A staff member shows how patients are tested in a special room at the sleep disorders clinic at Sunnybrook Health Sciences Centre in Toronto. Many drivers have undiagnosed and untreated sleep apnea; many are middle-aged, overweight and suffer from hypertension. (Canadian Press)

When Bob Martin, 59, was diagnosed with obstructive sleep apnea, he had to surrender his driver's licence to the Ontario Ministry of Transportation.

The Mayo Clinic calls sleep apnea a "potentially serious sleep disorder." When asleep, the person's back throat muscles relax, causing repeated stops and starts in breathing. It sometimes reduces oxygen levels, and can be accompanied by loud snoring.

Martin, a technical writer for the Construction Safety Association of Canada, experienced an average of 54.1 combined apnea/respiratory events per hour during the night, according to his doctor, not during the day. So why the licence suspension?

"Sleep apnea causes impairment in performance and is associated with an increased risk of motor vehicle crashes compared to the general population of drivers," says Dr. Charles George, chair of the University of Western Ontario's respirology division, in one of several recent obstructive sleep apnea (OSA) studies.

In short, drivers with OSA receive insufficient nighttime sleep, so they can have difficulty concentrating, their minds can wander and they can fall asleep at the wheel.

George, who is also the sleep lab director at London Health Sciences Centre's South Street Hospital, says the accident risk is two to six times higher for those suffering from sleep apnea than it is for regular drivers. His study, published in the September issue of the American Journal of Respiratory and Critical Care Medicine, summarizes previous research and suggests options.

Many drivers have undiagnosed and untreated sleep apnea; many are middle-aged, overweight and suffer from hypertension. Men get OSA twice as often as women, but women's occurrences increase after menopause.

Truck driver Charlie Resch shows a machine he keeps in the cab of his truck to help him deal with his sleep apnea - it allows him to breathe clearly while asleep. Dr. Charles George, chair of the University of Western Ontario's respirology division, says the accident risk is two to six times higher for those suffering from sleep apnea than it is for regular drivers. (Mike Roemer/Associated Press)

Most provincial and territorial highway traffic acts require Canadian medical doctors to report diagnosed sleep apnea to the motor vehicle licensing board. (In Alberta, Nova Scotia and Quebec, reporting is discretionary). The board temporarily suspends drivers' licences until they receive treatment and show progress.

Drivers must notify their auto insurers, as well, because "during the time of suspension the risk profile may have changed with regard to a new principal driver" of the person's vehicle, says James Geuzebroek, manager of media relations for the Insurance Bureau of Canada. For example, the principal driver taking over for the suspended sufferer of sleep apnea could be someone with a better or worse driving record, and this affects the insurance premium. Also, not reporting the driver change to the insurer "could void some of the coverage" if the new driver has an accident during the suspended period.

But what about the rights of the patient? Here lies the conundrum.

"Two-thirds of [OSA] patients never had an accident," says George. "Most people need a vehicle to get around. [It can be] a problem with living in a rural area. Every day I get angry patients who ask, 'Why did you pull my licence?' I have to do damage control."

A U.S. study led by Alan Pack and an Australian study led by Mark Howard found sleep apnea occurred in commercial motor vehicle drivers at rates of 17.6 per cent in the U.S. study and 15.8 per cent in the Australian study. The difficulty, says George, is determining which drivers will crash. He doesn't recommend screening all commercial drivers because of the magnitude and cost, plus "there is limited data on accident risk in CMVDs [commercial motor vehicle drivers]."

Treatment

Unfortunately, there's no easy fix.

"There are no pills we can give for sleep apnea," says George.

OSA treatment includes continuous positive airway pressure nasal therapy. A small machine moves air pressure through a nose mask to keep upper airways open while a person sleeps, preventing apnea and halting snoring.

Provincial health insurance provides partial coverage. Martin spent $1,040 for a continuous positive airway pressure machine; OHIP (the Ontario Health Insurance Plan) covered $780 and his private work insurance paid $260. CPAP reduced his nighttime apnea/respiratory events to fewer than 10 an hour.

For 20 per cent of patients put on CPAP, it doesn't work well, says George, but there are alternatives that might help them.

Alternatives include a weight control program for overweight patients with mild OSA, "because losing the weight can often get the airways open for the oxygen and can avoid the CPAP machine. Some patients benefit [from] using a dental device attached to top and bottom teeth. [It] pulls the lower jaw forward, pulls on the tongue and opens the airway," he says.

The Canadian Medical Association publishes tips for doctors in Determining Medical Fitness to Operate Motor Vehicles: CMA Driver's Guide 7th edition. The guide suggests telling patients about their condition privately, having spouses present for emotional support, talking to patients diplomatically and with respect, realizing that a patient's take on driving competence isn't always accurate, acknowledging previous good driving records, and stressing the need to stop driving because "medical conditions can make even the best drivers unsafe."

Patient's experiences

What happened to Martin?

He took an overnight polysomnogram test at a Toronto-area sleep clinic in December 2006. While sleeping, Martin's sleep cycles and stages were monitored. He was attached by electrodes to equipment measuring activity in his heart, lungs and brain, his oxygen levels and breathing patterns, and the movement of his limbs.

Martin reviewed the results with his family doctor in April 2007, then voluntarily surrendered his licence before seeing a respiratory specialist.

By that time, his wife, Jeanette, had banished him to the guest room.

"She told people it [snoring] was so loud that, if she smothered me in my sleep, she'd just have to play a tape of my snoring and no jury would EVER convict her," he says.

• On May 15, Martin saw a respiratory specialist who said being treated qualified him for licence reinstatement.
• On May 25, he collected his nasal therapy machine and within a week received notice of licence suspension starting June 1.
• On July 31, he had another polysomnogram.
• On Aug. 21, his specialist wrote to the Ministry of Transportation, requesting licence reinstatement.
• On Oct. 1, Martin received a temporary driver's licence with a note saying that he met the ministry's criteria for resumption of driving and could get back behind the wheel as of Sept. 28.
• In mid-October, his permanent licence arrived.

Martin says he didn't mind rising at 5:30 a.m. to ride three buses and a subway from his Richmond Hill home to his Toronto job from April until October. But there were other inconveniences that did bother him.

"I couldn't drive on our two-week camping trip to Sandbanks Provincial Park," he says. "Son brought trailer down and back; wife had to drive back via Highway 2. [She's] not a fan of 401."

What irked him in particular was losing his one current piece of photo identification. He had to negotiate with Casino Rama officials, for example, to let him use a newly expired passport.

George says the inconvenience to individuals is outweighed by public safety issues. "I'm not the licence police," he tells belligerent drivers.

He compares treatment with CPAP to treating diabetes with insulin, and points out that while there are people with OSA who never get into an accident, there are also "people who smoke all their life and die at a ripe old age. How can you assign risk? We don't want to pick up the pieces from a road disaster."

[an error occurred while processing this directive]