Elsevier

Sleep Medicine

Volume 9, Issue 4, May 2008, Pages 362-375
Sleep Medicine

Original article
Medico-legal implications of sleep apnoea syndrome: Driving license regulations in Europe

https://doi.org/10.1016/j.sleep.2007.05.008Get rights and content

Abstract

Background

Sleep apnoea syndrome (SAS), one of the main medical causes of excessive daytime sleepiness, has been shown to be a risk factor for traffic accidents. Treating SAS results in a normalized rate of traffic accidents. As part of the COST Action B-26, we looked at driving license regulations, and especially at its medical aspects in the European region.

Methods

We obtained data from Transport Authorities in 25 countries (Austria, AT; Belgium, BE; Czech Republic, CZ; Denmark, DK; Estonia, EE; Finland, FI; France, FR; Germany, DE; Greece, GR; Hungary, HU; Ireland, IE; Italy, IT; Lithuania, LT; Luxembourg, LU; Malta, MT; Netherlands, NL; Norway, EC; Poland, PL; Portugal, PT; Slovakia, SK; Slovenia, SI; Spain, ES; Sweden, SE; Switzerland, CH; United Kingdom, UK).

Results

Driving license regulations date from 1997 onwards. Excessive daytime sleepiness is mentioned in nine, whereas sleep apnoea syndrome is mentioned in 10 countries. A patient with untreated sleep apnoea is always considered unfit to drive. To recover the driving capacity, seven countries rely on a physician’s medical certificate based on symptom control and compliance with therapy, whereas in two countries it is up to the patient to decide (on his doctor’s advice) to drive again. Only FR requires a normalized electroencephalography (EEG)-based Maintenance of Wakefulness Test for professional drivers. Rare conditions (e.g., narcolepsy) are considered a driving safety risk more frequently than sleep apnoea syndrome.

Conclusion

Despite the available scientific evidence, most countries in Europe do not include sleep apnoea syndrome or excessive daytime sleepiness among the specific medical conditions to be considered when judging whether or not a person is fit to drive. A unified European Directive seems desirable.

Introduction

Sleep remains a somewhat mysterious realm, at the frontier of psychology, physiology, medicine and quackery. Why we sleep is still unknown, yet we cannot avoid sleeping sooner or later. We can only postpone the moment by a few hours at the most. As one remains awake, sleepiness increases and finally vigilance becomes unstable, with short moments of sleep interspersing into wakefulness.

Obstructive sleep apnoea syndrome (OSAS) is a prevalent disease [1] that disturbs sleep quality and continuity by confronting the sleeper with a very uncomfortable choice: sleep or breathe [2]. When the sleeper suffering from OSAS sleeps, the pharynx, which lacks rigid structures, becomes collapsible. Its internal diameters progressively narrow until airflow becomes insufficient or even stops altogether [3]. As seconds go by, and inefficient respiratory efforts ensue, asphyxia progressively develops until the sleep process is interrupted: sleep is made lighter or a full arousal reaction appears [4]. This allows resumption of respiration (frequently accompanied by loud snoring) and subsequent resumption of sleep. In a patient with OSAS, this succession of events repeats several dozens to hundreds of times per night, for years, rendering sleep unrefreshing and non-restorative [5]. It is, therefore, not surprising to note that daytime sleepiness is, together with snoring, one of the cardinal symptoms of the disease [6].

Several studies coming from different parts of the world have shed light on the abnormally high incidence of traffic accidents in patients suffering from OSAS. European authors have contributed to many of these studies, generally conducted in the last decade of the 20th century and published mainly between 1995 and 2003 [7], [8], [9], [10], [11], [12], [13]. Several methodologies were used, from retrospective studies to prospective case-control studies, based not only on patients’ memories but also on reports from insurance companies. Moreover, treatment effects have been assessed, showing that treating the disease results in a decrease (“normalization”) of the motor traffic accident rate. Thus, the body of scientific evidence linking OSAS to motor traffic accidents has not only a physiologic basis but a quite solid epidemiologic basis. Table 1 shows the main studies on OSAS as a risk factor for motor vehicle traffic accidents.

It should be kept in mind that OSAS is not the only medical cause of excessive daytime sleepiness. Other diseases, like narcolepsy, may lead to similar or even greater levels of daytime sleepiness. However, the epidemiology of OSAS makes it by far the more prevalent medical cause of excessive sleepiness. The estimated prevalence of OSAS is in the range of 4% of adult males and 1–2% of adult females [1], whereas narcolepsy has a prevalence of about 0.05% [14]. Of course, a driver does not need to have a disease to experience sleepiness. A night without sleep may simply put him in a state of sleep deprivation with excessive sleepiness, decrease in attention [15], and high risk of being involved in a motor traffic accident. Nevertheless, sleep deprivation is not a disease and can be avoided, whereas OSAS chronically affects thousands of drivers. It has, therefore, a definite place in the list of medical risks for driving. It is unfortunate that the real prevalence of sleepiness-related motor vehicle accidents is unknown in the European Union. This is at least partly due to the fact that routine police accident statistics generally do not report accidents due to suspected or declared sleepiness.

According to available literature, the risk of traffic accidents presented by OSAS probably exceeds that presented by epilepsy or cardiac arrhythmias. It is thus somewhat surprising to note that OSAS is almost absent from medical directives concerning driving license regulations in Europe. A first survey conducted between 1998 and 2000 and published in 2002 by a Task Force of the European Respiratory Society showed that only 6 of the 15 European Union countries mentioned OSAS [16]. Norway and Switzerland, also part of the survey, did not mention OSAS. The six countries that include OSAS among medical conditions that may increase the risk of traffic accidents were Belgium, France, Netherlands, Spain, Sweden and the United Kingdom. Since that time, the European Union has enlarged to 25 countries, and the awareness of OSAS among the medical community and the general public has probably increased.

Therefore, it seems reasonable to expect a progressive inclusion of OSAS among the medical conditions needing specific attention from driving licensing authorities of other European Union countries. As part of the COST Action B-26, dealing mainly with OSAS as a risk factor for cardiovascular diseases and its genetic determinants, a third working group was created to review the issue of motor vehicle license regulations in the newly enlarged European landscape.

Section snippets

Material and methods

We tried to contact Transport Ministries of all 25 European Union countries, plus some European countries not belonging to the European Union (Switzerland, Norway). The full list of countries is given in Table 2. A simple questionnaire agreed upon during an initial meeting was sent to the addresses available through the European Union, Internet National sites, or National Telephone Books. The questionnaire included questions related to medical conditions known to impair driving capacities; to

Results

We obtained partial data for 25 countries: Austria (AT); Belgium (BE); Czech Republic (CZ); Denmark (DK); Estonia (EE), Finland (FI); France (FR), Germany (DE); Greece (GR); Hungary (HU); Ireland (IE); Italy (IT); Lithuania (LT); Luxemburg (LU); Malta (MT); Netherlands (NL); Norway (EC), Poland (PL); Portugal (PT); Slovakia (SK); Slovenia (SI), Spain (ES); Sweden (SE); Switzerland (CH); and United Kingdom (UK). The extracted data are presented in Table 3.

Driving license regulations date mostly

Discussion

The main result of this survey of driving license regulations in European Union countries is the great heterogeneity we have found. This heterogeneity concerns almost every aspect of the medical specifications, as well as many administrative aspects. As far as sleep apnoea is concerned, the situation has not much evolved since 2002, the date of the publication of the first survey. Ten countries (out of 25) explicitly mentioned OSAS in 2006, whereas only six (out of 15) did in 2002 (BE, ES, FR,

Acknowledgements

The authors wish to acknowledge the invaluable cooperation of the following persons: Joël Valmain (European Commission); Truls Vaa (EC); Anastassios Trakadas (GR); Robert Lauer (LU); Gordon Buhagiar (MT); Adriana Lehotska (SK); Marius Vitenas (LT); Leja Dolenc (SI); Jon Iversen (EC); Arne-Birger Knapskog (EC); Niall Brady (IE); Thomas Hollenstein (AT); Grete Aad (DK); Tarja Saaresranta (FI); Marion Hochmann (DE); Guy Staus (LU); C. Zuidema (NL); Macrej Bittner (PL); Marie Topelius (SE); Isabel

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1

COST is an intergovernmental European framework for international cooperation between nationally funded research activities. COST creates scientific networks and enables scientists to collaborate in a wide spectrum of activities in research and technology. COST activities are administered by the COST Office. ESF provides the COST Office through an European Commission contract. COST is supported by the European Union RTD Framework programme.

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