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Assessing Roadworthiness

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Posted by Krishna on March 23, 2003 at 12:41:59:

Case description:

A middle-aged morbidly obese individual with OSA is referred to you to be evaluated for a decision regarding driving safety.

The patient had first been referred to you several months ago for a possible sleep disorder after an episode of slumping over the wheel briefly while driving, going left of center and having a motor vehicle collision resulting in a fatality. Other extensive neurologic and cardiac evaluation conducted by the patient’s primary care physician was negative. Alcohol and substance abuse were ruled out as causative factors in the MVA.

Review of Systems at initial evaluation: Prior to the MVA, sleep pattern was normal. After the MVA, the individual had been having difficulty staying asleep past 2 – 3 AM, despite typical bedtime. However, depression symptoms were denied. Prior to the MVA, there were symptoms of snoring, waking with a dry mouth and waking with nasal plugging, though there was no clear history of observed apneic episodes in sleep. There were no symptoms to suggest narcolepsy, RLS, PLMS or other parasomnias. The ESS was normal! On the night before the MVA, the patient didn’t get great sleep due to chronic lower back pain. However, the patient reported no feeling of sleepiness while going about work that included driving in the hours prior to the MVA that occurred in the middle of the afternoon.

The patient had a history of lower back injury with chronic pain for many years for which Darvocet-N was prescribed on a p. r. n. basis, and used QD / BID.

NPSG showed OSA and sleep maintenance insomnia and the patient was brought in for a second night of polysomnography to guide titration of PAP therapy. CPAP was successfully titrated up to 8 cm water and this level was prescribed for regular use during sleep.

Now: The patient reports diligent usage about 6.5 hours each night in the last several months, confirmed by data downloaded from the device. Sleep maintenance insomnia has resolved and sleep efficiency is high as per the patient. The patient reports only infrequent days of feeling down because of the life altering events. While the patient denies any daytime sleepiness (including inability to fall asleep on lying down in the afternoon for a nap) and has a low-normal ESS, latency to sleep onset is short at less than five minutes at HS of approx. 10 – 10:30 PM. No snoring or other OSA-related symptoms while using CPAP. Again, no symptoms of RLS, PLMS, other parasomnias or narcolepsy. There has been further weight gain of about 15 lb since the first evaluation, raising BMI further about 2 kg/m-sq. Currently, the patient reports using no medications at all.

The main issue on hand now is permission to drive. Living in a typical suburban North American setting, the individual is dependent on driving for a living. Of course, other relevant issues, if any, also need to be answered when you evaluate this individual.

Analyze the above description in detail to provide a differential diagnosis for the initial evaluation and a separate one for the current situation. What all would you do to address the issue of allowing this individual to resume driving? Detail your line of management at this point and what decisions you will make based on possible outcomes with specific key action items in your plan.

Keep your answers brief and in bullet-form but don’t be telegraphic to the point of being cryptic!

’njoy.

P. S. – I have a list of alternatives (for actions to be taken at this point) that I will post as a follow-up to this posting, to take the discussion further.

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PLEASE ONLY CLICK THE SUBMIT FOLLOW UP BUTTON ONCE!!. Thanks, Sandman

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