From: Subject: Drowsy Driving Date: Tue, 29 Jun 2010 10:57:00 -0600 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01CB1779.CCE93BB0" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3664 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01CB1779.CCE93BB0 Content-Type: text/html; charset="utf-8" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.nhtsa.gov/people/injury/drowsy_driving1/drowsy.html =EF=BB=BF Drowsy Driving 3D"NHTSA=20




D R O W S Y = D R I V I N=20 G
A N D
AU T O M O B I L E = C=20 R A S H E S

NCSDR/NHTSA EXPERT PANEL ON DRIVER FATIGUE AND=20 SLEEPINESS

CONTENTS

NCSDR/NHTSA=20 Expert Panel on Driver Fatigue and Sleepiness

Acknowledgments=20

Executive=20 Summary

I.    =20 Introduction=20

II.   =20 Biology of Human Sleep and Sleepiness

III.  =20 Characteristics of Drowsy-Driving Crashes

IV.  =20 Risks for Drowsy-Driving Crashes

V.    =20 Population Groups at Highest Risk

VI.  =20 Countermeasures

VII.=20 Focusing an Educational Campaign: Panel Recommendations

References

Figures

Figure=20 1.  Latency To Sleep at 2-Hour Intervals Across the 24-Hour = Day

Figure=20 2.  Performance Slows With Sleep Deprivation

Figure=20 3.  Time of Occurrence of Crashes

Figure=20 4.  Interaction Between Alcohol and Sleepiness

NCSDR/NHTSA EXPERT PANEL ON DRIVER FATIGUE AND=20 SLEEPINESS

Kingman P. Strohl, = M.D.
Panel=20 Chairman Director, Center for Sleep Disorders Research
Division = of=20 Pulmonary and Critical Care Medicine
Cleveland Veterans = Administration=20 Hospital

Sharon L. Merritt, Ed.D.,=20 R.N.
Director =
Department of=20 Medical-Surgical Nursing Center for Narcolepsy Research=20
University of Illinois

Jesse Blatt, Ph.D.=20
Senior Research Psychologist=20
Office of Research and Traffic Records=20
National Highway Traffic Safety Administration=20

Allan I. = Pack, Ph.D.,=20 M.D.
Director =
Center for=20 Sleep and Respiratory Neurobiology
University of = Pennsylvania Medical Center

Forrest Council,=20 Ph.D
Director =
University of=20 North Carolina Highway Safety Research Center

Susan = Rogus, R.N.,=20 M.S.
Coordinator, Sleep Education = Activities=20
Office of Prevention, Education, and Control = National=20 Heart, Lung, and Blood Institute

Kate Georges=20
Special Assistant to Executive Deputy=20 Commissioner
Department of Motor Vehicles State = of New=20 York

Thomas = Roth, Ph.D.=20
Division Head
Sleep=20 Disorders and Research Center
Henry Ford = Hospital=20

James Kiley, Ph.D.=20
Director National Center on Sleep = Disorders=20 Research
National Heart, Lung, and Blood=20 Institute
National Institutes of = Health

 Jane = Stutts, Ph.D.=20
Manager, Epidemiological Studies=20
University of North Carolina =
Highway=20 Safety Research Center

Roger Kurrus=20
Division Chief, =
Consumer=20 Automotive Safety Information Division
National = Highway=20 Traffic Safety Administration

Pat = Waller, Ph.D.=20
Director
University = of=20 Michigan
Transportation Research Institute=20

Anne T. McCartt, Ph.D.=20
Deputy Director =
Institute=20 for Traffic Safety Management and Research =
State of New=20 York

David Willis=20
President
AAA = Foundation=20 for Traffic = Safety

ACKNOWLEDGMENTS

The Expert Panel on Driver Fatigue and Sleepiness = especially=20 acknowledges Joy Mara of Joy R. Mara Communications for her assistance = in the=20 writing of this report. The panel would like to thank the following = people for=20 their assistance in reviewing and commenting on the report: Mary = Carskadon,=20 David Dinges, Lynn Butler, Nick Teare, Toben Nelson, Nancy Isaac, Kathy = Rechen,=20 and, at Prospect Associates, Donald Cunningham and Wendel Schneider. It = also=20 thanks Cathy Lonergan for logistical support.

EXECUTIVE SUMMARY

Drowsy driving is a serious problem that leads to = thousands of=20 automobile crashes each year. This report, sponsored by the National = Center on=20 Sleep Disorders Research (NCSDR) of the Na-tional Heart, Lung, and Blood = Institute of the National Institutes of Health, and the National Highway = Traffic=20 Safety Administration (NHTSA), is designed to provide direction to an=20 NCSDR/NHTSA educational campaign to combat drowsy driving. The report = presents=20 the results of a literature review and opinions of the Expert Panel on = Driver=20 Fatigue and Sleepiness regarding key issues involved in the problem. =

BIOLOGY OF HUMAN SLEEP AND = SLEEPINESS=20

Sleep is a neurobiologic need with predictable patterns = of=20 sleepiness and wakefulness. Sleepiness results from the sleep component = of the=20 circadian cycle of sleep and wakefulness, restriction of sleep, and/or=20 interruption or fragmentation of sleep. The loss of one night's sleep = can lead=20 to extreme short-term sleepiness, while habitually restricting sleep by = 1 or 2=20 hours a night can lead to chronic sleepiness. Sleeping is the most = effective way=20 to reduce sleepiness.

Sleepiness causes auto crashes because it impairs = performance and=20 can ultimately lead to the inability to resist falling asleep at the = wheel.=20 Critical aspects of driving impairment associated with sleepiness are = reaction=20 time, vigilance, attention, and information processing.

CRASH CHARACTERISTICS

Subjective and objective tools are available to = approximate or=20 detect sleepiness. However, unlike the situation with alcohol-related = crashes,=20 no blood, breath, or other measurable test is currently available to = quantify=20 levels of sleepiness at the crash site. Although current understanding = largely=20 comes from inferential evidence, a typical crash related to sleepiness = has the=20 following characteristics:

RISKS FOR DROWSY-DRIVING CRASHES =

Although evidence is limited or inferential, chronic = predisposing=20 factors and acute situational factors recognized as increasing the risk = of=20 drowsy driving and related crashes include:

These factors have cumulative effects; a combination of = them=20 substantially increases crash risk.

POPULATION GROUPS AT HIGHEST RISK =

Although no driver is immune, the following three = population=20 groups are at highest risk, based on evidence from crash reports and=20 self-reports of sleep behavior and driving performance.

COUNTERMEASURES

To prevent drowsy driving and its consequences, = Americans need=20 information on approaches that may reduce their risks. The public needs = to be=20 informed of the benefits of specific behaviors that help avoid becoming = drowsy=20 while driving. Helpful behaviors include (1) planning to get sufficient = sleep,=20 (2) not drinking even small amounts of alcohol when sleepy, and (3) = limiting=20 driving between midnight and 6 a.m. As soon as a driver becomes sleepy, = the key=20 behavioral step is to stop driving-for example, letting a passenger = drive or=20 stopping to sleep before continuing a trip. Two remedial actions can = make a=20 short-term difference in driving alertness: taking a short nap (about 15 = to 20=20 minutes) and consuming caffeine equivalent to two cups of coffee. The=20 effectiveness of any other steps to improve alertness when sleepy, such = as=20 opening a window or listening to the radio, has not been demonstrated. =

A more informed medical community could help reduce = drowsy driving=20 by talking to patients about the need for adequate sleep, an important = behavior=20 for good health as well as drowsy-driving prevention. The detection and=20 management of illnesses that can cause sleepiness, such as SAS and = narcolepsy,=20 are other health care-related countermeasures.

Information could be provided to the public and = policymakers about=20 the purpose and meaning of shoulder rumble strips, which alarm or awaken = sleepy=20 drivers whose vehicles are going off the road. These rumble strips = placed on=20 high-speed, controlled-access, rural roads reduce drive-off-the-road = crashes by=20 30 to 50 percent. However, rumble strips are not a solution for sleepy = drivers,=20 who must view any wake-up alert as an indication of impairment-a signal = to stop=20 driving and get adequate sleep before driving again.

Employers, unions, and shift work employees need to be = informed=20 about effective measures they can take to reduce sleepiness resulting = from shift=20 work schedules. Countermeasures include following effective strategies = for=20 scheduling shift changes and, when shift work precludes normal nighttime = sleep,=20 planning a time and an environment to obtain sufficient restorative = sleep.

FOCUSING AN EDUCATIONAL CAMPAIGN: = PANEL=20 RECOMMENDATIONS

To assist the educational campaign in developing its = educational=20 initiatives, the panel recommended the following three priority = areas:

  1. Educate young males (ages 16 to 24) about drowsy = driving and how=20 to reduce lifestyle- related risks.

  2. Promote shoulder rumble strips as an effective = countermeasure=20 for drowsy driving; in this context, raise public and policymaker = awareness=20 about drowsy-driving risks and how to reduce them.

  3. Educate shift workers about the risks of drowsy = driving and how=20 to reduce them.

The panel also identified complementary messages for the = campaigns=20 and called for the active involvement of other organizations in an = effort to=20 promote sufficient sleep-as a public health benefit as well as a means = to reduce=20 the risk of fall-asleep crashes.

I. INTRODUCTION

In the 1996 appropriations bill for the U.S. Department of = Transportation,=20 the Senate Appropriations Committee report noted that "NHTSA data = indicate that=20 in recent years there have been about 56,000 crashes annually in which = driver=20 drowsiness/fatigue was cited by police. Annual averages of roughly = 40,000=20 nonfatal injuries and 1,550 fatalities result from these crashes. It is = widely=20 recognized that these statistics underreport the extent of these types = of=20 crashes. These statistics also do not deal with crashes caused by driver = inattention, which is believed to be a larger problem."

In response, Congress allocated funds for a public education campaign = on=20 drowsy driving among noncommercial drivers, to be sponsored by the = National=20 Highway Traffic Safety Administration (NHTSA) and the National Center on = Sleep=20 Disorders Research (NCSDR) of the National Heart, Lung, and Blood = Institute, the=20 National Institutes of Health. This focus complements Federal Highway=20 Administration efforts to address the problem among commercial vehicle = drivers=20 (Federal Register, 1996).

To provide evidence-based direction to this campaign, the Expert = Panel on=20 Driver Fatigue and Sleepiness reviewed the research conducted to date on = drowsy-driving crashes. The resulting report outlines the following:=20

In addition to summarizing what is known-and what remains = unknown-from sleep=20 and highway safety research, the report also presents the panel's=20 recommendations for the highest priority target audiences and = educational=20 message points for the NCSDR/NHTSA campaign.

METHODS AND KNOWLEDGE BASE OF THIS REPORT =

The panel conducted a wide-ranging search for information on sleep, = circadian=20 rhythms, sleepiness, drowsiness, sleep physiology, and sleep disorders, = as well=20 as on the association of these topics with driving risk and crash = prevention.=20 The panel conducted literature searches of online databases in traffic = safety,=20 medicine, and physiology using the keywords listed above and following=20 suggestions for linkage to related topics (e.g., technology, alerting = devices,=20 industrial accidents, and shift work). In addition, the panel requested = or was=20 forwarded formal and informal reviews and monographs by Federal, State, = and=20 nongovernmental agencies. Although there was no formal ranking of the = scientific=20 rigor of all this material, original papers, reviews, monographs, and = reports=20 selected for citation reflect the higher levels of evidence available on = the=20 topic and literature upon which the major concepts or opinions of the = panel=20 report are based. The references provided do not, however, reflect all = resources=20 available or reviewed by the panel; when possible, more recent material = or=20 reviews are preferentially cited.

The principal types of primary data the panel used fall into the = following=20 categories:=20

The literature reviewed had variations in design, method, rigor, = populations=20 included, methodological detail, outcome measures, and other variables, = all of=20 which precluded a strict comparison. In addition, the number of studies = is=20 relatively small, and some of the studies do not represent large numbers = of=20 crashes or feature crash numbers or frequency as an outcome measure.

RESEARCH NEEDS

The panel identified three major categories in which more evidence is = needed:=20

Quantification of the problem. To allow = accurate=20 estimates of the true prevalence of drowsy-driving crashes, it will be = important=20 to develop a standard manner by which law enforce- ment officers can = assess and=20 report crashes resulting from drowsy driving. Currently, States use = different=20 definitions and have varying reporting requirements, which hinder=20 quantification. However, this is not just a reporting problem; a method = for=20 objectively assessing sleepiness at the crash site also would enable = better=20 quantification.

Risks. More information is needed on = chronic and=20 acute risks for drowsy-driving crashes. For example, capturing = information on=20 drivers' precrash behaviors (e.g., duration of prior wakefulness, recent = sleep-wake patterns, the quality and quantity of sleep, work hours, and = work=20 patterns [day shift, night shift, rotating shift]) could enhance = understanding=20 of the problems. It is important to learn more about at-risk drivers who = do not=20 crash and about the impact of drowsiness on driving at all points on the = continuum, from low-level drowsiness to falling asleep at the wheel. =

Countermeasures. Additional information and = research are needed on measures that increase or restore driver = alertness or=20 reduce crash risk or incidence. In addition, studies should determine = whether=20 early recognition, treatment, and management of sleepiness and sleep = disorders=20 reduce crash risk or incidence. Educational approaches that are = effective for=20 reaching high-risk audiences will need to be developed and tested; = ultimately,=20 the impact of such approaches on drowsy-driving knowledge, attitudes, = and=20 behaviors will need to be examined.

II. BIOLOGY OF = HUMAN SLEEP=20 AND SLEEPINESS

Sleepiness, also referred to as drowsiness, is defined in this report = as the=20 need to fall asleep, a process that is the result of both the circadian = rhythm=20 and the need to sleep (see below). Sleep can be irresistible; = recognition is=20 emerging that neurobiologically based sleepiness contributes to human = error in a=20 variety of settings, and driving is no exception (=EF=BF=BDkerstedt, = 1995a, 1995b;=20 Dinges, 1995; Horne, 1988; Sharpley, 1996; Martikainen, 1992). In the = more=20 recent surveys and reporting of noncommercial crashes, investigators = have begun=20 to collect and analyze data for instances in which the driver may have = fallen=20 asleep.

The terms "fatigue" and "inattention" are sometimes used = interchangeably with=20 sleepiness; however, these terms have individual meanings (Brown, 1994). = Strictly speaking, fatigue is the consequence of physical labor or a = prolonged=20 experience and is defined as a disinclination to continue the task at = hand. In=20 regard to driving, a psychologically based conflict occurs between the=20 disinclination to drive and the need to drive. One result can be a = progressive=20 withdrawal of attention to the tasks required for safe driving. = Inattention can=20 result from fatigue, but the crash literature also identifies = preoccupation,=20 distractions inside the vehicle, and other behaviors as inattention = (Treat et=20 al., 1979).

The driving literature before 1985 made little mention of sleepiness = and=20 instead focused on the prevention of inattention and fatigue; traffic = crash=20 forms did not have a category for reporting sleepiness as a crash cause. = Certainly, sleepiness can contribute to fatigue and inattention, and = given the=20 lack of objective tests or uniform reporting requirements to distinguish = these=20 different crash causes, misclassification and inconsistencies in the = primary=20 data and the literature can be expected. Some, but not all, recent = studies and=20 reviews make an explicit assumption that given the uncertainty in crash = reports,=20 all crashes in the fatigue and inattention categories should be = attributed to=20 sleepiness. The panel suspects that sleepiness-related crashes are still = very=20 often reported in the categories of fatigue and inattention, and it = reached=20 consensus that sleepiness is an underrecognized feature of noncommercial = automobile crashes.

The panel concluded that the data on fatigue and inattention provide = less=20 support for defining risk factors and high-risk groups than the data on=20 sleepiness or drowsiness. In addition, sleepiness is identifiable, = predictable,=20 and preventable.

THE SLEEP-WAKE CYCLE

A body of literature exists on the mechanisms of human sleep and = sleepiness=20 that affect driving risks. The sleep-wake cycle is governed by both = homeostatic=20 and circadian factors. Homeostasis relates to the neurobiological need = to sleep;=20 the longer the period of wakefulness, the more pressure builds for sleep = and the=20 more difficult it is to resist (Dinges, 1995). The circadian pacemaker = is an=20 internal body clock that completes a cycle approximately every 24 hours. = Homeostatic factors govern circadian factors to regulate the timing of=20 sleepiness and wakefulness.

These processes create a predictable pattern of two sleepiness peaks, = which=20 commonly occur about 12 hours after the midsleep period (during the = afternoon=20 for most people who sleep at night) and before the next consolidated = sleep=20 period (most commonly at night, before bedtime) (Richardson et al., = 1982; see=20 figure 1). Sleep and wakefulness also are influenced by the light/dark = cycle,=20 which in humans most often means wakefulness during daylight and sleep = during=20 darkness. People whose sleep is out of phase with this cycle, such as = night=20 workers, air crews, and travelers who cross several time zones, can = experience=20 sleep loss and sleep disruption that reduce alertness = (=EF=BF=BDkerstedt, 1995b; Samel=20 et al., 1995).

The panel noted that the sleep-wake cycle is intrinsic and = inevitable, not a=20 pattern to which people voluntarily adhere or can decide to ignore. = Despite the=20 tendency of society today to give sleep less priority than other = activities,=20 sleepiness and performance impairment are neurobiological responses of = the human=20 brain to sleep deprivation. Training, occupation, education, motivation, = skill=20 level, and intelligence exert no influence on reducing the need for = sleep.=20 Micro-sleeps, or involuntary intrusions of sleep or near sleep, can = overcome the=20 best intentions to remain awake.

SLEEPINESS IMPAIRS PERFORMANCE

Sleepiness leads to crashes because it impairs elements of human = performance=20 that are critical to safe driving (Dinges, Kribbs, 1991). Relevant = impairments=20 identified in laboratory and in-vehicle studies include:=20

Often, people use physical activity and dietary stimulants to cope = with sleep=20 loss, masking their level of sleepiness. However, when they sit still, = perform=20 repetitive tasks (such as driving long distances), get bored, or let = down their=20 coping defenses, sleep comes quickly (Mitler et al., 1988; National=20 Transportation Safety Board, 1995).

3D"figure

Figure 1. Latency to sleep at 2-hour = intervals across=20 the 24-hour day. Testing during the daytime followed standard Multiple = Sleep=20 Latency Test procedures. During the night, from 2330 to 0800 hours = (based on a=20 24-hour clock), subjects were awakened every 2 hours for 15 minutes, = and=20 latency of return to sleep was measured. Elderly subjects (n =3D 10) = were 60 to=20 83 years of age; young subjects (n =3D 8) were 19 to 23 years of age = (Carskadon=20 and Dement, 1987).

3D"Figure

Figure 2. Performance slows with sleep = deprivation. A=20 summary of data (Kribbs, Dinges, 1994) on reaction to an event marker=20 presented to a subject every 4 seconds or so over a 10-minute period. = As=20 reaction time is longer, the inverse value is reduced, indicating a = slowing of=20 the perception/reaction response. The response to an event marker = slows more=20 across time in the sleep-deprived (very sleepy) subject than in a = subject who=20 has had normal amounts of sleep.

 

THE CAUSES OF SLEEPINESS/DROWSY DRIVING =

Although alcohol and some medications can independently induce = sleepiness,=20 the primary causes of sleepiness and drowsy driving in people without = sleep=20 disorders are sleep restriction and sleep fragmentation.

Sleep restriction or loss. Short duration = of sleep=20 appears to have the greatest negative effects on alertness (Rosenthal et = al.,=20 1993a; Gillberg, 1995). Although the need for sleep varies among = individuals,=20 sleeping 8 hours per 24-hour period is common, and 7 to 9 hours is = needed to=20 optimize performance (Carskadon, Roth, 1991). Experimental evidence = shows that=20 sleeping less than 4 consolidated hours per night impairs performance on = vigilance tasks (Naitoh, 1992). Acute sleep loss, even the loss of one = night of=20 sleep, results in extreme sleepiness (Carskadon, 1993b). The effects of = sleep=20 loss are cumulative (Carskadon, Dement, 1981). Regularly losing 1 to 2 = hours of=20 sleep a night can create a "sleep debt" and lead to chronic sleepiness = over=20 time. Only sleep can reduce sleep debt. In a recent study, people whose = sleep=20 was restricted to 4 to 5 hours per night for 1 week needed two full = nights of=20 sleep to recover vigilance, performance, and normal mood (Dinges et al., = 1997).=20

Both external and internal factors can lead to a restriction in the = time=20 available for sleep. External factors, some beyond the individual's = control,=20 include work hours, job and family responsibilities, and school bus or = school=20 opening times. Internal or personal factors sometimes are involuntary, = such as a=20 medication effect that interrupts sleep. Often, however, reasons for = sleep=20 restriction represent a lifestyle choice-sleeping less to have more time = to=20 work, study, socialize, or engage in other activities.

Job-Related Sleep Restriction. Contemporary society = functions 24=20 hours a day. Economic pressures and the global economy place increased = demands=20 on many people to work instead of sleep, and work hours and demands are = a major=20 cause of sleep loss. For example, respondents to the New York State = survey who=20 reported drowsy-driving incidents cited a variety of reasons related to = work=20 patterns. These included working more than one job, working extended = shifts (day=20 plus evening plus night), and working many hours a week (McCartt et al., = 1996).=20

Personal Demands and Lifestyle Choices. Many Americans do = not get=20 the sleep they need because their schedules do not allow adequate time = for it.=20 Juggling work and family responsibilities, combining work and education, = and=20 making time for enjoyable pastimes often leave little time left over for = sleeping. Many Americans are unaware of the negative effects this choice = can=20 have on health and functioning (Mitler et al., 1988). F

rom high-profile politicians and celebrities to the general = population,=20 people often see sleep as a luxury. One in four respondents who reported = sleeping difficulties in a recent Gallup Survey said you cannot be = successful in=20 a career and get enough sleep (National Sleep Foundation, 1995).

Sleep fragmentation. Sleep is an active = process,=20 and adequate time in bed does not mean that adequate sleep has been = obtained.=20 Sleep disruption and fragmentation cause inadequate sleep and can = negatively=20 affect functioning (Dinges, 1995). Similar to sleep restriction, sleep=20 fragmentation can have internal and external causes. The primary = internal cause=20 is illness, including untreated sleep disorders. Externally, = disturbances such=20 as noise, children, activity and lights, a restless spouse, or = job-related=20 duties (e.g., workers who are on call) can interrupt and reduce the = quality and=20 quantity of sleep. Studies of commercial vehicle drivers present similar = findings. For example, the National Transportation Safety Board (1995) = concluded=20 that the critical factors in predicting crashes related to sleepiness = (which=20 this report called "fatigue") were duration of the most recent sleep = period, the=20 amount of sleep in the previous 24 hours, and fragmented sleep patterns. =

Circadian factors. As noted earlier, the = circadian=20 pacemaker regularly produces feelings of sleepiness during the afternoon = and=20 evening, even among people who are not sleep deprived (Dinges, 1995). = Shift work=20 also can disturb sleep by interfering with circadian sleep patterns.

EVALUATING SLEEPINESS

An ideal measure of sleepiness would be a physiologically based = screening=20 tool that is rapid and suitable for repeated administration (Mitler, = Miller,=20 1996). No measures currently exist for measuring sleepiness in the = immediacy of=20 crash situations. Furthermore, a crash is likely to be an altering = circumstance.=20 A measuring system would be performance based and in vehicle, linked to = alerting=20 devices designed to prevent the driver from falling asleep.

The current tools for the assessment of sleepiness are based on=20 questionnaires and electrophysiological measures of sleep, and there is = interest=20 in vehicle-based monitors. A comprehensive review of these efforts is = beyond the=20 scope of the present report. In the following brief discussion, some = tools for=20 the assessment of sleepiness are described to illustrate the different=20 subjective and objective measures of chronic and situational (acute) = sleepiness=20 and the vehicle-based technology to sense sleepiness.

Assessment for chronic sleepiness. The = Epworth=20 Sleepiness Scale (ESS) (Johns, 1991) is an eight-item, self-report = measure that=20 quantifies individuals' sleepiness by their tendency to fall asleep "in = your=20 usual way of life in recent times" in situations like sitting and = reading,=20 watching TV, and sitting in a car that is stopped for traffic. People = scoring 10=20 to 14 are rated as moderately sleepy, whereas a rating of 15 or greater=20 indicates severe sleepiness. The ESS is not designed to be used to = assess=20 situational sleepiness or to measure sleepiness in response to an acute = sleep=20 loss. The ESS has been used in research on driver sleepiness and in = correlations=20 of sleepiness to driving performance in people with medical disorders. =

Other rating tools that measure an individual's experience with = sleepiness=20 over an extended period of time and contain a component or scale that is = congruent with measuring sleepiness include the Pittsburgh Sleep Quality = Index=20 (Buysse et al., 1989) and the Sleep-Wake Activity Inventory (Rosenthal = et al.,=20 1993b). Other self-report instruments obtain historical information = pertinent to=20 sleepiness using patient logs and sleep-wake diaries (Douglas et al., = 1990) and=20 the Sleep Disorders Questionnaire (Douglas et al., 1994). The = information=20 gathered with these instruments has not been as widely applied to = assessments of=20 noncommercial crashes.

Laboratory tools for measuring sleepiness include the Multiple Sleep = Latency=20 Test (MSLT) (Carskadon et al., 1986; Carskadon, Dement, 1987) and the=20 Maintenance of Wakefulness Test (MWT) (Mitler et al., 1982). The MSLT = mea- sures=20 the tendency to fall asleep in a standardized sleep-promoting situation = during=20 four or five 20-minute nap opportunities that are spaced 2 hours apart=20 throughout the day and in which the individual is instructed to try to = fall=20 asleep. Sleep is determined by predefined brain wave sleep-staging = criteria. The=20 presumption under-lying this test is that people who fall asleep faster = are=20 sleepier. Individuals who fall asleep in 5 minutes or less are = considered=20 pathologically sleepy; taking 10 minutes or more to fall asleep is = considered=20 normal. In the MWT, individuals are instructed to remain awake, and the = time it=20 takes (if ever) in 20 minutes to fall asleep by brain wave criteria is = the=20 measure of sleepiness.

Although the relative risk for fall-asleep crashes has not been = established,=20 individuals who exhibit a sleep latency of less than 15 minutes on the = MWT are=20 categorically too sleepy to drive a motor vehicle (Mitler, Miller, = 1996).

The MSLT and MWT were developed for neuro- physiologic assessment and = are=20 sensitive to acute as well as chronic sleep loss. Both assume = standardization of=20 procedures involving specially trained personnel and are not valid if = the=20 individual being tested is ill or in pain (Carskadon, 1993b). The panel = thought=20 that the use of these medical tests may not be practical for crash = assessment;=20 however, the use of a modified "nap test" has been used along with=20 questionnaires for field assessment of driver sleepiness (Philip et al., = 1997).=20

Assessment for acute sleepiness. Acute = sleepiness=20 is defined as a need for sleep that is present at a particular point in = time.=20 The Stanford Sleepiness Scale (SSS) (Hoddes et al., 1973) is an = instrument that=20 contains seven statements through which people rate their current level = of=20 alertness (e.g., 1=3D "feeling...wide awake" to 7=3D "...sleep onset = soon..."). The=20 scale correlates with standard performance measures, is sensitive to = sleep loss,=20 and can be administered repeatedly throughout a 24-hour period. In some=20 situations, the scale does not appear to correlate well with behavioral=20 indicators of sleepiness; in other words, people with obvious signs of=20 sleepiness have chosen ratings 1 or 2.

The Karolinska Sleep Diary (=EF=BF=BDkerstedt et al., 1994) contains = questions=20 relating to self-reports of the quality of sleep. Laboratory and some = field=20 studies suggest that most subjective sleep measures in this scale show = strong=20 covariation and relation to sleep continuity across a wide spectrum of = prior=20 sleep length and fragmentation. As in the SSS, several questions are = asked to=20 determine values for subjective sleepiness.

A Visual Analogue Scale (VAS) for sleepiness permits the subjects to = rate=20 their "sleepiness" in a continuum along a 100-mm line (Wewers, Low, = 1990).=20 Anchors for sleepiness range from "just about asleep" (left end) to "as = wide=20 awake as I can be" (right end). Persons rate their current feelings by = placing a=20 mark on the line that indicates how sleepy they are feeling. The VAS is = scored=20 by measuring the distance in millimeters from one end of the scale to = the mark=20 placed on the line. The VAS is convenient and rapidly administered over = repeated=20 measurements.

In all these attempts to measure subjective sleepiness, a person's = response=20 is dependent on both the presentation of the instructions and the = subject's=20 interpretation of those instructions. Problems related to these factors = may=20 confound interpretation between studies and between groups of different = ages or=20 cultures.

Vehicle-based tools. There are some = in-vehicle=20 systems that are intended to measure sleepiness or some behavior = associated with=20 sleepiness in commercial and noncommercial driving. Examples include = brain wave=20 monitors, eye-closure monitors, devices that detect steering variance, = and=20 tracking devices that detect lane drift (Dinges, 1995). This technology = is cur-=20 rently being examined in physiologic, psychophysiologic, and = crash-prevention=20 domains. There is insufficient evidence at present to judge its = application and=20 efficacy in regard to noncommercial driving.

III. = CHARACTERISTICS OF=20 DROWSY-DRIVING CRASHES

As noted in section II, unlike the situation with alcohol-related = crashes, no=20 blood, breath, or other objective test for sleepiness currently exists = that is=20 administered to a driver at the scene of a crash. No definitive criteria = are=20 available for establishing how sleepy a driver is or a threshold at = which driver=20 sleepiness affects safety. If drivers are unharmed in a crash, = hyperarousal=20 following the crash usually eliminates any residual impairment that = could assist=20 investigating officers in attributing a crash to sleepiness.

As a result, our understanding of drowsy-driving crashes is based on=20 subjective evidence, such as police crash reports and driver = self-reports=20 following the event, and may rely on surrogate mea- sures of sleepiness, = such as=20 duration of sleep in a recent timeframe or sleep/work patterns. Some = researchers=20 have addressed the problem by analyzing only those crashes known not to = be=20 caused by alcohol (because alcohol can cause sleepiness and affect other = performance variables), mechanical problems, or other factors and by = looking for=20 evidence of a sleepiness effect in categories of inattention or fatigue. = Thus,=20 reports on drowsy driving are often inferential. The strength of the = inferences=20 is increased when different types of studies reach similar conclusions. =

The characteristics of drowsy-driving crashes reported below resemble = the=20 inclusion criteria that some researchers have used to define a crash as = having=20 been caused by drowsiness. This similarity suggests the possibility that = the=20 researchers' initial assumptions influenced the determination of crash=20 characteristics. Despite these caveats, a fairly clear picture emerges = from=20 studies conducted to date of the typical crash related to sleepiness. =

The problem occurs during late-night hours. = Drowsy-driving crashes occur predominantly after midnight, with a = smaller=20 secondary peak in the midafternoon (Studies of police crash reports: = Pack et=20 al., 1995; Knipling, Wang, 1994; New York State GTSC Sleep Task Force, = 1994; New=20 York State Task Force on Drowsy Driving, 1996; Langlois et al., 1985; = Lavie et=20 al., 1986; Mitler et al., 1988; Horne, Reyner 1995b; Studies based on = driver=20 self-reports: Maycock, 1996; McCartt et al., 1996). Studies of = commercial=20 drivers show a similar pattern (see figure 3). According to a 1996 = report, time=20 of day was the most consistent factor influencing driver fatigue and = alertness.=20 Driver drowsiness was markedly greater during night driving than during = daytime=20 driving, with drowsiness peaking from late evening until dawn (Wylie et = al.,=20 1996). Nighttime and midafternoon peaks are consistent with human = circadian=20 sleepiness patterns.

The risk of a crash related to sleepiness increases during nighttime = hours=20 among both younger drivers (25 years of age and younger) and drivers = between the=20 ages of 26 and 45. However, younger drivers have no increased risk = during the=20 afternoon, when the predictable circadian sleepiness peak is expected. = Drivers=20 ages 45 through 65 have fewer nighttime crashes, with a peak at 7 a.m. = Drivers=20 ages older than 65 are more likely to have fall-asleep crashes during = the=20 midafternoon (Pack et al., 1995; Wang, Knipling, Goodman, 1996).

3D"Figure

Figure 3. Time of occurrence of crashes in = drivers of=20 different ages in which the crashes were attributed by the police to = the=20 driver being asleep but in which alcohol was not judged to be = involved. The=20 four panels show plots for drivers of the following ages: (A) drivers = 25 years=20 of age or younger; (B) drivers between 26 and 45 years of age, = inclusive;=20 (C) drivers between = 46 and 65=20 years of age, inclusive; and (D) drivers older than 65 years. In each = panel,=20 the X axis is the time of day and the Y axis is the = number of=20 crashes. However, the scale of the Y axis is different for each = panel.=20 The data are for the years 1990 to 1992,=20 inclusive.

 

Fall-asleep crashes are likely to be serious. = The=20 morbidity and mortality associated with drowsy-driving crashes are high, = perhaps=20 because of the higher speeds involved (Horne, Reyner, 1995b) combined = with=20 delayed reaction time. In North Carolina, more of these crashes resulted = in=20 injury compared with other, nonalcohol-related crashes-fatalities = occurred in=20 1.4 percent and 0.5 percent, respectively (Pack et al., 1995). Pack = (1995) and=20 Maycock (1996) both conclude that a higher proportion of the most = serious=20 crashes are sleepiness related.

A single vehicle leaves the roadway. An = analysis of=20 police crash reports in North Carolina showed the majority of the = nonalcohol,=20 drowsy-driving crashes were single-vehicle roadway departures (Pack et = al.,=20 1995). Among New York State drivers surveyed about their lifetime = experience=20 with drowsy driving, almost one-half of those who had a fall-asleep or=20 drowsy-driving crash reported a single-vehicle roadway departure; about=20 one-fourth of those who had fallen asleep without crashing also reported = going=20 off the road (McCartt et al., 1996). NHTSA General Estimates System data = reflect=20 the same trend but also suggest that sleepiness may play a role in = rear-end=20 crashes and head-on crashes (Knipling, Wang, 1994).

The crash occurs on a high-speed road. In=20 comparison with other types of crashes, drowsy-driving crashes more = often take=20 place on highways and major roadways with speed limits of 55 to 65 mph=20 (Knipling, Wang, 1994; Wang, Knipling, Goodman, 1996). Pack and = colleagues=20 (1995) found that most sleepiness-related crashes occur at higher = speeds,=20 attributing this finding to the effect of sleep loss on reaction time. = NHTSA=20 figures show that most drowsiness- or fatigue-related crashes occur on = higher=20 speed roads in nonurban areas. However, Maycock (1996) found that a = greater=20 absolute number occur in built-up areas. Panel members noted the = possibility=20 that more crashes occur on high-speed roads because more long-distance = nighttime=20 driving occurs on highways.

The driver does not attempt to avoid crashing.=20 NHTSA data show that sleepy drivers are less likely than = alert=20 drivers to take corrective action before a crash (Wang, Knipling, = Goodman,=20 1996). Anecdotal reports also suggest that evidence of a corrective = maneuver,=20 such as skid marks or brake lights, is usually absent in fall-asleep = crashes.=20

The driver is alone in the vehicle. In the = New York=20 State survey of lifetime incidents, 82 percent of drowsy-driving crashes = involved a single occupant (McCartt et al., 1996). Conversely, = respondents who=20 reported having fallen asleep without crashing were less likely to have = been=20 alone in the automobile.

Wilkins and colleagues (1997) confirmed that crashes attributed to = driver=20 fatigue have characteristics similar to those cited above regarding = driver age,=20 time of day, crash type, and severity. But, in addition, when alcohol=20 involvement was combined with fatigue or sleepiness, the patterns became = more=20 pronounced. For example, "asleep with alcohol" crashes involved a higher = percentage of young males than did crashes in which the driver was = asleep with=20 no evidence of alcohol.

IV. RISKS FOR DROWSY-DRIVING CRASHES

Although its conclusions were based on a limited body of knowledge, = the panel=20 identified a number of chronic predisposing factors and acute = situational=20 factors that increase the risk of drowsy driving and drowsy-driving = crashes.=20 These include sleep loss, driving patterns that disregard the normal = sleep-wake=20 cycle or represent driving increased time or miles (exposure), the use = of=20 sedating medication, sleep disorders such as sleep apnea syndrome (SAS) = and=20 narcolepsy, and the increased drowsiness and performance impairment that = result=20 from consuming alcohol when drowsy. All factors may interact, and with = the=20 exception of medical disorders, all factors may have either chronic or = acute=20 effects.

SLEEP LOSS

As noted in section II, external and internal factors and current = lack of=20 knowledge and attitudes about sleep cause many Americans to get = inadequate sleep=20 either occasionally (acute sleepiness) or routinely (chronic = sleepiness). Those=20 who suffer chronic sleep restriction and sleepiness may also combine = this=20 lifestyle pattern with situational acute sleep loss, aggravating their = risk of=20 drowsy driving.

Chronic sleepiness. In a recent Gallup = survey,=20 approximately one-half of U.S. adults reported experiencing sleeping=20 difficulties sometimes, with about 1 in 10 saying the difficulties are = frequent=20 (National Sleep Foundation, 1995). In a 1997 followup survey, three of = four=20 Americans who reported getting as much or more sleep than they "need" = said they=20 were sleepy during the day. One in three of the adult public was deemed=20 "significantly" sleepy on the Epworth Sleepiness Scale (ESS), and 1 in = 20 scored=20 at the "severe" sleepiness level (National Sleep Foundation Survey, = 1997).

In the New York State survey, the reported frequency of drowsy = driving in the=20 past year was associated with the quantity and quality of sleep = obtained. For=20 example, those who reported having fair or poor sleep quality were more = likely=20 to have driven drowsy sometimes or very often than were those who said = their=20 sleep was good or excellent (McCartt et al., 1996).

In addition, Maycock (1996) found that higher scores on the ESS were=20 positively associated with crashes. Drivers who reported having trouble = staying=20 awake during the day were more likely to report having sometimes or very = often=20 driven drowsy (McCartt et al., 1996).

Acute sleep loss. As discussed in section = II, the=20 loss of even one night of sleep may cause extreme sleepiness. Short-term = work=20 demands, child care, socializing, preparing for a trip or vacation, and = "pulling=20 all nighters" are common causes of acute sleep loss.

Sleep-restrictive work patterns. Working = the night=20 shift, overtime, or rotating shifts is a risk for drowsy driving that = may be=20 both chronic and acute. In the New York State survey, nearly one-half = the drowsy=20 drivers who crashed (and more than one-third of those who drove drowsy = without=20 crashing) reported having worked the night shift or overtime prior to = the=20 incident. In addition, a higher reported frequency of driving drowsy was = associated with working a rotating shift, working a greater number of = hours per=20 week, and more frequently driving for one's job (McCartt et al., 1996). = In the=20 British study (Maycock, 1996), respondents said that working the night = shift led=20 to sleepiness while driving, and in many studies a majority of shift = workers=20 admit having slept involuntarily on the night shift. The return to day = work and=20 morning shifts starting between 4 a.m. and 7 a.m. also may lead to = sleepiness.=20 EEG studies of sleep in rotating shift workers in both the natural = environment=20 and the laboratory have shown that day sleep after night work and early = night=20 sleep before morning work (e.g., going to sleep at 7 or 8 p.m. before a = 4 a.m.=20 shift) is 2 to 4 hours shorter than night sleep (=EF=BF=BDkerstedt, = 1995a).

In addition, a study of hospital house staff working around the clock = (Marcus, Loughlin, 1996) found higher levels of sleepiness and crashes = following=20 on-call periods. In a survey of hospital nurses, night nurses and = rotators were=20 more likely than nurses on other shifts to report nodding off at work = and at the=20 wheel and having had a driving mishap on the way home from work (Gold et = al.,=20 1992). (For more on this topic, see section V on shift workers.)

DRIVING PATTERNS

Driving patterns, including both time of day and amount of time = driven, can=20 increase crash risk. As detailed in section III, the greatest proportion = of=20 drowsy-driving crashes occurs during the late-night hours. The biology = of the=20 sleep-wake cycle predicts sleepiness during this time period, which is a = circadian sleepiness peak and a usual time of darkness. Other driving = time=20 patterns that increase risk include driving a larger number of miles = each year=20 and a greater number of hours each day (McCartt et al., 1996) and = driving a=20 longer time without taking a break or, more often, driving for 3 hours = or longer=20 (Maycock, 1996).

THE USE OF SEDATING MEDICATIONS

A number of studies indicate that using certain medications increases = the=20 risk of sleepiness-related crashes, particularly using prescribed = benzodiazepine=20 anxiolytics, long-acting hypnotics, sedating antihistamines (H1 class), = and=20 tricyclic antidepressants (Kozena et al., 1995; Van Laar et al., 1995; = Ray et=20 al., 1992; Leveille et al., 1994; Ceutel, 1995; Gengo, Manning, 1990). = The risks=20 are higher with higher drug doses and for people taking more than one = sedating=20 drug simultaneously (Ray et al., 1992). Younger males have higher risks = than do=20 females or other age groups across all drug classes. It appears that = risk is=20 highest soon after the drug regimen is initiated and falls to near = normal after=20 several months (Ceutel, 1995). Recreational drug use also may exacerbate = sleepiness effects (Kerr et al., 1991).

UNTREATED SLEEP DISORDERS: SLEEP APNEA SYNDROME = AND=20 NARCOLEPSY

Untreated sleep apnea syndrome and narcolepsy increase the risk of = automobile=20 crashes (Findley et al., 1995; George et al., 1987; Aldrich, 1989; = Alpert et=20 al., 1992; Broughton et al., 1981; Broughton et al., 1984). No current = data link=20 other sleep disorders with drowsy-driving crashes. However, other = medical=20 disorders causing disturbed sleep and excessive daytime sleepiness could = pose=20 risks.

In sleep apnea syndrome, brief interruptions of air flow and loss of = oxygen=20 during sleep disrupt and fragment sleep. The condition also is = associated with=20 loud, chronic snoring. Although people with untreated sleep apnea = syndrome may=20 not be aware of the brief disturbances, poor sleep quality often leads = to=20 daytime sleepiness. Narcolepsy is a disorder of the sleep-wake mechanism = that=20 also causes excessive daytime sleepiness. In untreated patients, = involuntary 10-=20 to 20-minute naps are common at 2- to 3-hour intervals throughout the = day.=20 Cataplexy, a sudden loss of muscle tone ranging from slight weakness to = complete=20 collapse, is another major symptom of narcolepsy that increases the risk = of=20 crash. These conditions are unrecognized and untreated in a substantial = number=20 of people (National Sleep Foundation Survey, 1997; American Thoracic = Society,=20 1994). (See section V for more information on sleep apnea syndrome and=20 narcolepsy.)

CONSUMPTION OF ALCOHOL INTERACTS WITH SLEEPINESS = TO=20 INCREASE DROWSINESS AND IMPAIRMENT

Although sleepiness and alcohol are distinct crash causes, the data = also show=20 some evidence of overlap. NHTSA found that drivers had consumed some = alcohol in=20 nearly 20 percent of all sleepiness-related, single-vehicle crashes = (Wang,=20 Knipling, Goodman, 1996). More than one in three New York State drivers = surveyed=20 in drowsy-driving crashes said they had drunk some alcohol (McCartt et = al.,=20 1996), and police-reported, fall-asleep crashes had a higher proportion = of=20 alcohol involvement than other types of crashes in that State. (New York = GTSC=20 Task Force, 1994; New York State Task Force, 1996).

Laboratory studies explain and predict these patterns. Many = researchers have=20 shown that sleepiness and alcohol interact, with sleep restriction = exacerbating=20 the sedating effects of alcohol, and the combination adversely affecting = psychomotor skills to an extent greater than that of sleepiness or = alcohol alone=20 (Roehrs et al. 1994; Wilkinson, 1968; Huntley, Centybear, 1974; Peeke et = al.,=20 1980). Driving simulation tests specifically show this effect, even with = modest=20 reductions in sleep, low alcohol doses, and low blood ethanol = concentrations. In=20 a driving simulation study, alcohol levels below the legal driving limit = produced a greater number of deviations from the road after 4 hours of = sleep=20 than after 8 hours of sleep (Roehrs et al., 1994) (see figure 4).

3D"Figure

Figure 4. Interaction between alcohol and = sleepiness.=20 These data from Roehrs et al. (1994) were collected in a laboratory = using a=20 driving simulator. Studies were performed in the morning after either = 8 hours=20 or 4 hours of time in bed the previous night and with either a low = dose of=20 ethanol or placebo. The number of off-road deviations by the driver = was 4=20 times higher after 8 hours of sleep time but 15 times higher with only = 4 hours=20 of sleep time.

It is possible that the effects of low levels of blood alcohol may = have an=20 interaction with circadian rhythms that produces sleepiness in the = afternoon and=20 evening (Roehrs et al., 1994; Horne, Baumber, 1991; Horne, Gibbons, = 1991). The=20 panel speculated that drinking alcohol before driving in the afternoon = or at=20 night might pose special risks given the circadian effects.

INTERACTIONS AMONG FACTORS INCREASE OVERALL RISK=20

Some of the crash-related factors have been studied more than others. = The=20 panel could not find evidence to determine whether chronic or acute = situations=20 pose the greater risk for crashes. However, it is clear that = these=20 factors are cumulative, and any combination of chronic and acute factors = substantially increases crash risk. For example, people with = chronic=20 sleep loss who drive in the early morning hours are likely to be at = greater risk=20 than are early morning drivers who slept well the night before and = usually get=20 enough sleep.

V. POPULATION GROUPS AT HIGHEST RISK

All drivers who experience the chronic or acute situations described = in=20 section IV are at risk for drowsy driving and drowsy-driving crashes. = Although=20 no one is immune from risk, research to date clearly identifies three = broad=20 population groups at high risk for drowsy-driving crashes. Their higher = risk is=20 based on (1) evidence from crash data of a greater absolute or relative = number=20 of fall-asleep crashes and/or (2) increased intermediate risk, based on=20 subjective reports of their having higher levels of sleepiness and more = of the=20 chronic or acute factors that underlie risk for everyone. The three = groups at=20 high risk are young people, shift workers, and people with untreated = sleep=20 conditions.

YOUNG PEOPLE, ESPECIALLY YOUNG MEN

Virtually all studies that analyzed data by gender and age group = found that=20 young people, and males in particular, were the most likely to be = involved in=20 fall-asleep crashes (Pack et al., 1995; Horne, Reyner, 1995b; Maycock, = 1996;=20 Knipling, Wang, 1994). Definitions of "young" differed among authors; = the ages=20 included in this category fell between 16 and 29.

Young people. Knipling and Wang (1995) = found that=20 drivers younger than 30 accounted for almost two-thirds of = drowsy-driving=20 crashes, despite representing only about one-fourth of licensed drivers. = These=20 drivers were four times more likely to have such a crash than were = drivers ages=20 30 years or older. In Pack and colleagues' study (1995), 20 was the peak = age of=20 occurrence of drowsy-driving crashes, whereas in New York State the = greatest=20 number of drowsy drivers (on self-report) were within the 25-to-34 age = group=20 (McCartt et al., 1996), and both the 18-to-24 and 25-to-39 age groups = were=20 overrepresented in fall-asleep crashes (New York State Task Force, = 1996).

Horne and Reyner (1995a) suggest that a combination of having more of = the=20 chronic and acute risk factors and frequently being on the roads during=20 nighttime hours (greater exposure) may explain the greater incidence of=20 drowsiness-related crashes in youth. Carskadon (1990) offers a variety = of=20 age-specific reasons for the involvement of younger people, particularly = adolescents. During this period, young people are learning to drive,=20 experimenting and taking risks, and testing limits. At the same time, = this age=20 group is at risk for excessive sleepiness because of the following:=20

The panel felt that vulnerability may be further increased when young = people=20 use alcohol or other drugs because sleepy youth are likely to be unaware = of the=20 interaction of sleepiness and alcohol and may not recognize related = impairments=20 they experience.

Males. In North Carolina, males were found = to be at=20 the wheel in about three of four fall-asleep crashes (Pack et al., = 1995). NHTSA=20 data show that males are 5 times more likely than females to be involved = in=20 drowsy-driving crashes (Wang, Knipling, Goodman, 1996). The reasons = young males=20 have more crashes than do young females are not clear because both young = men and=20 young women are likely to be chronically sleep-deprived.

SHIFT WORKERS

Most shift workers have at least occasional sleep disturbances, and=20 approximately one-third complain of fatigue (=EF=BF=BDkerstedt, 1995a, = 1995b, 1995c).=20 Older shift workers appear to have more sleep-related difficulties than = do=20 younger workers, but no gender differences have been found (Harma, = 1993). Night=20 shift workers typically get 1.5 fewer hours of sleep per 24 hours as = compared=20 with day workers. The midnight to 8 a.m. shift carries the greatest risk = of=20 sleep disruption because it requires workers to contradict circadian = patterns in=20 order to sleep during the day (Kessler, 1992).

Investigations have demonstrated that circadian phase disruptions = caused by=20 rotating shift work are associated with lapses of attention, increased = reaction=20 time, and decreased performance (Dinges et al., 1987; Hamilton et al., = 1972;=20 Williams et al., 1959). A study of hospital nurses reached similar = conclusions=20 based on "real world" experiences. Rotating shifts (working four or more = day or=20 evening shifts and four night shifts or more within a month) caused the = most=20 severe sleep disruptions of any work schedule. Nurses on rotating = schedules=20 reported more "accidents" (including auto crashes, on-the-job errors, = and=20 on-the-job personal injuries due to sleepiness) and more near-miss = crashes than=20 did nurses on other schedules (Gold et al., 1992). About 95 percent of = night=20 nurses working 12-hour shifts reported having had an automobile accident = or=20 near-miss accident while driving home from night work (Novak, = Auvil-Novak,=20 1996).

Hospital interns and residents routinely lose sleep during on-call = periods,=20 which may last 24 hours or more. A survey of house staff at a large = urban=20 medical school found that respondents averaged 3 hours of sleep during = 33-hour=20 on-call shifts, much of which was fragmented by frequent interruptions = (Marcus,=20 Loughlin, 1996). About 25 percent reported that they had been involved = in a=20 motor vehicle crash, 40 percent of which occurred while driving home = from work=20 after an on-call night. Others reported frequently falling asleep at the = wheel=20 without crashing, for example, while stopped at a traffic light.

Although this evidence does not demonstrate a conclusive association = between=20 shift work and crashes, the panel believes that shift workers' increased = risks=20 for sleepiness are likely to translate into an increased risk for = automobile=20 crashes. Competing demands from family, second jobs, and recreation = often=20 further restrict the hours available for sleep and further disrupt the = sleep=20 schedule.

The panel also designated shift workers as a high-risk group because = the=20 number of people who perform shift work-and are thus exposed to crash = risk-is=20 increasing. This sector is growing at a rate of 3 percent per year, as=20 businesses such as overnight deliveries, round-the-clock computer = operations,=20 overnight cleaning crews, 24-hour markets, and continuous-operation = factories=20 prosper and expand. Currently about one in five men (20.2 percent) and = almost=20 one in six women (15 percent) work other than a daytime shift, including = evening, night, rotating, split, and irregular shifts (Kessler, 1992). =

PEOPLE WITH UNTREATED SLEEP APNEA SYNDROME AND = NARCOLEPSY=20

Although the absolute number of crashes is low, crash risk is = increased among=20 people with untreated sleep apnea syndrome (SAS) and narcolepsy. The = proportion=20 of crashes is higher for people with untreated narcolepsy than it is for = people=20 with untreated SAS. However, because SAS is more common than narcolepsy, = the=20 absolute number of crashes is higher for those with untreated SAS = (Aldrich,=20 1989). In addition, patients with untreated SAS or narcolepsy perform = less well=20 on driving simulation and vigilance or attention tests than do people = without=20 these disorders (Findley, 1995; American Thoracic Society, 1994; = Haraldsson et=20 al., 1990). Undiagnosed sleep-disordered breathing, ranging from = habitual=20 snoring to repeated breathing interruptions, also increases the = likelihood of=20 crashes in a dose-response manner (Stradling et al., 1991; Philip et = al., 1996;=20 Hanning, Welch, 1996; Ohayon, Priest, Caulet, et al., 1997).

Although these conditions place people at higher risk for = drowsy-driving=20 crashes, they are not invariably linked with impaired driving. For = example, many=20 people with these disorders report no auto crashes (Findley et al., = 1988;=20 Aldrich, 1989). Findley and colleagues (1989) found that patients with = severe=20 untreated sleep apnea had more frequent crashes than did those with = untreated=20 mild apnea. A patient who can recognize impending uncontrollable = sleepiness and=20 take precautions is less likely to be at risk than one who is unaware of = or=20 denies his or her sleepiness (Aldrich, 1989).

Sleep apnea syndrome is somewhat more common among males than among = females,=20 and typical patients tend to be overweight and middle aged or older, = with a=20 large collar size and history of loud snoring; however, women and men = without=20 this profile also have the disorder (American Thoracic Society, 1994). = People=20 with narcolepsy are as likely to be female as male, and the disorder = usually=20 begins in adolescence. The time from onset of symptoms to diagnosis of=20 narcolepsy averages 10 years (American Thoracic Society, 1994; National=20 Commission on Sleep Disorders Research, 1993). Currently, many people = with these=20 conditions are undiagnosed and untreated, unaware of the potentially = serious=20 consequences of driving while drowsy, or unaware of the seriousness of = the=20 difficulty they may experience in maintaining alertness (Arbus et al., = 1991;=20 Hansotia, 1997). Falling asleep at the wheel may be a major factor that=20 motivates undiagnosed patients to seek medical care. The matter is = rarely raised=20 in driver or law enforcement education, and even health care = professionals may=20 not recognize a history of sleepiness as a risk factor for fall-asleep = crashes.=20 Medical systems have been successful in identifying only a fraction of = the=20 population with symptomatic sleep apnea (Strohl, Redline, 1996).

VI. COUNTERMEASURES =

The panel reviewed the knowledge base in four categories of = countermeasures:=20 behavioral, medical, alerting devices, and shift work. They found only a = few=20 scientific evaluations of potential countermeasures, most of which were=20 laboratory studies. Reports that exist tend to address the biological=20 feasibility of reducing drowsiness or improving alertness, rather than=20 demonstrate an intervention that reduces drowsy-driving crashes. As = noted=20 earlier, more research is needed on this topic.

Countermeasures for drowsy driving aim either to prevent it or to = ameliorate=20 it after it occurs. The panel concluded that preventing = drowsiness with=20 adequate sleep before driving is both easier and much more successful = than any=20 remedial measure reviewed. Methods of obtaining adequate = sustained=20 sleep include creating a positive sleep environment (a room that is = cool, quiet,=20 and dark) and sleeping at regularly scheduled times. Such measures are = often=20 promoted as "sleep hygiene" and make intuitive sense; however, few = rigorous=20 studies support all sleep hygiene claims.

The panel noted that the wake-up effects from remedial approaches to = existing=20 sleepiness do not last long. At best they can help sleepy drivers stay = awake and=20 alert long enough to find a motel, call for a ride, or stop driving and = sleep.=20 They are not a substitute for good sleep habits and should not be viewed = as a=20 "driving strategy" that can get drowsy drivers safely to their = destination.

BEHAVIORAL INTERVENTIONS

In addition to getting adequate sleep before driving, drivers can = plan ahead=20 to reduce the risk of drowsy driving in other ways. Some evidence exists = that=20 napping before a long drive may help make up for sleep loss in the short = term=20 and enhance wakefulness during the drive. Napping has the greatest = effect on=20 performance several hours after the nap (Dinges et al., 1987; Dinges, = 1992,=20 1995). Two other proven interventions avoid known problem situations: = not=20 drinking alcohol when sleepy (Roehrs et al., 1994) and not driving = between=20 midnight and 6 a.m. (Mitler et al., 1988; =EF=BF=BDkerstedt, 1995c), = especially well=20 into the period when sleep is usual (Brown, 1994). Graduated = driver-licensing=20 programs that disallow late-night driving among younger drivers can = mandate this=20 risk-avoiding behavior (Waller, 1989; Frith, Perkins, 1992).

When a driver becomes drowsy, the most obvious behavioral step for = avoiding a=20 crash is to stop driving and sleep for an extended period. When this = approach is=20 not practical and another driver is not available to take over, studies = have=20 found two remedial actions that can make a short-term difference:

Napping. Taking a break for a short nap = (about 15=20 to 20 minutes) has been shown to improve subsequent performance, even = among=20 sleep-deprived people (Horne, Reyner, 1995a; Dinges et al., 1987; Philip = et al.,=20 1997). Naitoh (1992) found that short naps every 6 hours during a = 35-hour=20 (otherwise sleepless) period was effective in maintaining performance in = the=20 laboratory. However, nappers are often groggy for about 15 minutes upon=20 awakening from naps longer than 20 minutes (Dinges, 1992). Practical = issues with=20 this strategy include the inability of some people to take short naps = and the=20 need for secure rest areas. The New York State survey found that about = one-third=20 of drivers had needed or wanted to stop in the past year, but a rest = area was=20 not available. Many also were unlikely to use a rest area when they were = driving=20 alone at night.

Consuming caffeine. Caffeine, even in low = doses,=20 significantly improves alertness in sleepy people (but only marginally = in those=20 already alert) (Regina et al., 1974; Lumley et al., 1987; Griffiths et = al.,=20 1990; Lorist et al., 1994). The minimum dose needed can be obtained in = about two=20 cups of percolated coffee, although caffeine content of coffee varies = widely=20 (Fox, 1993). Caffeine also is available in other forms such as=20 caffeine-fortified soft drinks and tablets. In driving simulators,=20 sleep-deprived drivers who consumed caffeine reduced lane deviations, = potential=20 crashes, and sleepiness for about an hour after consumption (Horne, = Reyner,=20 1995a).

In addition, limited evidence suggests that physical discomfort (such = as=20 sitting in an uncomfortable seat or position and shivering or sweating) = may also=20 keep sleepy drivers awake (=EF=BF=BDkerstedt, Ficca, 1997). Nicotine can = improve=20 short-term performance significantly in people with cognitive or = attention=20 performance impairments such as those from sleepiness (Kerr et al., = 1991).=20 Obviously, however, smoking tobacco should not be generally recommended = in an=20 educational campaign as a drowsy-driving countermeasure because the=20 well-established risks substantially outweigh the possible benefits. The = panel=20 found no evidence of effectiveness for commonly accepted remedial = approaches=20 such as brief exercise (e.g., getting out of the car and walking around = for a=20 few minutes) (Horne, 1988), listening to the car radio, or opening the = car=20 windows (Horne, Reyner, 1995a). The panel found no studies evaluating = other=20 driver-reported steps such as talking to another passenger, talking on a = cellular phone or CB radio, chewing gum or ice, or snacking. One study = suggests=20 that talking on a cellular phone while driving is associated with = increased=20 crash risk (Redelmeier, Tibshirani, 1997).

MEDICAL INTERVENTIONS TO TREAT NARCOLEPSY AND = SLEEP APNEA=20 SYNDROME

Although effective treatments are available for both narcolepsy and=20 obstructive sleep apnea, relief of sleepiness and related symptoms is = not always=20 easily achievable for all patients (Broughton et al., 1981; Haraldsson = et al.,=20 1995). Although treatment can improve driving simulator performance = (Findley et=20 al., 1989), individual performance varies. A few studies to date have = evaluated=20 crash experiences of patients successfully treated for these disorders = and found=20 a positive effect (Cassel et al., 1996; Haraldsson et al., 1995). An = impediment=20 to diagnosis is a lack of physician education on the recognition of = sleepiness=20 and sleep disorders (National Commission on Sleep Disorders Research, = 1993).=20

ALERTING DEVICES

To date, research has validated only one type of device that alarms = or=20 awakens drivers who are drowsy or asleep-shoulder rumble strips placed = on=20 high-speed, controlled-access, rural roads. A recent synthesis of = reports on the=20 effectiveness of rumble strips shows that they reduce drive-off-the-road = crashes=20 by 30 to 50 percent-the only countermeasure the panel found in any = category that=20 has a demonstrated effect on crashes. Rumble strips also appear to be a=20 relatively low-cost solution with a positive benefit-to-cost ratio = (Garder,=20 Alexander, 1995; National Sleep Foundation, June 1997). However, the=20 effectiveness of rumble strips has been demonstrated only in=20 drive-off-the-highway crashes; their value with other types of = sleepiness or=20 inattention crashes or other types of roads has not been studied.

Section II lists some of the technological in-vehicle monitors = designed to=20 detect and evaluate driver sleepiness. Some of these devices contain = alarms or=20 other alerting devices that go off when indications of sleepiness occur. = Controlled trials are needed to evaluate the usefulness of these tools. =

An inherent deficiency in all types of alerting devices is that many = people=20 continue to drive even when they know they are drowsy and fighting to = stay=20 awake. Although an effective alerting device may prevent one crash, a = driver who=20 falls asleep once is likely to fall asleep again unless he or she stops = driving.=20 Some safety experts have expressed concern that alerting devices may in = fact=20 give drivers a false sense of security, encourage them to drive long = after=20 impairment, and inhibit their taking effective behavioral measures to = prevent or=20 relieve sleepiness (Lisper et al., 1986; Dinges, 1995; Horne, Reyner, = 1995a).=20

SHIFT WORK MEASURES

Research has shown that effective steps are available for both = employers and=20 employees to reduce the likelihood of excessive sleepiness and drowsy = driving.=20 Because of the complexity of the issues involved (Rosekind et al., = 1995), a=20 combination of alertness management approaches is likely to be most = effective.=20 Researchers also have found differences in individual tolerance to shift = work=20 (Harma, 1993); knowing more about the biological and behavioral factors = that=20 determine these differences could provide direction for future = educational=20 efforts.

EMPLOYER MANAGEMENT OF WORK SCHEDULES =

Several approaches have been effective in reducing sleepiness caused = by=20 working irregular hours and nighttime hours. To minimize disruption and = help=20 employees adjust to circadian rhythm changes, employers should educate = employees=20 about the problem (Harma, 1993). In addition, periods of work longer = than 8=20 hours have been shown to impair task performance and increase crashes. = For=20 example, performance appears worse with a 12-hour, 4-day week schedule = than with=20 an 8-hour, 6-day week (Brown, 1994). In jobs with extended hours, the = scheduling=20 of work and rest periods to conform to circadian rhythms promotes better = sleep=20 and performance (Stampi, 1994). Another effective approach is to allow = and=20 facilitate napping for night shift workers (Dinges, 1992; Naitoh, 1992). =

EMPLOYEE BEHAVIORAL STEPS

Shift workers themselves can take steps to reduce their risks of = drowsy=20 driving by planning time and creating an environment for uninterrupted,=20 restorative sleep (good sleep hygiene) (Minors, Waterhouse, 1981; Rosa, = 1990).=20 Shift workers who completed a 4-month physical training program reported = sleeping longer and feeling less fatigue than did matched controls who = did not=20 participate in the program. However, individual response to the stresses = of=20 shift work varies (Harma, 1993), and the background factors or coping = strategies=20 that enable some workers to adapt successfully to this situation are not = well=20 defined. The behavioral steps discussed earlier for younger males also = seem=20 reasonable for reducing risk in this population.

Nurses working the night shift reported using white noise, telephone=20 answering machines, and light-darkening shades to improve the quality = and=20 quantity of daytime sleep (Novak, Auvil-Novak, 1996).

USING BRIGHT LIGHT TREATMENTS

Several studies show that timed exposure to bright light has been = successful=20 in helping shift workers and those suffering from jet lag adapt to and = overcome=20 circadian phase disruption (Czeisler et al., 1990; Stampi, 1994). This = approach=20 promotes longer, uninterrupted sleep, which may help reduce sleepiness = on the=20 job and behind the wheel. The panel did not find data linking such = treatment to=20 changes in rates of crashes or industrial accidents.

VII. FOCUSING AN EDUCATIONAL CAMPAIGN: PANEL=20 RECOMMENDATIONS

To assist the NCSDR/NHTSA in developing its educational initiatives, = the=20 panel recommended three priorities for the campaign=20

  1. Educate young males (ages 16 to 24) about drowsy driving and how = to reduce=20 lifestyle-related risks.=20
  2. Promote shoulder rumble strips as an effective countermeasure for = drowsy=20 driving; in this context, raise public awareness about drowsy-driving = risks=20 and how to reduce them.=20
  3. Educate shift workers about the risks of drowsy-driving and how to = reduce=20 them.

EDUCATE YOUNG MALES ABOUT DROWSY DRIVING AND HOW = TO REDUCE=20 LIFESTYLE-RELATED RISKS

Young males, ages 16 to 24, received highest priority because of = their clear=20 over-representation in crash statistics and because many of their = lifestyle=20 risks are amenable to change. Although males up to age 45 have increased = crash=20 risks, the panel targeted only the younger group to enable specific = tailoring of=20 educational messages to this population's needs and preferences. In = fact,=20 campaign designers may want to segment further, creating different = messages for=20 the 16-to-18 and 19-to-24 age groups. The younger group is high school = age and=20 more likely to live at home with parents; members of the older group are = more=20 likely to be working or in college, living on their own and less subject = to=20 parental authority. The panel also believes it may be worthwhile to = educate=20 preteen boys, their parents, and their schools to influence attitudes = before=20 problems begin. The messages might be the following: sleepiness is not=20 inevitable for teens, and it is not okay to drive when you are sleepy. =

The panel recognized that the risk-taking behaviors of younger men = will be a=20 challenge in developing successful educational approaches. Focus group = research=20 is needed to develop a better understanding of young men's perceptions = of=20 fall-asleep crash risk and the kinds of interventions that would be = effective=20 with this group. Based on the literature, however, the panel suggests = that=20 campaign designers consider the following message points, many of which = are=20 appropriate for all public audiences:

Sleepiness is a serious risk for young male drivers.=20 Although little is known about the knowledge and attitudes = of this=20 group regarding sleepiness and driving risk, surveys of the general = population=20 suggest that knowledge of the risk is likely to be low and awareness = will need=20 to be raised. It also will be important for messages to affect = attitudes, so=20 that young men and their parents believe the risk is serious and young = men are=20 vulnerable. Misconceptions that sleepiness is inevitable at this age and = that=20 chronic sleepiness is a safe lifestyle choice need to be overcome. = Under-=20 standing the concept of sleep debt could be useful, as could recognizing = the=20 uncontrollable nature of falling asleep at high levels of drowsiness. =

Driving between midnight and 6 a.m. is a high-risk=20 situation. Scheduling a trip at another time is a simple = way to=20 reduce risk, especially if the drive is long.

An active lifestyle that restricts sleep is a special = risk.=20 Many young men will recognize themselves in the picture of = a=20 chronically sleepy student who also works part-time, participates in=20 extracurricular activities, and has an active social life. The "all = nighter"=20 represents an acute risk because extreme tiredness follows one sleepless = night.=20 The recommended action is not to start a long drive after one or more = sleepless=20 nights (e.g., do not drive home from college the day your exams are = over; get a=20 good night's sleep first).

Drinking alcohol increases sleepiness, and the = combination of=20 alcohol and sleepiness decreases performance and increases risk, even at = low=20 levels of alcohol use. A message that would convince young = men not=20 to drink when they are already sleepy could be useful. However, focus = groups of=20 youth in New York State revealed that drowsy-driving messages could be = lost or=20 ignored if paired with "don't drink and drive" messages, which some = believe are=20 already overemphasized (New York GTSC Sleep Task Force, 1994).

You can take effective steps if you become sleepy while=20 driving. These steps include stopping driving altogether, = if=20 possible; consuming the caffeine equivalent of two cups of coffee; = taking a=20 20-minute nap, and after the nap, driving to the closest safe resting = spot, such=20 as a motel, friend's house, or home; and sleeping.

Successful strategies from drinking and driving campaigns might also = be=20 adapted to drowsy driving if focus groups confirm their appeal. For = example, an=20 educational campaign could suggest that teens call a friend or a parent = for a=20 ride or let a friend drive home instead of driving while sleepy. = Complementary=20 educational messages to parents might suggest that they tell teenagers = to call=20 for a ride at any hour without recriminations if they feel too sleepy to = drive.=20 In another alcohol strategy variation, parents might allow sleepy = friends of=20 teens to sleep over rather than drive home.

The campaign also could counter common misconceptions of useful "stay = awake"=20 behaviors, such as exercising, turning on the radio, or opening the = windows,=20 which have not been shown to prevent sleep attacks.

Messages to policymakers could promote the value of graduated driver=20 licensing that does not permit younger drivers to drive during late = night hours=20 (e.g., after midnight). These leaders may need information on the = drowsy-driving=20 problem and the special risks of driving during this period for all = drivers and=20 especially for younger ones.

PROMOTE SHOULDER RUMBLE STRIPS AS AN EFFECTIVE=20 COUNTERMEASURE FOR DROWSY DRIVING; IN THIS CONTEXT, RAISE PUBLIC = AWARENESS ABOUT=20 DROWSY-DRIVING RISKS AND HOW TO REDUCE THEM

The panel believes that focusing a campaign on shoulder rumble strips = offers=20 multiple educational opportunities to convey key drowsy-driving = messages.

Messages to the general public can explain the following:

What rumble strips are and why they are increasingly = being used.=20 A message that rumble strips are designed to arouse sleepy = drivers=20 before they drive off the road could be an attention-getting way to = highlight=20 the prevalence of chronic sleepiness and point out the risks and = possible=20 consequences of drowsy driving. People who have driven over a rumble = strip in=20 the past could personalize the risk, and even seeing the strips on the = highway=20 in the future could repeatedly remind people of the message.

What to do when awakened by driving over a rumble=20 strip. Rumble strips act as an alarm clock, alerting = drivers to=20 the fact that they are too impaired to drive safely. The key to safety = is what=20 the driver does after hearing the alarm. In the short term, = risk-reducing=20 actions include stopping immediately if possible (e.g., a more alert = driver can=20 take over); consuming the caffeine equivalent of two cups of coffee; and = taking=20 a 20-minute nap. Then the driver should get off the road (e.g., at a = motel or=20 rest stop) as soon as possible and sleep.

In the longer term, planning ahead can help people avoid driving = while=20 drowsy. Key steps include planning sleep and naps before long trips, = scheduling=20 trips to avoid midnight through 6 a.m. driving, and avoiding alcohol and = sedating medicines while sleepy or sleep deprived.

The limitations of rumble strips. Rumble = strips=20 should not give drivers a false sense of security about driving while = sleepy.=20 The strips are useful as alerting devices, but they will not protect = drivers who=20 continue to drive while drowsy. Being awakened by driving over a rumble = strip is=20 a warning to change sleep and driving behaviors for safety. The strips = are not a=20 technological quick fix for sleepy drivers.

Messages to policymakers, especially from States in which rumble = strips are=20 not currently used, can emphasize what rumble strips are, their relative = cost-effectiveness, and why they are a valuable addition to highways in = rural=20 areas. Policymakers also may need information on the risks of drowsy = driving and=20 crashes to put the need for rumble strips in perspective.

EDUCATE SHIFT WORKERS ABOUT THE RISKS OF DROWSY = DRIVING AND=20 HOW TO REDUCE THEM

Employers, unions, and shift workers are potential target audiences = for=20 education on shift work and drowsy driving issues. The panel believes = that an=20 initial focus on employees would complement and reinforce other = drowsy-driving=20 messages directed to the public. Although many shift workers are not in = a=20 position to change or affect their fundamental work situation, they and = their=20 families may benefit from information on their risks for drowsy driving = and=20 effective countermeasures. Key message points include the following: =

Shift work may increase the risk of drowsy-driving=20 crashes. Night-, early morning-, and rotating-shift = workers are=20 often sleepy because their work times are inconsistent with the natural=20 sleep-wake cycle. Workers on these shifts routinely get less sleep and = lower=20 quality sleep than do day workers. Driving while sleepy is a risky = behavior that=20 leads to many serious crashes each year.

Driving between midnight and 6 a.m. and driving home = immediately=20 after an extended or night shift are special risks for a drowsy-driving = crash.=20 Driving during late night/early morning hours increases = risk for=20 all drivers because those hours are a natural period of sleepiness. Many = drowsy-driving crashes occur at this time. Driving while acutely tired, = such as=20 after a night shift, also increases the risk of crashing. Shift workers, = many of=20 whom are already chronically sleep deprived, are at extra risk.

You can take effective steps to reduce your risks.=20 First, it is important to give regular priority to getting = good=20 sleep by creating a quiet, cool, dark environment, allowing sufficient = time for=20 sleep, and trying to sleep during the same hours each day. Another = strategy is=20 to avoid driving home from work while sleepy (e.g., getting a ride from = a family=20 member, taking a cab, napping before heading home). Consuming caffeine=20 equivalent to two cups of coffee may help improve alertness for a short = period.=20

OTHER ORGANIZATIONS CAN PROVIDE DROWSY DRIVING = EDUCATION=20

The panel recognizes that limitations in resources will not allow = NCSDR/NHTSA=20 to conduct all needed educational interventions. However, other sponsors = can=20 make an important contribution by disseminating messages to high-risk = audiences,=20 intermediaries, and gatekeepers, such as industries where shift work is=20 prevalent. Potential sponsors may include consumer, voluntary, health = care=20 professional, and industry groups and other government agencies. The = panel=20 encourages such groups to use this report and resulting campaign = materials to=20 inform and assist their own audience-specific efforts. NCSDR/NHTSA = efforts to=20 educate the public, especially youth, about the importance of sleep and = sleep=20 hygiene should complement other initiatives and, in combination, = reinforce=20 messages on the prevention of fall-asleep crashes.

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