related.”

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Carole Upcraft has launched an e-petition calling for the government to pressure lorry drivers to have tests for sleep apnoea, which causes daytime sleepiness and fatigue.

Her son Daniel, 32, suffered brain damage and his fiancée Nicola Culshaw, 33, was killed when their car was hit by a lorry while queuing for the Dartford tunnel on the M25 in April last year. The lorry driver, 40-year-old David Thomas from Upminster, was initially charged with causing death by dangerous driving, but the case was dropped when it was discovered he had undiagnosed sleep apnoea.

Library supervisor Mrs Upcraft, of Knoll Rise, Orpington, said: “There is no point in being vengeful here. We just need to find a positive out of what happened. We do not want another family to go through what we have gone through. Research shows that 41 per cent of HGV drivers have a sleep disorder of one kind or another, but most of them won’t be aware of it.”

The petition reads:

Tired drivers cause violent deaths & horrific injuries

Responsible department: Department for Transport

I would like a debate to raise awareness for the early diagnosis of HGV drivers with sleep apnoea. Last year my son and his fiancee were crashed into by a driver who had undiagnosed sleep apnoea. My son was left with serious brain injuries and his fiancee was killed. The driver was charged with death by dangerous driving but days before the trial the case was dropped by the CPS as he was driving unaware of this medical condition. There are clear criteria and indicators as to who is likely to suffer this condition. Please help raise awareness with haulage employers and GP’s. So that no other person is killed by a condition that is treatable.

To sign the petition, which needs 100,000 signatures to be considered by the government, go to epetitions.direct.gov.uk/petitions/5851

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The father of Toby Tweddell, who was killed in a road accident in 2006, has  spoken out on radio 5 live calling for all lorry drivers to be screened for sleep apnoea. The driver responsible for the accident also joined the call for action.

This tragic case demonstrates the fatal consequences of the lack of awareness of the condition, both within the medical profession, and by drivers themselves.  It also shows that commercial drivers have nothing to fear from a positive diagnosis as the driver in this case was absolved of resposibility for the accident having been misdiagnosed. He is still driving today having been treated successfully.

The coroner of the case, and Toby’s parents both called for screening at the time of the killing, and five years later nothing has been done and road deaths due to sleep apnoea have continued. However, with the Corporate Manslaughter Act now in full force a similar case could now result in the driver’s employers being sued for negligence. Hopefully companies will now take action before this happens again.

The BBC reported at the time, “Mr Tweddell, 25, from Sale, Greater Manchester, was killed when a lorry driver ploughed into a queue of traffic on the M62 in Merseyside in 2006. Lorry driver Colin Wrighton had been suffering obstructive sleep apnoea. The 54-year-old’s condition had yet to be diagnosed but he had complained to his doctor about feeling tired four months before the accident. Tests had been run for diabetes, which came back negative.

“Mr Wrighton was initially charged with causing death by dangerous driving, but the Crown Prosecution Service offered no evidence against him after his sleeping condition was revealed. In giving his narrative verdict, which was released as a statement, the coroner said: “It is my intention to prepare a Rule 43 Report to the Lord Chancellor concerning obstructive sleep apnoea in an endeavour to reduce the number of deaths that arise annually from this condition.”

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The results of a new study of 1000 drivers by the road safety charity Brake and Cambridge Weight Plan shows that one in eight drivers have nodded off at the wheel. They also found that one in seven (13%) of drivers suffer from sleep apnoea.

Julie Townsend, Brake’s campaigns director, said: “Tiredness at the wheel kills. Driving a vehicle is a huge responsibility that must be taken seriously. That means stopping when we feel drowsy and certainly never starting a journey tired. It’s a matter of life and death. We still have widespread misunderstanding of how to prevent driver tiredness, and ignorance about factors like sleep apnoea, a condition that can be treated. These messages still need to get through to the public, which is why we are calling for renewed efforts from the Government to tackle this issue urgently.”

Professor Tony Leeds, Medical Director, Cambridge Weight Plan, said: “Driver tiredness can have devastating results, but it is avoidable if drivers follow road safety and medical advice. I urge drivers to manage their sleep needs: make sure you get sufficient rest each night, and stop and rest if you feel sleepy at the wheel. If you often feel tired, there might be an underlying medical problem, so you should seek appropriate professional advice. A common cause of tiredness is obstructive sleep apnoea, which is more common among commercial drivers, and is linked to greater risk of crashing. Sleep apnoea is linked to body mass index, so overweight drivers should be particularly alert to the possibility of suffering from this disorder, but aware that it is treatable.”

I have long been calling for companies to test their drivers for sleep apnoea as a matter of routine. The test is simple and effective, and treatment is free on the NHS so will cost companies nothing to resolve, and will saving lives. With the Corporate Manslaughter Act now in force companies can and will be held legally responsible for failing to protect their employees, so there is every reason for employers of commercial drivers to act on this now.

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This BBC news item outlines the issue of sleep apnoea and road safety very effectively. As mentioned in the video a possible 25 road accidents a year are sleep related in Lincolnshire alone. I am calling for mandatory testing for all HGV drivers as identifying and treating sleep apnoea in drivers will save lives.

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It is suspected that about 20% of car accidents are sleep related and research has show that sleepiness can impair driving more than drink! Indeed patients with Obstructive Sleep Apnoea (OSA) have a 7-12 fold chance of a road traffic accident (RTA) compared to those who do not and treating the condition can reduce the accident rate by 83%.

It has been reported that up to 1:6 Heavy Goods Vehicle (HGV)   drivers are thought to have OSA and some Unions are calling for mandatory testing for all drivers. Falling asleep at the wheel results in far more serve injuries and likelihood of death as there is no attempt at breaking and evasive manoeuvres. In Lincolnshire we adopted a multi agency approach to this issue with significant success (see graph).

In the UK only 20% of patients have been diagnosed and only half of these have been treated  and the British Thoracic Society

(BTS) estimates that if you treated 59,400 you could reduce RTA’s by 7000 and over 400 lives would be saved and £400 million in RTA costs over 5 years.


RTA trends in Lincolnshire 2003-2009

The UK Driver Vehicle Licensing Agency (DVLA) has regulations for people who have been diagnosed with sleep apnoea, because these drivers are much more likely to be involved in crashes by falling asleep at the wheel. However, the clinical advice can be variable; from do not drive until on therapy to it is ok if you are not sleepy at the wheel.  This seems to be something of a grey area and needs clarification.

The DVLA requires:

Group 1 licence holders (car/ motorcycle) diagnosed with sleep apnoea must stop driving until the symptoms have been controlled and confirmed by medical opinion.

Group 2 licence holders (LGV) diagnosed with sleep apnoea must stop driving until the symptoms have been controlled, and must have ongoing treatment. Licensing reviews will be carried out regularly, usually annually.

A new leaflet ‘Think! Tiredness Can Kill’ has been published by the DVLA, offering advice for drivers on the risks of sleepiness while driving.

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