Abstract
Purpose
Excessive daytime sleepiness (EDS) while driving is a major international public health issue resulting in a more than doubled risk of motor vehicle accidents (MVAs). Obstructive sleep apnea (OSA) is the most frequent medical cause of EDS. Therefore, the European Union Directive 2014/85/EU determined that “untreated moderate to severe OSA coincident with EDS constitutes a medical disorder leading to unfitness to drive.” The paper aims are to provide a brief review of sleepiness and its implications for driving safety, as well as to describe the subjective and objective methods to accurately evaluate EDS in order to assess fitness to drive in patients with OSA.
Methods
We examined databases including PubMed, Medline, and EMBASE using the search terms “sleepiness at the wheel, excessive daytime sleepiness, sleepiness measure, sleep-wake cycle, obstructive sleep apnea, driving license, fitness to drive.”
Results
Significant interindividual variability in EDS exists in patients with comparable severity of OSA. Objective methods of measuring EDS are too expensive and time consuming to be suitable for the certification of driving licenses. The reliability of subjective methods depends upon the clinical setting and subjective tools assess only limited aspects of EDS. Objective measures, such as biochemical biomarkers, must, therefore, support subjective methods.
Conclusions
Extensive data have supported different subjective and objective methods for the appraisal of EDS in patients with OSA depending upon the clinical and experimental setting. Challenges remain to determine an appropriate tool for the evaluation of fitness to drive.
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References
Quera-Salva MA, Hartley S, Sauvagnac-Quera R, Sagaspe P, Taillard J, Contrand B, Micoulaud JA, Lagarde E, Barbot F, Philip P (2016) Association between reported sleep need and sleepiness at the wheel: comparative study on French highways between 1996 and 2011. BMJ Open 6:e012382. https://doi.org/10.1136/bmjopen-2016-012382
Zwahlen D, Jackowski C, Pfäffli M (2016) Sleepiness, driving, and motor vehicle accidents: a questionnaire-based survey. J Forensic Legal Med 44:183–187. https://doi.org/10.1016/j.jflm.2016.10.014
Nabi H, Guéguen A, Chiron M et al (2006) Awareness of driving while sleepy and road traffic accidents: prospective study in GAZEL cohort. BMJ 333:75
Connor J, Norton R, Ameratunga S et al (2002) Driver sleepiness and risk of serious injury to car occupants: population based case–control study. BMJ 324:1125
Stutts JC, Wilkins JW, Scott Osberg J et al (2003) Driver risk factors for sleep-related crashes. Accid Anal Prev 35:321–331
Global status report on road safety 2018: summary. Geneva: World Health Organization; 2018 (WHO/NMH/NVI/18.20). Licence: CC BY-NC-SA 3.0 IGO). https://www.who.int/violence_injury_prevention/road_safety_status/2018/GSRRS2018_Summary_EN.pdf. Accessed December 2018
https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries. Accessed December 2018
Gonçalves M, Amici R, Lucas R, Åkerstedt T, Cirignotta F, Horne J, Léger D, McNicholas WT, Partinen M, Téran-Santos J, Peigneux P, Grote L, National Representatives as Study Collaborators (2015) Sleepiness at the wheel across Europe: a survey of 19 countries. J Sleep Res 24(3):242–253
Tefft BC (2012) Prevalence of motor vehicle crashes involving drowsy drivers, United States, 1999–2008. Accid Anal Prev 45:180–186
Philip P, Taillard J, Guilleminault C et al (1999) Long distance driving and self-induced sleep deprivation among automobile drivers. Sleep 22:475–480
de Mello MT, Narciso FV, Tufik S, Paiva T, Spence DW, Bahammam AS, Verster JC, Pandi-Perumal SR (2013) Sleep disorders as a cause of motor vehicle collisions. Int J Prev Med 4(3):246–257
Garbarino S, Nobili L, Beelke M, De Carli F, Ferrillo F (2001) The contributing role of sleepiness in highway vehicle accidents. Sleep 24(2):203–206
Bioulac S, Micoulaud-Franchi JA, Arnaud M, Sagaspe P, Moore N, Salvo F, Philip P (2017) Risk of motor vehicle accidents related to sleepiness at the wheel: a systematic review and meta-analysis. Sleep. 1(10):40. https://doi.org/10.1093/sleep/zsx134
Krieger J (2007) Sleep apnea and driving: how can this be dealt with? Eur Respir Rev 16(106):189–195
Mathis J, Seeger R, Ewert U (2003) Excessive daytime sleepiness, crashes and driving capability. Schweiz Arch Neurol Psychiatr 154(07):329–338
Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D, Tobback N, Mooser V, Preisig M, Malhotra A, Waeber G, Vollenweider P, Tafti M, Haba-Rubio J (2015) Prevalence of sleep disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med 3(4):310–318
Findley LJ, Unverzagt ME, Suratt PM (1988) Automobile accidents involving patients with obstructive sleep apnea. Am Rev Respir Dis 138(2):337–340
Mulgrew AT, Nasvadi G, Butt A, Cheema R, Fox N, Fleetham JA, Ryan CF, Cooper P, Ayas NT (2008) Risk and severity of motor vehicle crashes in patients with obstructive sleep apnea/hypopnoea. Thorax. 63(6):536–541. https://doi.org/10.1136/thx.2007.085464
Garbarino S, Pitidis A, Giustini M, Taggi F, Sanna A (2015) Motor vehicle accidents and obstructive sleep apnea syndrome: a methodology to calculate the related burden of injuries. Chron Respir Dis 12(4):320–328. https://doi.org/10.1177/1479972315594624
Strohl KP, Brown DB, Collop N, George C, Grunstein R, Han F, Kline L, Malhotra A, Pack A, Phillips B, Rodenstein D, Schwab R, Weaver T, Wilson K, ATS Ad Hoc Committee on Sleep Apnea, Sleepiness, and Driving Risk in Noncommercial Drivers (2013) An official American Thoracic Society Clinical Practice Guideline: sleep apnea, sleepiness, and driving risk in noncommercial drivers. An update of a 1994 Statement. Am J Respir Crit Care Med 187(11):1259–1266. https://doi.org/10.1164/rccm.201304-0726ST
Masa JF, Rubio M, Findley LJ (2000) Habitually sleepy drivers have a high frequency of automobile crashes associated with respiratory disorders during sleep. Am J Respir Crit Care Med 162(4 Pt 1):1407–1412
https://eur-lex.europa.eu/legal-content/GA/TXT/?uri=CELEX:32014L0085. visited February 2019
Bonsignore MR, Randerath W, Riha R, Smyth D, Gratziou C, Goncalves M, McNicholas WT (2016) New rules on driver licensing for patients with obstructive sleep apnea: EU Directive 2014/85/EU. Eur Respir J 47(1):39–34
Grote L, Svedmyr S, Hedner J (2018) Certification of fitness to drive in sleep apnea patients: are we doing the right thing? J Sleep Res 27(6):e12719
Siegel JM (2009) Sleep viewed as a state of adaptive inactivity. Nat Rev Neurosci 10:747–753
Buxton OM, Cain SW, O'Connor SP, Porter JH, Duffy JF, Wang W, Czeisler CA, Shea SA (2012) Adverse metabolic consequences in humans of prolonged sleep restriction combined with circadian disruption. Sci Transl Med 4(129):129ra43. https://doi.org/10.1126/scitranslmed.3003200
Garbarino S, Lanteri P, Durando P, Magnavita N, Sannita WG (2016) Co-morbidity, mortality, quality of life and the healthcare/welfare/social costs of disordered sleep: a rapid review. Int J Environ Res Public Health 13(8):E831
Goel N, Basner M, Rao H, Dinges DF (2013) Circadian rhythms, sleep deprivation, and human performance. Prog Mol Biol Transl Sci 119:155–190. https://doi.org/10.1016/B978-0-12-396971-2.00007-5
Wittmann M, Dinich J, Merrow M, Roenneberg T (2006) Social jetlag: misalignment of biological and social time. Chronobiol Int 23(1–2):497–509
Gottlieb DJ, Redline S, Nieto FJ, Baldwin CM, Newman AB, Resnick HE, Punjabi NM (2006) Association of usual sleep duration with hypertension: the Sleep Heart Health Study. Sleep 29(8):1009–1014
Gangwisch JE, Heymsfield SB, Boden-Albala B, Buijs RM, Kreier F, Pickering TG, Rundle AG, Zammit GK, Malaspina D (2007) Sleep duration as a risk factor for diabetes incidence in a large U.S. sample. Sleep 30(12):1667–1673
Borbély AA, Daan S, Wirz-Justice A, Deboer T (2016) The two-process model of sleep regulation: a reappraisal. J Sleep Res 25(2):131–143. https://doi.org/10.1111/jsr.12371
Johns MW (2010) A new perspective on sleepiness. Sleep Biol Rhythms 8:170–179. https://doi.org/10.1111/j.1479-8425.2010.00450.x
Saper CB, Cano G, Scammell TE (2005) Homeostatic, circadian, and emotional regulation of sleep. J Comp Neurol 493:92–98. https://doi.org/10.1002/cne.20770
Lockley, S. W., & Foster, R. G. (2012). Sleep: a very short introduction (Vol. 295). Oxford University Press
George PT (2018) The psycho-sensory wake drive—a power source for power naps and other common sleepwake phenomena: a hypothesis. Sleep Breath 22(1):41–48. https://doi.org/10.1007/s11325-017-1505-6
Moldofsky H (1992) Evaluation of daytime sleepiness. Clin Chest Med 13:417–425
Bliwise D (2001) Is the measurement of sleepiness the Holy Grail of sleep medicine? Am J Respir Crit Care Med 163:1517–1519
Cluydts R, De Valck E, Verstraeten E, Theys P (2002) Daytime sleepiness and its evaluation. Sleep Med Rev 6:83–96
Stepanski E (2002) Controversies in the measurement of daytime sleepiness. Sleep Med Rev 6:79–81
Ogilvie RD (2001) The process of falling asleep. Sleep Med Rev 5(3):247–270
American Academy of Sleep Medicine (2014) International Classification of Sleep Disorders, 3rd edn. American Academy of Sleep Medicine, Darien
Randerath W, Bassetti CL, Bonsignore MR, Farre R, Ferini-Strambi L, Grote L, Hedner J, Kohler M, Martinez-Garcia MA, Mihaicuta S, Montserrat J, Pepin JL, Pevernagie D, Pizza F, Polo O, Riha R, Ryan S, Verbraecken J, McNicholas WT (2018) Challenges and perspectives in obstructive sleep apnea: report by an ad hoc working group of the Sleep Disordered Breathing Group of the European Respiratory Society and the European Sleep Research Society. Eur Respir J 52(3):1702616
Ohayon MM (2008) From wakefulness to excessive sleepiness: what we know and still need to know. Sleep Med Rev 12:129–141. https://doi.org/10.1016/j.smrv.2008.01.001
Sleep in America 2009 poll highlights & key findings. National Sleep Foundation. 2009. Available at: https://www.sleepfoundation.org/sites/default/files/inlinefiles/2009%20NSF%20POLL%20 PRESS%20RELEASE.pdf. Accessed May 2019
Roth T (2015) Effects of excessive daytime sleepiness and fatigue on overall health and cognitive function. J Clin Psychiatry 76(9):e1145
Gujar N, Yoo SS, Hu P, Walker MP (2011) Sleep deprivation amplifies reactivity of brain reward networks, biasing the appraisal of positive emotional experiences. J Neurosci 31:4466–4474. https://doi.org/10.1523/JNEUROSCI.3220-10.2011
Womack SD, Hook JN, Reyna SH, Ramos M (2013) Sleep loss and risk-taking behavior: a review of the literature. Behav Sleep Med 11:343–359. https://doi.org/10.1080/15402002.2012.703628
Hisler G, Krizan Z (2019) Sleepiness and behavioral risk-taking: do sleepy people take more or less risk? Behav Sleep Med 17(3):364–377. https://doi.org/10.1080/15402002.2017.1357122
Carberry JC, Amatoury J, Eckert DJ (2018) Personalized management approach for OSA. Chest 153(3):744–755. https://doi.org/10.1016/j.chest.2017.06.011
Owens RL, Edwards BA, Eckert DJ, Jordan AS, Sands SA, Malhotra A, White DP, Loring SH, Butler JP, Wellman A (2015) An integrative model of physiological traits can be used to predict obstructive sleep apnea and response to non positive airway pressure therapy. Sleep 38(6):961–970. https://doi.org/10.5665/sleep.4750
Saaresranta T, Hedner J, Bonsignore MR, Riha RL, McNicholas WT, Penzel T, Anttalainen U, Kvamme JA, Pretl M, Sliwinski P, Verbraecken J, Grote L, ESADA study group (2016) Clinical phenotypes and comorbidity in European sleep apnea patients. PLoS One 11(10):e0163439. https://doi.org/10.1371/journal.pone.0163439
Garbarino S, Scoditti E, Lanteri P, Conte L, Magnavita N, Toraldo DM (2018) Obstructive sleep apnea with or without excessive daytime sleepiness: clinical and experimental data-driven phenotyping. Front Neurol 9:505
Silva GE, Goodwin JL, Vana KD, Quan SF (2016) Obstructive sleep apnea and quality of life: comparison of the SAQLI, FOSQ, and SF-36 questionnaires. Southwest J Pulm Crit Care 13(3):137–149
Lindberg E, Carter N, Gislason T, Janson C (2001) Role of snoring and daytime sleepiness in occupational accidents. Am J Respir Crit Care Med 164(11):2031–2035
Kapur VK, Resnick HE, Gottlieb DJ (2008) Sleep Heart Health Study Group. Sleep disordered breathing and hypertension: does self-reported sleepiness modify the association? Sleep 31(8):1127–1132
Ronksley PE, Hemmelgarn BR, Heitman SJ, Hanly PJ, Faris PD, Quan H, Tsai WH (2009) Obstructive sleep apnea is associated with diabetes in sleepy subjects. Thorax 64(10):834–839
Garbarino S, Guglielmi O, Campus C, Mascialino B, Pizzorni D, Nobili L, Mancardi GL, Ferini-Strambi L (2016) Screening, diagnosis, and management of obstructive sleep apnea in dangerous-goods truck drivers: to be aware or not? Sleep Med 25:98–104
Frost, Sullivan (2016) Hidden health crisis costing America billions. Under diagnosis and undertreating obstructive sleep apnea draining healthcare system. American Academy of Sleep Medicine, Darien (https://aasm.org/resources/pdf/sleep-apnea-economic-crisis.pdf visited May 2019)
Vgontzas AN (2008) Excessive daytime sleepiness in sleep apnea: it is not just apnea hypopnea index. Sleep Med 9(7):712–714
Roure N, Gomez S, Mediano O, Duran J, Pena Mde L, Capote F, Teran J, Masa JF, Alonso ML, Corral J et al (2008) Daytime sleepiness and polysomnography in obstructive sleep apnea patients. Sleep Med 9:727–731
Prasad B, Steffen AD, Van Dongen HPA, Pack FM, Strakovsky I, Staley B, Dinges DF, Maislin G, Pack AI, Weaver TE (2018) Determinants of sleepiness in obstructive sleep apnea. Sleep. https://doi.org/10.1093/sleep/zsx199
Punjabi NM, O'hearn DJ, Neubauer DN, Nieto FJ, Schwartz AR, Smith PL, Bandeen-Roche K (1999) Modeling hypersomnolence in sleepdisordered breathing. A novel approach using survival analysis. Am J Respir Crit Care Med 159(6):1703–1709
Batool-Anwar S, Kales SN, Patel SR, Varvarigou V, DeYoung PN, Malhotra A (2014) Obstructive sleep apnea and psychomotor vigilance task performance. Nat Sci Sleep 6:65–71
Lee IS, Bardwell WA, Ancoli-Israel S, Dimsdale JE (2010) Number of lapses during the psychomotor vigilance task as an objective measure of fatigue. J Clin Sleep Med 6(2):163–168
Sharkey KM, Orff HJ, Tosi C, Harrington D, Roye GD, Millman RP (2013) Subjective sleepiness and daytime functioning in bariatric patients with obstructive sleep apnea. Sleep Breath 17(1):267–274
Malhotra A, White DP (2002) Obstructive sleep apnea. Lancet 360(9328):237–245
Jordan AS, McSharry DG, Malhotra A (2014) Adult obstructive sleep apnea. Lancet 383(9918):736–747
Slater G, Pengo MF, Kosky C, Steier J (2013) Obesity as an independent predictor of subjective excessive daytime sleepiness. Respir Med 107(2):305–309
Gozal D, Serpero LD, Kheirandish-Gozal L, Capdevila OS, Khalyfa A, Tauman R (2010) Sleep measures and morning plasma TNFalpha levels in children with sleep-disordered breathing. Sleep 33(3):319–325
Bravo Mde L, Serpero LD, Barceló A, Barbé F, Agustí A, Gozal D (2007) Inflammatory proteins in patients with obstructive sleep apnea with and without daytime sleepiness. Sleep Breath 11(3):177–185
Li Y, Vgontzas AN, Fernandez-Mendoza J, Kritikou I, Basta M, Pejovic S, Gaines J, Bixler EO. (2017) Objective, but not subjective, sleepiness is associated with inflammation in sleep apnea. Sleep. ;40(2). doi: https://doi.org/10.1093/sleep/zsw033
DeMartino T, Ghoul RE, Wang L, Bena J, Hazen SL, Tracy R, Patel SR, Auckley D, Mehra R (2016) Oxidative stress and inflammation differentially elevated in objective versus habitual subjective reduced sleep duration in obstructive sleep apnea. Sleep 39(7):1361–1369. https://doi.org/10.5665/sleep.5964
Priou P, Le Vaillant M, Meslier N, Paris A, Pigeanne T, Nguyen XL, Alizon C, Bizieux-Thaminy A, Leclair-Visonneau L, Humeau MP, Gagnadoux F, IRSR sleep cohort group (2014) Cumulative association of obstructive sleep apnea severity and short sleep duration with the risk for hypertension. PLoS One 9:e115666
Garbarino S, Guglielmi O, Sanna A, Mancardi GL, Magnavita N (2016) Risk of occupational accidents in workers with obstructive sleep apnea: systematic review and meta-analysis. Sleep 39(6):1211–1218. https://doi.org/10.5665/sleep.5834
Sanna A, Passali D, De Benedetto M, Marano G, Loglisci M, Garbarino S (2017) Obstructive sleep apnea syndrome and public health: the Italian way. Sleep Breath 21(4):995–996
Ferini-Strambi L, Sforza M, Poletti M, Giarrusso F, Galbiati A (2017) Daytime sleepiness: more than just obstructive sleep apnea (OSA). Med Lav 108(4):260–266. https://doi.org/10.23749/mdl.v108i4.6497
Murray BJ (2017) Subjective and objective assessment of hypersomnolence. Sleep Med Clin 12(3):313–322
Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 14:540–545
Kingshott RN, Sime PJ, Engleman HM, Douglas NJ (1995) Self assessment of daytime sleepiness: patient versus partner. Thorax 50:994–995
Baldwin CM, Kapur VK, Holberg CJ, Rosen C, Nieto FJ, Sleep Heart Health Study Group (2004) Associations between gender and measures of daytime somnolence in the Sleep Heart Health Study. Sleep 27:305–311
Ulander M, Arestedt K, Svanborg E, Johansson P, Broström A (2013) The fairness of the Epworth Sleepiness Scale: two approaches to differential item functioning. Sleep Breath 17:157–165. https://doi.org/10.1007/s11325-012-0664-8
Baiardi S, La Morgia C, Sciamanna L, Gerosa A, Cirignotta F, Mondini S (2018) Is the Epworth Sleepiness Scale a useful tool for screening excessive daytime sleepiness in commercial drivers? Accid Anal Prev 110:187–189
Guglielmi O, Magnavita N, Garbarino S (2018) Sleep quality, obstructive sleep apnea, and psychological distress in truck drivers: a cross-sectional study. Soc Psychiatry Psychiatr Epidemiol 53(5):531–536
Garbarino S, Durando P, Guglielmi O, Dini G, Bersi F, Fornarino S, Toletone A, Chiorri C, Magnavita N (2016) Sleep apnea, sleep debt and daytime sleepiness are independently associated with road accidents. A cross-sectional study on truck drivers. PLoS One 11(11):e0166262
Garbarino S, Magnavita N, Guglielmi O, Maestri M, Dini G, Bersi FM, Toletone A, Chiorri C, Durando P (2017) Insomnia is associated with road accidents. Further evidence from a study on truck drivers. PLoS One 12(10):e0187256
Kendzerska TB, Smith PM, Brignardello-Petersen R, Leung RS, Tomlinson GA (2014) Evaluation of the measurement properties of the Epworth Sleepiness Scale: a systematic review. Sleep Med Rev 18(4):321–331
Partinen M, Gislason T (1995) Basic Nordic Sleep Questionnaire (BNSQ): a quantitated measure of subjective sleep complaints. J Sleep Res 4:150–155
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328:1230–1235
Young T, Finn L, Kim H (1997) Nasal obstruction as a risk factor for sleep-disordered breathing. The University of Wisconsin Sleep and Respiratory Research Group. J Allergy Clin Immunol 99:S757–S762. https://doi.org/10.1016/s0091-6749(97)70124-6
Young T, Hutton R, Finn L, Badr S, Palta M (1996) The gender bias in sleep apnea diagnosis. Are women missed because they have different symptoms? Arch Intern Med 156:2445–2451. https://doi.org/10.1001/archinte.1996.00440200055007
Hara C, Lopes Rocha F, Lima, Costa MF (2004) Prevalence of excessive daytime sleepiness and associated factors in a Brazilian community: the Bambui study. Sleep Med 5:31–36. https://doi.org/10.1016/j.sleep.2003.09.009
Kallin SA, Lindberg E, Sommar JN, Bossios A, Ekerljung L, Malinovschi A, Middelveld R, Janson C (2018) Excessive daytime sleepiness in asthma: what are the risk factors? J Asthma 55(8):844–850. https://doi.org/10.1080/02770903.2016.1263316
Thorarinsdottir EH, Bjornsdottir E, Benediktsdottir B, Janson C, Gislason T, Aspelund T, Kuna ST, Pack AI, Arnardottir ES (2019) Definition of excessive daytime sleepiness in the general population: feeling sleepy relates better to sleep-related symptoms and quality of life than the Epworth Sleepiness Scale score. Results from an epidemiological study. J Sleep Res 10:e12852. https://doi.org/10.1111/jsr.12852
MacLean AW, Fekken GC, Saskin P, Knowles JB (1992) Psychometric evaluation of the Stanford Sleepiness Scale. J Sleep Res 1:35–39
Hoddes E, Dement WC, Zarcone V (1972) The development and use of the Stanford Sleepiness Scale (SSS). Psychophysiology 9:150
Herscovitch J, Broughton R (1981) Sensitivity of the Stanford Sleepiness Scale to the effects of cumulative partial sleep deprivation and recovery oversleeping. Sleep 4(1):83–91
Ayeni A, Beghal GS, Pengo MF, Shah N, Steier J (2019) Self-reported sleepiness in the context of fitness-to-drive. Sleep Breath. https://doi.org/10.1007/s11325-019-01810-w
Guaita M, Salamero M, Vilaseca I, Iranzo A, Montserrat JM, Gaig C, Embid C, Romero M, Serradell M, Leon C, de Pablo J, Santamaria J (2015) The Barcelona Sleepiness Index: a new instrument to assess excessive daytime sleepiness in sleep disordered breathing. J Clin Sleep Med 11:1289–1298
Miley AÅ, Kecklund G, Åkerstedt T (2016) Comparing two versions of the Karolinska Sleepiness Scale (KSS). Sleep Biol Rhythms 14(3):257–260. https://doi.org/10.1007/s41105-016-0048-8
Littner MR, Kushida C, Wise M et al (2005) Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. An American Academy of Sleep Medicine report. Sleep 28:113–121
Arand D, Bonnet M, Hurwitz T, Mitler M, Rosa R, Sangal RB (2005) The clinical use of the MSLT and MWT. Sleep 28:123–44. 104
Wise MS (2006) Objective measures of sleepiness and wakefulness: application to the real world? J Clin Neurophysiol 23(1):39–49
Carskadon MA, Dement WC (1982) Nocturnal determinants of daytime sleepiness. Sleep 5(Suppl 2):S73–S81
Mitler MM, Gujavarty KS, Browman CP (1982a) Maintenance of wakefulness test: a polysomnographic technique for evaluating treatment efficacy in patients with excessive somnolence. Electroencephalogr Clin Neurophysiol 53:658–661
Philip P, Chaufton C, Taillard J, Sagaspe P, Léger D, Raimondi M, Vakulin A, Capelli A (2013) Maintenance of Wakefulness Test scores and driving performance in sleep disorder patients and controls. Int J Psychophysiol 89(2):195–202. https://doi.org/10.1016/j.ijpsycho.2013.05.013
Sagaspe P, Taillard J, Chaumet G, Guilleminault C, Coste O, Moore N et al (2007) Maintenance of wakefulness test as a predictor of driving performance in patients with untreated obstructive sleep apnea. Sleep 30(3):327–330
Philip P, Sagaspe P, Taillard J, Chaumet G, Bayon V, Coste O et al (2008) Maintenance of Wakefulness Test, obstructive sleep apnea syndrome, and driving risk. Ann Neurol 64(4):410–416
Pizza F, Contardi S, Mondini S, Trentin L, Cirignotta F (2009) Daytime sleepiness and driving performance in patients with obstructive sleep apnea: comparison of the MSLT, the MWT, and a simulated driving task. Sleep. 32(3):382–391
George CF (2003) Driving simulators in clinical practice. Sleep Med Rev 7:311–320
George CF, Boudreau AC, Smiley A (1996) Simulated driving performance in patients with obstructive sleep apnea. Am J Respir Crit Care Med 154:175–181
George CF, Boudreau AC, Smiley A (1997) Effects of nasal CPAP on simulated driving performance in patients with obstructive sleep apnea. Thorax 52:648–653
Vakulin A, Catcheside PG, Baulk SD, Antic NA, Banks S, Dorrian J, McEvoy RD (2014) Individual variability and predictors of driving simulator impairment in patients with obstructive sleep apnea. J Clin Sleep Med 10(6):647–655. https://doi.org/10.5664/jcsm.3792
Kaye SA, Lewis I, Freeman J (2018) Comparison of self-report and objective measures of driving behavior and road safety: a systematic review. J Saf Res 65:141–151. https://doi.org/10.1016/j.jsr.2018.02.012
Moller HJ, Kayumov L, Bulmash EL, Nhan J, Shapiro CM (2006) Simulator performance, microsleep episodes, and subjective sleepiness: normative data using convergent methodologies to assess driver drowsiness. J Psychosom Res 61(3):335–342. https://doi.org/10.1016/j.jpsychores.2006.04.007
Schmidt EA, Schrauf M, Simon M, Fritzsche M, Buchner A, Kincses WE (2009) Drivers’ misjudgement of vigilance state during prolonged monotonous daytime driving. Accid Anal Prev 41(5):1087–1093
Olson LG, Cole MF, Ambrogetti A (1998) Correlations among Epworth Sleepiness Scale scores, multiple sleep latency tests and psychological symptoms. J Sleep Res 7(4):248–253
Kritikou I, Basta M, Vgontzas AN, Pejovic S, Liao D, Tsaoussoglou M, Bixler EO, Stefanakis Z, Chrousos GP (2014) Sleep apnea, sleepiness, inflammation and insulin resistance in middle-aged males and females. Eur Respir J 43(1):145–155
Sforza E, Haba-Rubio J, De Bilbao F, Rochat T, Ibanez V (2004) Performance vigilance task and sleepiness in patients with sleep-disordered breathing. Eur Respir J 24(2):279–285
Dinges DF, Powell JW (1985) Microcomputer analyses of performance on a portable, simple visual RT task during sustained operations. Behav Res Methods Instrum Comput 17:652. https://doi.org/10.3758/BF03200977
Gillberg M, Kecklund G, Akerstedt T (1994) Relations between performances and subjective ratings of sleepiness during a night awake. Sleep 17:236–241
Dorrian J, Hursh S, Waggoner L, Grant C, Pajcin M, Gupta C, Coates A, Kennaway D, Wittert G, Heilbronn L, Vedova CD, Banks S (2019) How much is left in your “sleep tank”? Proof of concept for a simple model for sleep history feedback. Accid Anal Prev 126:177–183. https://doi.org/10.1016/j.aap.2018.01.007
Nir Y, Andrillon T, Marmelshtein A, Suthana N, Cirelli C, Tononi G, Fried I (2017) Selective neuronal lapses precede human cognitive lapses following sleep deprivation. Nat Med 23(12):1474–1480. https://doi.org/10.1038/nm.4433
Li Y, Vgontzas A, Kritikou I, Fernandez-Mendoza J, Basta M, Pejovic S, Gaines J, Bixler EO (2017) Psychomotor vigilance test and its association with daytime sleepiness and inflammation in sleep apnea: clinical implications. J Clin Sleep Med 13(9):1049–1056. https://doi.org/10.5664/jcsm.6720
Kitamura T, Miyazaki S, Kadotani H, Kanemura T, Sulaiman HB, Takeuchi S, Tabata T, Suzuki H (2018) Non-REM sleep-disordered breathing affects performance on the psychomotor vigilance task. Sleep Breath 22(2):329–335
Pejovic S, Basta M, Vgontzas AN, Kritikou I, Shaffer ML, Tsaoussoglou M, Stiffler D, Stefanakis Z, Bixler EO, Chrousos GP (2013) Effects of recovery sleep after one work week of mild sleep restriction on interleukin-6 and cortisol secretion and daytime sleepiness and performance. Am J Physiol Endocrinol Metab 305(7):E890–E896
Basner M, Dinges DF (2011) Maximizing sensitivity of the psychomotor vigilance test (PVT) to sleep loss. Sleep 34(5):581–591
Kim H, Dinges DF, Young T (2007) Sleep-disordered breathing and psychomotor vigilance in a communitybased sample. Sleep 30(10):1309–1316
McNicholas W, editor. New standards and guidelines for drivers with obstructive sleep apnea syndrome. Report of the Obstructive Sleep Apnea Working Group [Internet]. Brussels: European Commission; 2013 [. Available from: https://ec.europa.eu/transport/road_safety/sites/roadsafety/files/pdf/behavior/sleep_apnea.pdf (visited May 2019)
Feketeová E, Mucska I, Klobučníková K, Grešová S, Stimmelová J, Paraničová I, Trojová I, Rosenberger J, Rimárová K, Dorko E (2018) EU questionnaire to screen for obstructive sleep apnea validated in Slovakia. Cent Eur J Public Health 26(Suppl):S32–S36. https://doi.org/10.21101/cejph.a5278
Nunes FS, Danzi-Soares NJ, Genta PR, Drager LF, Cesar LA, Lorenzi-Filho G (2015) Critical evaluation of screening questionnaires for obstructive sleep apnea in patients undergoing coronary artery bypass grafting and abdominal surgery. Sleep Breath 19(1):115–122
Adams RJ, Appleton SL, Vakulin A, Lang C, Martin SA, Taylor AW, Wittert GA (2016) Association of daytime sleepiness with obstructive sleep apnea and comorbidities varies by sleepiness definition in a population cohort of men. Respirology 21:1314–1321. https://doi.org/10.1111/resp.12829
Pilcher JJ, Pury CL, Muth ER (2003) Assessing subjective daytime sleepiness: an internal state versus behavior approach. Behav Med 29:60–67
Huamani C, Rey de Castro J, Mezones-Holguin E (2014) Sleepiness and nocturnal hypoxemia in Peruvian men with obstructive sleep apnea. Sleep Breath 18:467–473
Antic NA, Catcheside P, Buchan C, Hensley M, Naughton MT, Rowland S, Williamson B, Windler S, McEvoy RD (2011) The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA. Sleep 34(1):111–119
Pack AI (2016) Application of personalized, predictive, preventative, and participatory (P4) medicine to obstructive sleep apnea. A roadmap for improving care? Ann Am Thorac Soc 13:1456–1467
Jullian-Desayes I, Joyeux-Faure M, Tamisier R, Launois S, Borel AL, Levy P, Pepin JL (2015) Impact of obstructive sleep apnea treatment by continuous positive airway pressure on cardiometabolic biomarkers: a systematic review from sham CPAP randomized controlled trials. Sleep Med Rev 21:23–38
Sanchez-de-la-Torre M, Khalyfa A, Sanchez-de-la-Torre A, Martinez-Alonso M, Martinez-Garcia MA, Barcelo A, Lloberes P, Campos-Rodriguez F, Capote F, Diaz-de-Atauri MJ, Somoza M, Gonzalez M, Masa JF, Gozal D, Barbe F (2015) Precision medicine in patients with resistant hypertension and obstructive sleep apnea: blood pressure response to continuous positive airway pressure treatment. J Am Coll Cardiol 66:1023–1032
Schwarz EI, Martinez-Lozano Sinues P, Bregy L, Gaisl T, Garcia Gomez D, Gaugg MT, Suter Y, Stebler N, Nussbaumer-Ochsner Y, Bloch KE, Stradling JR, Zenobi R, Kohler M (2016) Effects of CPAP therapy withdrawal on exhaled breath pattern in obstructive sleep apnea. Thorax 71:110–117
Vgontzas AN, Bixler EO, Lin HM, Prolo P, Trakada G, Chrousos GP (2005) IL-6 and its circadian secretion in humans. Neuroimmunomodulation 12(3):131–140
Luz GP, Guimarães TM, Weaver TE, Nery LE, Silva LO, Badke L, Coelho G, Millani-Carneiro A, Tufik S, Bittencourt L (2016) Impaired sustained attention and lapses are present in patients with mild obstructive sleep apnea. Sleep Breath 20(2):681–687
Larue GS, Rakotonirainy A, Pettitt AN (2011) Driving performance impairments due to hypovigilance on monotonous roads. Accid Anal Prev 43:2037–2046
Kim H, Young T (2005) Subjective daytime sleepiness: dimensions and correlates in the general population. Sleep 28:625–634
Arnardottir ES, Maislin G, Schwab RJ, Staley B, Benediktsdottir B, Olafsson I, Juliusson S, Romer M, Gislason T, Pack AI (2012) The interaction of obstructive sleep apnea and obesity on the inflammatory markers C-reactive protein and interleukin-6: the Icelandic Sleep Apnea Cohort. Sleep 35(7):921–932. https://doi.org/10.5665/sleep.1952
Sunwoo BY, Jackson N, Maislin G, Gurubhagavatula I, George CF, Pack AI (2012) Reliability of a single objective measure in assessing sleepiness. Sleep 35(1):149–158. https://doi.org/10.5665/sleep.1606
Zhang C, Varvarigou V, Parks PD, Gautam S, Bueno AV, Malhotra A, Kales SN (2012) Psychomotor vigilance testing of professional drivers in the occupational health clinic: a potential objective screen for daytime sleepiness. J Occup Environ Med 54(3):296–302
Fleming WE, Ferouz-Colborn A, Samoszuk MK, Azad A, Lu J, Riley JS, Cruz AB, Podolak S, Clark DJ, Bray KR, Southwick PC (2016) Blood biomarkers of endocrine, immune, inflammatory, and metabolic systems in obstructive sleep apnea. Clin Biochem 49(12):854–861
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Garbarino, S. Excessive daytime sleepiness in obstructive sleep apnea: implications for driving licenses. Sleep Breath 24, 37–47 (2020). https://doi.org/10.1007/s11325-019-01903-6
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DOI: https://doi.org/10.1007/s11325-019-01903-6