Commercial Drivers ‘STOP’ Drowsy Driving

Alert commercial drivers are an essential component of a safe transportation system, which includes business logistics strategies for the optimal distribution of goods and services. Yet, they are more likely to drive drowsy according to data from the Centers for Disease Control (CDC). Drowsy drivers are less attentive. They have a slower reaction time, and a decreased ability to make decisions.

Trucking accidents are on the rise because most commercial drivers work long shifts, drive long distances, or suffer from sleep apnea. According to the National Institutes of Health, adults need 7 or 8 hours of sleep a day, while adolescents need 9 or 10 hours.The National Highway Traffic Safety Administration estimates that 2.5% of fatal crashes and 2% of injury crashes involve drowsy driving.

Drivers who drive long distances and work long shifts should try to create a relaxing bedtime routine in an environment that is comfortable and cool, and blocks out all light and noise. They should also know the signs of obstructive sleep apnea (OSA) which occurs due to a blockage in the upper airway that interferes with the ability to breathe normally. OSA may contribute to tiredness, excessive daytime sleepiness, mood swings, memory loss, and problems concentrating while performing various routine activities.

If OSA symptoms are present, the driver may use the STOP questionnaire. It is a concise and easy-to-use screening tool that can identify patients with a high risk for OSA.

Four questions are answered respectively, related to snoring, tiredness during the daytime, observed apnea, and high blood pressure (STOP).

High risk for OSA is determined by answering yes to two or more questions. The driver should consider making an appointment with a board certified sleep specialist who will determine if a sleep study is necessary if there is a high risk for sleep apnea, which can lead to high blood pressure, diabetes, stroke, and cancer.

STOP Questionnaire for Obstructive Sleep Apnea (OSA)

Height: _________ inches Weight: _________ lbs

Age: _______ Male / Female Body Mass Index (BMI): _________

Collar size of shirt: S M L XL or _________ inches

Neck Circumference: _________ cm

 

The STOP test consists of four questions:

  1. Snoring

Do you snore loudly (louder than talking or loud enough to be heard through closed door)?

Yes No

  1. Tired

Do you often feel tired, fatigued or sleepy during the day?

Yes No

  1. Observed

Has anyone observed you stop breathing during your sleep?

Yes No

  1. Blood Pressure

Do you have or are you being treated for high blood pressure?

Yes No

High risk of OSA: answering yes to two or more questions

Low risk of OSA: answering yes to less than two questions

*Chung, F., Yegneswaran, B., Liao, P., Chung, S., Vairavanathan, S., Islam, S., Khajehdehi, A., Shapiro C. (2008). STOP questionnaire. A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108 (5), 812-21.

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Is Getting too Little Sleep Making You Sick?

Published Fall 2012 in Broward Health Magazine

Do you wake up with morning headaches or have high blood pressure? Do you have difficulty with acid reflux? Has your child been diagnosed with attention deficit hyperactivity disorder (ADHD)? If so, Obstructive Sleep Apnea (OSA) may be to blame.

OSA is the most common sleep disorder. It begins with a blockage in the upper airway that interferes with breathing normally when asleep. The blockage leads to loud snoring, followed by silence, then choking or gasping for air, causing one to arouse momentarily from sleep or to wake up completely.

The most recognized symptoms are daytime sleepiness, fatigue, memory loss, mood swings, trouble concentrating and poor academic performance in children.

OSA is a serious condition, because quality sleep influences the regulation of body weight and metabolism, and insufficient sleep can lead to obesity and contribute to medical problems such as high blood pressure, diabetes and cancer. In fact, less than seven hours of sleep may alter hormone levels that regulate the appetite, which can lead to overeating. Furthering the problem is that OSA reduces daytime energy, which results in decreased physical activity and, ultimately, weight gain.

In addition to weight problems, OSA can increase the risk of Type 2 diabetes and is associated with insulin resistance and a rise in insulin secretion to maintain normal glucose tolerance.

Lack of sleep is also linked to more aggressive breast cancers and may raise the risk of cancer recurrence in older women. Data on over 400 breast cancer patients revealed women who averaged less than six hours of sleep a night before their diagnoses had more aggressive tumors than women who slept longer.

Adults aren’t the only ones who can suffer from OSA. In children, there has been an increased association between ADHD and sleep apnea. OSA can cause mild inattention or hyperactivity. Sleep disordered breathing may contribute to some mild ADHD-like symptoms, including decreased attention span and learning problems.

If you are exhibiting OSA symptoms, a simple overnight sleep study can be conducted to diagnose sleep apnea. A sleep study should also be considered before starting long-term drug treatment for ADHD.

Sleep studies can be performed at Broward Health Coral Springs or Broward Health Medical Center and involve monitoring breathing patterns, as well as brain wave activity to determine light or deep sleep, blood oxygen levels, heart rhythm, legmovements and snoring.

For more information about sleep disorders, visit BrowardHealth.org/sleep.

Melissa Brooks, MBA, RPSGT, CRT, is the clinical coordinator of the Sleep Disorders Center at Broward Health Coral Springs.

REFERENCES

Centers for Disease Control and Prevention (2012). Adult Obesity Facts. Retrieved August 28, 2012, from http://www.cdc.gov/obesity/data/adult.html

Chung, F., Yegneswaran, B., Liao, P., Chung, S., Vairavanathan, S., Islam, S., Khajehdehi, A., Shapiro C. (2008). STOP questionnaire. A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108 (5), 812-21.

Institute of Medicine. Sleep disorders and sleep deprivation: An unmet public health problem. 2006. Washington, D.C.: National Academies Press;

Jean-Philippe Chaput*, Jean-Pierre Després*,†, Claude Bouchard‡ and Angelo Tremblay* Short Sleep Duration is Associated with Reduced Leptin Levels and Increased Adiposity: Results from the Québec Family Study. Obesity (2007) 15, 253–261; doi:10.1038/oby.2007.512

Kryger MH: Diagnosis and management of sleep apnea syndrome. Clin Cornerstone 2000; 2:39–47

Lack of Sleep Found to be a New Risk Factor for Aggressive Breast Cancers (2012). Retrieved August 28, 2012, from http://www.msnbc.msn.com/id/48802740/ns/local_news-peoria_il/

Pagel JF. Obstructive sleep apnea (OSA) in primary care: evidence-based practice. J Am Board Fam Med 2007; 20: 392–8.

Sushmita Pamidi, Kristen Wroblewski, Josiane Broussard, Andrew Day, Erin C. Hanlon, Varghese Abraham, and Esra Tasali. Obstructive Sleep Apnea in Young Lean Men: Impact on insulin sensitivity and secretion Diabetes Care published ahead of print August 21, 2012, doi:10.2337/dc12-0841

Walters AS; Silvestri R; Zucconi M; Chandrashekariah R; Konofal E. Review of the Possible Relationship and Hypothetical Links Between Attention Deficit Hyperactivity Disorder (ADHD) and the Sim- ple Sleep Related Movement Disorders, Parasomnias, Hypersomnias, and Circadian Rhythm Disorders. J Clin Sleep Med 2008;4(6):591-600.

Why are Black People Dying in Their Sleep?

May 26, 2012
By Melissa Bynes Brooks

Public awareness has increased about the health risks associated with obstructive sleep apnea (OSA). While Blacks suffering from obesity and daytime sleepiness are more likely to seek initial sleep consultations, most Blacks are less likely to have a medical evaluation or seek treatment for OSA. They are not aware of the inherent risks of having OSA.

This may be because symptoms of sleep disorders are not routinely screened for or recognized in the primary care setting. To date, the United States Preventive Services Task Forces, the American Academy of Family Physicians, and the Center for Disease Control have not recommended routine screening for sleep disorders.

The use of validated questionnaires may be able to efficiently identify patients at risk for common sleep disorders though further study is required.

In a community-based sample of Black patients, of the 421 patients referred by their private care physicians, 38% followed the recommendation for a sleep consultation. Even when Blacks have adequate insurance coverage, they are not as likely as their White counterparts to utilize available services. This suggests that physicians practicing in those communities may have to develop innovative strategies to encourage participation of Black patients in healthcare practices.

Ethnic differences highlight the need to further examine social support, socioeconomic status, access to care, and cultural factors to guide future health-related quality of life (HR-QOL).

OSA, the most common breathing sleep disorder, sets off an unstable chain of physiological reactions.

It begins with a blockage in the upper airway which interferes with the ability to breathe normally while sleeping. The blockage leads to loud snoring followed by silence. Oxygen levels decrease in the blood. Then chemoreceptors in the brain detect increased carbon dioxide levels in the blood. This results in the person choking or gasping for air, arousing momentarily or waking up completely from their sleep. At the same time, rapid changes occur with the heart rate, heart rhythm, and blood pressure. The body works overtime to recover from each episode lasting at least 10 seconds.

Throughout all this, the individual is totally clueless. After awakening, the only traces of life threatening events are symptoms of tiredness, excessive daytime sleepiness, dry mouth, morning headaches, and sometimes memory loss. In fact, sleep interruption due to OSA is often times mistaken as a need to get up and use the bathroom. The alternative to the interruptions caused by the apnea is sudden death.

That scenario brings Reggie White to mind, the former NFL football player, who reportedly suffered from sleep apnea which was believed to play a role in his death from a fatal cardiac arrhythmia. Nighttime is the deadliest time of day in persons with obstructive sleep apnea, according to a report in The New England Journal of Medicine, 2005, by Apoor S. Gami, MD, and colleagues of the Mayo Clinic in Rochester, Minn.

Those at high risk for OSA are: Black, Hispanic or Pacific Islander; male; over the age of 65; related to someone who has sleep apnea; and a smoker. Demographics are steadily changing to include children and adolescents because of increased obesity and diabetes rates in these groups.
Physical risk factors are attributes of a thick neck, deviated septum, receding chin, enlarged tonsils or adenoids.

OSA is directly linked to high blood pressure, heart disease, diabetes, obesity, and cancer. Blacks have a higher risk of death from OSA because of greater genetic tendencies for these medical conditions.

First, more than 40 percent of non-Hispanic Blacks have high blood pressure (HBP) which is more severe in Blacks than Whites and develops earlier in life. It contributes to 14% of deaths occurring in the United States, and to nearly half of all cardiovascular disease-related deaths annually. From 1997 to 2007, the death rate caused by high blood pressure increased to 9.0%, and the actual number of deaths rose 35.6%.

OSA represents an independent risk factor for high blood pressure. Hypertension constitutes a significant predictor of cardiovascular deaths among patients with OSA. The prevalence of resistant hypertension itself among men with a diagnosis of OSA may be as high as 85%. Blacks exhibit greater resistance to treatment and black women have the highest prevalence of hypertension and the lowest blood pressure control.

Blacks with a family history of hypertension are likely to have higher baseline blood pressure, a greater number of lower blood oxygen levels, and more episodes of “not breathing” while asleep, when compared to Whites.

Second, the National Commission on Sleep Disorders Research estimated that sleep apnea is probably responsible for 38,000 cardiovascular deaths yearly, with an associated 42 million dollars spent on related hospitalizations. Obstructive sleep apnea increases the risk of heart failure by 140%, the risk of stroke by 60%, and the risk of coronary heart disease by 30%.

The evaluation, diagnosis, treatment, and management of OSA have significant positive effects in reducing cardiovascular disease risk.
Linkage between obstructive sleep apnea and cardiovascular disease has been corroborated by evidence that treatment of sleep apnea with continuous positive airway pressure (CPAP) reduces systolic blood pressure, improves left ventricular systolic function, and diminishes platelet activation.

CPAP is a treatment that uses mild air pressure to keep the airways open. CPAP typically is used by people who have breathing problems, such as sleep apnea. Sleep medicine care providers, generalists, and specialists focusing on cardiovascular disease in OSA patients, need to emphasize preventative and ongoing care for active cardiovascular diseases. Care for OSA should also be initiated.

Third, more than 24 million Americans have diabetes mellitus (DM), and nearly one million new cases of diabetes are diagnosed every year. Type 2 diabetes accounts for 90% to 95% of all cases of diabetes. Diabetes mellitus was the sixth leading cause of death in 2002, with the risk of death almost twice that of non-diabetic patients of similar age. According to the Centers for Disease Control and Prevention, Blacks have a 1.8-fold increase and Hispanics have a 1.7-fold increase in the prevalence of diabetes mellitus compared to Whites.

With diabetes, OSA is associated with impaired glucose tolerance and insulin resistance. Type 2 diabetes occurs when the body fails to use insulin effectively. Research suggests that OSA can contribute to the onset of diabetes.

Fourth, a little more than one-third of U.S. adults (35.7%) are obese. Non-Hispanic Blacks have the highest rates of obesity (44.1%) compared with Mexican Americans (39.3%), all Hispanics (37.9%) and non-Hispanic whites (32.6%). The link between OSA and obesity is somewhat of a “Catch 22.” While being overweight is a risk factor for OSA, OSA may promote weight gain by reducing daytime energy and physical activity, and disrupting metabolism. OSA may alter the levels of hormones that regulate your appetite, which may lead you to eat more.

Short sleep duration < 7 hours is associated with elevated prevalence of obesity.

Last, a recent study found that people with the most severe sleep apnea — those who have 30 or more episodes of low or no oxygen in an hour of sleep — had almost five times the risk of cancer death compared to someone without sleep apnea.

When you have cancer and you repeatedly have episodes of low or no oxygen, the cancer cells “try to compensate for the lack of oxygen by growing additional blood vessels to get more oxygen. It’s a defense mechanism,” Dr. Javier Nieto, Chair of the department of population health sciences at the University of Wisconsin School of Medicine and Public Health, in Madison said. And, as those blood vessels keep growing, it helps the tumor to spread, he explained.

In an effort to improve positive health outcomes, The Adult OSA Task Force of the American Academy of Sleep Medicine (AASM) recommends that questions regarding OSA should be incorporated into routine health evaluations. Suspicion of OSA should trigger a comprehensive sleep evaluation. The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea.

Melissa Bynes Brooks is the editor of BrooksSleepReview.
Contact information: melissabynesbrooks@comcast.net
Follow on Twitter @Mlbbrooks


References

American Heart Association (2012). High Blood Pressure and African Americans. Retrieved May 25, 2012, from http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYourRiskforHighBloodPressure/High-Blood-Pressure-and-African-Americans_UCM_301832_Article.jsp

Bachmann, R., Demede, M., Donat, M., Jean-Louis, G., McFarlane, S.I., Ogedegbe, G, Pandey, A., and Zizi, F. (2011). Resistant Hypertension and Obstructive Sleep Apnea in the Primary-Care Setting. Retrieved May 25, 2012, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132606/

Centers for Disease Control and Prevention (2012). Adult Obesity Facts. Retrieved May 12, 2012, from http://www.cdc.gov/obesity/data/adult.html

Daily Mail (2012). The Moment a Frantic Woman Heard 911 Dispatcher Snoring as She Tried to get Help for her Husband who Couldn’t Breathe. Retrieved May 25, 2012, from http://www.dailymail.co.uk/news/article-2148146/911-dispatcher-falls-asleep-snores-phone-woman-tries-ambulance.html#ixzz1vvLDw3K5

Epstein LJ; Kristo D; Strollo PJ; Friedman N; Malhotra A; Patil SP; Ramar K; Rogers R; Schwab RJ; Weaver EM; Weinstein MD. Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults. J Clin Sleep Med 2009; 5(3):263-276.

Gami, A.S. The New England Journal of Medicine, March 24, 2005; vol 352: pp 1206-1214.

Gordon, S. Health Day (2012). Sleep Apnea Linked to Higher Cancer Death Risk Cancer Compensates, Spreads in Search for Oxygen, Researcher Suggests. Retrieved May 25, 2012, from http://www.healthfinder.gov/news/newsstory.aspx?Docid=664843

Hudgel DW; Lamerato LE; Jacobsen GR; Drake CL. Assessment of Multiple Health Risks in a Single Obstructive Sleep Apnea Population. J Clin Sleep Med 2012; 8 (1):9-18.

Jean-Louis G; von Gizycki H; Zizi F; Dharawat A; Lazar JM; Brown CD. Evaluation of Sleep Apnea in a Sample of Black Patients. J Clin Sleep Med 2008; 4(5):421–425.

Jean-Louis G; Zizi F; Clark LT; Brown CD; McFarlane SI. Obstructive Sleep Apnea and Cardiovascular Disease: Role of the Metabolic Syndrome and its Components. J Clin Sleep Med 2008; 4(3):261- 272.

Mahmood K; Akhter N; Eldeirawi K; Önal E; Christman JW; Carley DW; Herdegen JJ. Prevalence of type 2 diabetes in patients with obstructive sleep apnea in a multi-ethnic sample. J Clin Sleep Med 2009; 5(3):215-221.

National Institutes of Health. Department of Health and Human Services (2012). What is CPAP? Retrieved May 25, 2012, from http://www.nhlbi.nih.gov/health/health-topics/topics/cpap/

Pagel JF. Obstructive sleep apnea (OSA) in primary care: evidence-based practice. J Am Board Fam Med 2007; 20: 392–8.

Senthilvel E; Auckley D; Dasarathy J. Evaluation of sleep disorders in the primary care setting: History Taking Compared to Questionnaires. J Clin Sleep Med 2011; 7(1):41-48.

Sleep Disturbances, Quality of Life, and Ethnicity: The Sleep Heart Health Study. Baldwin, C.M., Ph.D.; Ervin, A-M., Ph.D., MPH; Mays, M.Z., Ph.D.; Robbins, J., M.D.; Shafazand, S., M.D., M.S.; Walsleben, J., Ph.D.; Weaver, T., Ph.D. J Clin Sleep Med 2012; 6 (2):176-183.

Your Sleep. American Academy of Sleep Medicine (2008). Eight Health Risks of OSA. Retrieved May 25, 2012, from http://yoursleep.aasmnet.org/topic.aspx?id=87

Your Sleep. American Academy of Sleep Medicine (2004). OSA Believed to Have Contributed to the Death of NFL Legend Reggie White. Retrieved May 25, 2012, from http://yoursleep.aasmnet.org/article.aspx?id=33

STOP- Undiagnosed Obstructive Sleep Apnea Is a High Risk for Surgery

 

Providing patients with the most current health care information empowers them to be proactive and make better decisions about their treatment. Studies have indicated that obstructive sleep apnea (OSA) may be a risk factor that leads to adverse or harmful events in patients who undergo surgery. A patient with sleep apnea is more likely to experience complications[i] during and following major surgery due to breathing problems associated with certain medications and general anesthesia. Problems are more prevalent when the patient is sedated and lying on their back. It is important for a doctor to know when a patient has been diagnosed with obstructive sleep apnea and how it is being treated.

Sleep apnea is the most common breathing sleep disorder,[ii] and occurs due to a blockage in the upper airway that interferes with the ability to breathe normally. Symptoms may include tiredness, excessive daytime sleepiness, snoring, gasping for air or choking while asleep, dry mouth, morning headaches, high blood pressure, and abnormal body jerks or sounds when asleep. High risk groups for OSA are: male; over the age of 65; black, Hispanic, or a Pacific Islander; related to someone who has sleep apnea; and being a smoker. More risk factors include certain physical attributes, such as having a thick neck, deviated septum, receding chin, or enlarged tonsils or adenoids. Medical problems such as insulin resistance, diabetes mellitus, systemic hypertension, pulmonary hypertension,congestive heart failure, strokes, irregular heart rhythm, nocturnal angina, heart disease, obesity, stroke, heart attack, and early death may be caused or worsened by OSA.[iii]

The STOP questionnaire is a concise and easy-to-use screening tool to identify patients with a high risk for OSA. It has been developed and validated in surgical patients at preoperative clinics. The patient answers four questions respectively related to snoring, tiredness during daytime, observed apnea, and high blood pressure (STOP). High risk of OSA is determined by answering yes to two or more questions. Low risk of OSA is determined by answering yes to less than two questions.[iv] STOP promotes an optimal outcome before, during and after the surgery period.

Follow- up should be considered for patients at high risk before their scheduled surgery. Follow- up should include a medical examination, sleep history questionnaire, use of the Epworth Sleepiness Scale (ESS)[v] to measure the level of daytime sleepiness, and a polysomnogram to diagnose the severity of OSA and to determine the appropriate treatment.

A sleep study is performed in a sleep disorders center and involves the monitoring and recording of physiological activity such as breathing patterns, brain wave activity to determine light or deep sleep including dreams, blood oxygen levels, heart rhythm, leg movements, and snoring.

 

STOP Questionnaire for Obstructive Sleep Apnea (OSA)

Height: _________ inches Weight: _________ lbs

Age: _______ Male / Female Body Mass Index (BMI): _________

Collar size of shirt: S M L XL or _________ inches

Neck Circumference: _________ cm

The STOP test consists of four questions:

1. Snoring

Do you snore loudly (louder than talking or loud enough to be heard through closed door)?

Yes   No

2. Tired

Do you often feel tired, fatigued or sleepy during the day?

Yes   No

3. Observed

Has anyone observed you stop breathing during your sleep?

Yes   No

4. Blood Pressure

Do you have or are you being treated for high blood pressure?

Yes   No

High risk of OSA: answering yes to two or more questions

Low risk of OSA: answering yes to less than two questions

Chung, F., Yegneswaran, B., Liao, P., Chung, S., Vairavanathan, S., Islam, S., Khajehdehi, A., Shapiro C. (2008). STOP questionnaire. A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108 (5), 812-21.

 

References


[i] Mayo Foundation for Medical Education and Research (MFMER). (2010). Retrieved March 13, 2011, from http://www.mayoclinic.com/health/sleepapnea/DS00148/DSECTION=complications

[ii] Kryger MH: Diagnosis and management of sleep apnea syndrome. Clin Cornerstone 2000; 2:39–47

[iii] Pagel JF. Obstructive sleep apnea (OSA) in primary care: evidence-based practice. J Am Board Fam Med 2007; 20: 392–8.

[iv] Chung, F., Yegneswaran, B., Liao, P., Chung, S., Vairavanathan, S., Islam, S., Khajehdehi, A., Shapiro C. (2008).    STOP questionnaire. A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108 (5), 812-21.

[v] Copyright © MW Johns 1990-1997.  Used under license.

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The information provided is not a substitute for a consultation with a physician.