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Sleep Disorders, Sleepiness and the Risk of Traffic Accidents

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Sleep Disorders, Sleepiness and the Risk of Traffic Accidents Sleep disorders, sleepiness and the risk of traffic accidents Mahssa Karimi Doctoral thesis Department of Internal medicine and clinical nutrition Institute of Medicine Sahlgrenska Academy at University of Gothenburg Gothenburg 2014 Gothenburg 2014 Cover illustration: Earl Keleny Sleep disorders, sleepiness and the risk of traffic accidents © Mahssa Karimi 2014 [email protected] ISBN 978-91-628-8940-1 http://hdl.handle.net/2077/34848 Printed in Gothenburg, Sweden 2014 Aidla Trading Kompendiet AB This thesis is dedicated to my parents and my love Yashar Sleep disorders, sleepiness and the risk of traffic accidents Mahssa Karimi Department of Internal medicine and clinical nutrition, Institute of Medicine Sahlgrenska Academy at University of Gothenburg Göteborg, Sweden ABSTRACT The aim of this thesis was to identify the prevalence of sleep disorders, mainly obstructive sleep apnea (OSA), among public transport operators (PTO´s). Further to assess the risk of motor vehicle accident (MVA) in a group of patients with suspected OSA compared with the general population. Additionally, we aimed to identify specific risk factors linked to a history of MVA in these patients and to assess the prevalence of such factors in a large European sleep apnea patient database. We also determined the interventional effect of continuous positive airway pressure (CPAP) treatment on hypersomnolence, neurocognitive function and history of traffic accident. Finally, we investigated functional cognitive markers associated with history of MVA among PTO´s as well as single and multi-center cohorts of patients with OSA. The study used objective and subjective methods to assess sleep, sleep disorders, hypersomnia, vigilance and daytime cognitive performance. Data was extracted from a nationwide traffic accident registry (STRADA) for individual identification of MVA history. Sleep disorders including OSA, excessive daytime sleepiness, insomnia and restless legs syndrome (25%, 13%, 10% and 2%, respectively) were prevalent among PTO´s (n=87). Among clinical patients (n=1478) with suspected OSA the estimated risk of MVA was 2.5 times higher than in the matched general population. Measures of hypersomnolence, use of hypnotics, short sleep time, and driving distance (OR 2.0 to 2.7, p≤0.02) were associated with MVA risk, whereas conventional metrics of OSA severity were not. Compared with the general population, OSA patients were 1.9 times more likely to be injured in the MVA (p=0.01). We identified functional measures of neurocognitive dysfunction associated with MVA history (p<0.01). A mean nightly CPAP use of at least 4.0 hours was associated with improved neurocognitive function, reduced hypersomnia and a 70% reduction of MVA. It is concluded that conventional metrics of OSA are insufficient for the recognition of risk while markers of neurocognitive function may provide better identification of patients at risk. Our findings suggest that the high risk of MVA in OSA and the effectiveness of treatment in terms of accident reduction call for effective programs for detection and treatment of OSA. Keywords: motor vehicle accident, obstructive sleep apnea, neurocognitive function ISBN: 978-91-628-8940-1 1 SAMMANFATTNING PÅ SVENSKA Obstruktiv sömnapné (OSA) förekommer bland 9 respektive 24% av kvinnor och män. Uttalad dagtidströtthet, försämrad kognitiv funktion och ökad risk för trafikolyckor (TO) har associerats med OSA. Denna avhandling avsåg att fastställa prevalensen av sömnstörningar och framförallt OSA bland yrkesförare samt att identifiera risk faktorer för TO risk bland så väl kliniska patienter som yrkesförare. Effekten nattlig övertrycksbehandling med mask (CPAP) utvärderades hos patienter avseende risk för TO och i ett vidare perspektiv utvärderades kognitiv funktion hos yrkesförare med nyupptäckt OSA före och efter CPAP behandling. Såväl subjektiva som objektiva testmetoder användes för att fastställa sömn, sömnstörningar, hypersomni och kognitiv funktion under dagtid. Vi analyserade registerdata avseende trafikolycksfall för att fånga 10-års incidens av TO bland patienter och kontroller. Sömnrelaterade störningar i form av OSA, uttalad dagtidssömnighet, insomni eller rastlösa ben (25%, 13%, 10%, respektive 2%) identifierades bland yrkesförare (n=87). Kliniska patienter (n=1478) med misstänkt OSA hade en 2.5 gånger förhöjd risk för TO jämfört med befolkningen i övrigt (p<0.001). Hypersomnolens, kort habituell sovtid, användning av sömnmedel och hög trafikexposition (OR 2.0 till 2.7, p≤0.02) kunde associeras med ökad risk för TO. Däremot visade konventionella mått på svårighetsgrad av sömnapné ingen association med en ökad risk. Personskador relaterade till olyckan var 1.9 gånger vanligare bland OSA patienter jämfört med befolkningen (p=0.01). Vi identifierade fyra separata mått på kognitiv funktion i ett nykonstruerat dagtidstest som associerade med förekomst av TO (p<0.01). Behandling av OSA med CPAP var associerad med en kraftig reduktion av TO frekvens (från 7.6 till 2.5 TO/1000 förare och år). Denna reduktion visades enbart hos patienter som var följsamma med behandlingen (≥4 timmar/natt). Sammanfattningsvis talar objektiva och standardiserade nationella registerdata kring TO i en stor och väl karaktäriserad patientkohort för en påtaglig ökning av olycksrisk bland patienter med OSA. Prediktorer för risk kunde identifieras men konventionellt använda mått för att beskriva svårighetsgrad av OSA (t.ex. apné/hypopné index) bidrog inte till förbättrad identifikation av riskindivider. Våra data understryker betydelsen av att diagnostisera och behandla OSA i syfte att reducera TO frekvens. Avhandlingen illustrerar samtidigt utmaningen i att designa bättre verktyg för att identifiera patienter med OSA och ökad olycksfallsrisk i trafiken. 2 LIST OF ORIGINAL PAPERS This thesis is based on the following studies, referred to in the text by their Roman numerals. I. Karimi M, Eder DN, Eskandari D, Zou D, Hedner J, Grote L. Impaired vigilance and increased accident rate in public transport operators is associated with sleep disorders Accident Analysis and Prevention 2013; 51: 208-214 II. Karimi M, Hedner J, Häbel H, Nerman O, Grote L. A sleep apnea related risk of vehicle accidents is reduced by CPAP - Swedish Traffic Accident Registry data Submitted. III. Karimi M, Hedner J, Lombardi C, McNicholas WT, Penzel T, Riha RL, Rodenstein D, Grote L. Driving habits and risk factors for traffic accidents among sleep apnea patients – a European multi-center cohort study Submitted. IV. Karimi M, Hedner J, Zou D, Eskandari D, Lundqvist A-C, Grote L. Vigilance and attention deficits are associated with motor vehicle accidents in sleep apnea patients Manuscript. Paper I was reprinted with permission from Elsevier. i 3 CONTENT 4 ABBREVIATIONS ....................................................................................................IV 5 INTRODUCTION ....................................................................................................... 1 5.1 Traffic safety .................................................................................................... 1 5.2 Human factors involved in traffic accident risk ................................................ 2 Exposure to traffic ............................................................................................... 2 Gender, age and circadian influence ................................................................... 2 5.3 Sleep ................................................................................................................. 4 The function and regulation of sleep ................................................................... 4 The physiology of sleep ...................................................................................... 5 Microsleep ........................................................................................................... 6 Sleep disorders .................................................................................................... 7 5.4 Obstructive sleep apnea .................................................................................... 8 Pathophysiology and diagnostics ........................................................................ 8 Epidemiology .................................................................................................... 10 Risk factors ........................................................................................................ 10 Consequences of OSA and comorbidities ......................................................... 10 Treatment of OSA ............................................................................................. 10 OSA and motor vehicle accidents ..................................................................... 11 5.5 Impaired vigilance at the wheel ...................................................................... 12 5.6 Neurocognitive function ................................................................................. 13 Cognitive function and OSA ............................................................................. 13 Assessment of cognitive function in OSA ......................................................... 14 Cognitive function and prediction of MVA risk in OSA .................................. 15 6 AIM OF THIS THESIS............................................................................................... 16 7 METHODS ............................................................................................................
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