Posted by Jeremy Segal on April 01, 2003 at 10:08:17:In Reply to: Assessing Roadworthiness posted by Krishna on March 23, 2003 at 12:41:59:
Thanks for putting together such a nice question. These are my initial thoughts:
For the initial DDx:
For the initial episode of slumping over at the wheel while driving consider
-OSAS / UARS
-Sedative effects of pain medication
- Sleep disruption from chronic pain.
- Seizure Disorder
- Syncopal event
- In the absence of EDS I don’t think narcolepsy is likely.Because it is not clear that the initial event was related to EDS I would double check that the primary MD did a good w/up for seizure / syncope. Referral for sleep deprived EEG, holter monitor and ECHO +/- a tilt table test may not have been done. OSAS is common and could be a red herring.
The new early am awakening may be due to atypical depression, incomplete palliation of OSAS with CPAP not controlling him during REM periods, somatic pain (causing more sleep disruption as sleep drive is relieved).In terms of management I recommend:
Usual OSAS advice including avoidance of sedatives (including ETOH), good sleep hygiene, side sleeping, weight loss and regular CPAP use. Continue to have him use a CPAP device with download capability so that compliance can be assessed.
Consider formal evaluation for depression, or at least screening with a Beck Depression Inventory.
Consider a pain specialist referral to consider a nerve block rather than systemic medications and to make sure he is on the shortest acting, least sedating pain control for his back pain. His primary MD may also wish to re-evaluate his chronic back pain. Perhaps there is a disc prolapse that would be amenable to surgical repair.
A Maintenance of Wakefulness Test should be performed. For the 20 minute protocol he needs to stay awake at least 14.5min. If you do a 40 min protocol he needs to stay awake 22 minutes. The test may also indicate what time of day he is most vulnerable to falling asleep and he can be advised to avoid driving, or be especially cautious at these times of day. If he fails the MWT despite optimization of all the above mentioned factors then you could advise him to use caffeine, or you could prescribe an alerting medication such as Modafenil or Methylphenidate. Methylphenidate is useful because it is short actinig and he could use it before driving, especially during his “vulnerable period”.
Pt should be advised to avoid driving, and have other people drive him whenever possible. It is important to document that pt was warned about the consequences of driving while sleepy. I would have him sign a statement stating “ I have been informed that driving or using dangerous machinery while sleepy could result in another fatal accident.” Also, he should avoid driving within 1 – 2 hours of his usual bed time given the decreased Sleep Onset Latency.
Also, educate him on the additive effects of sedatives, ETOH and sleepiness. He should ideally not drink ETOH at all if he plans to drive that evening.
Legal issues may be important in your State. There may be mandatory reporting requirements for pts like this.
Pt should come back at 4 – 6 week intervals until you are confident he is optimally controlled.
- Re: Assessing Roadworthiness zzz in Ottawa 10:59 4/11/03 (2)
- Re: Assessing Roadworthiness Rett 15:37 4/11/03 (0)
- Re: Assessing Roadworthiness JSegal 13:59 4/11/03 (0)