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University of California San Diego, CA
Correspondence to: Katharine M. Rex, University of California, San Diego, 9500 Gilman Dr, Dept 0667, La Jolla, CA 92093-0667; e-mail: krex@ucsd.edu
To the Editor:
The American Medical Association1 has recommended that guidelines be developed for the driving licensure of persons who have sleep-related disorders that would be based on the extent to which those disorders contribute to traffic accidents and injuries. There is concern that regulators might attempt to restrict the driving privileges of apnea patients because of "lapses of consciousness" as defined by the "inability to respond rationally to the environment (excluding psychiatric conditions)."2
Kripke et al3 described a large population sample studied between 1990 and 1995, which may be the only randomly selected, ethnically representative objective survey of sleep-disordered breathing in a general US middle-aged population. Included were 190 women and 165 men between the ages of 40 and 64 years, and 65 women between the ages of 20 and 39 years. Home-based pulse oximetry data were collected to determine the incidence of 4% oxygen desaturation (ODI4) events each hour during sleep. More than half the male and almost half the female participants had at least five desaturation events per hour of sleep. The prevalence of > 20 events per hour was 9.3% for men and 5.2% for women.
Following the receipt of driving records, which spanned the previous 3 years in most cases, coded violation/accident data were calculated for each subject. Citations were scored from 1 to 3, according to the severity of the violation.
The 303 volunteer records had violation scores ranging from 0 to 7,
with 51 scores of > 0. The mean adjusted violation scores for groups
with increasing numbers of ODI4 events were not consistently related to
increasing the number of ODI4 events. Logistic regression for
any violation (ie, a score of 
1) showed no
significant effect of log10[ODI4], when age and
gender were controlled. The results of a logistic regression analysis
for violation scores of 3 (n = 20) were not significant, with no
predictor meeting p < 0.05 criteria. This survey demonstrated that
the relationship of desaturation incidents to sleepiness is very
weak,3
as other population samples have also
shown.4
5
6
7
This study had 80% power to detect if the
log10[ODI4] increases 0.3 log units or if the
risk of accident increases 76% (risk ratio, 1.76). Thus, the
possibility of any strong risk in our general population can be
excluded.
Young et al8
described an increased number of motor
vehicle accidents in men with apnea-hypopnea index (AHI) scores of
5 but also described an anomalous protective association of AHI
scores of 5 in women. There was no significant overall relationship
of the odds ratio to the AHI. Aldrich9
found that there
was no significantly higher self-reported accident rate among patients
with sleep apnea, narcolepsy, or other disorders of excessive daytime
sleepiness when compared to a control group. George et
al10
found that men with a mean (± SD)> found that male
subjects 49.3 ± 12.7 years old (SD) who had sleep apnea (AHI score,
73 ± 29) did significantly worse than control subjects on a divided
attention driving test. However, there was no relationship between the
level of the AHI and poor performance, and a large number of
symptomatic volunteers were as good as, or better than, control
subjects.
Neither this study nor the preponderance of previous studies supports a strong risk of accidents related to sleep apnea. Although the occurrence of five or more respiratory events per hour is exceptionally common in the population, it does not indicate a driving risk as great as that of single men under the age of 25 years, which we tolerate.
Acknowledgements
Deborah L. Wingard, Mary Anne Mowen, William J. Mason, Julian S. Smith, Robert L. Fell, Charles M. Senger, Raul S. Sepulveda, Matthew R. Marler, and Joseph D. Assmus assisted in this study.
Footnotes
This research was supported by National Institutes of Health grants HL40930, AG12364, HL55983, ES08930, and AG02711, and the Sam and Rose Stein Institute for Research on Aging.
References
This article has been cited by other articles:
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  J R Stradling and R J O Davies Sleep {middle dot} 1: Obstructive sleep apnoea/hypopnoea syndrome: definitions, epidemiology, and natural history Thorax, January 1, 2004; 59(1): 73 - 78. [Abstract] [Full Text] [PDF]
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