1. health and fitness
2. disorders
3. sleep disorders

Kørselsforbud - hvorfor lige mig?
Lægens dilemma verden rundt
Janko Moritz, Søvnapnøklinikken Slagelse
Fakta 1 søvnapnø (SA)

desaturation og hyperkapni

søvn fragmenteres

REM og dyb søvn reduceres

træthed og søvnighed

opmærksomhed og koncentration påvirkes

risiko for trafikuheld (aktiv) stiger med 2,52
(f.eks. Sassani A, Findley LJ, Kryger M, Goldlust E, George C, Davidson TM: Reducing
motorvehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome.
Sleep.2004;27:453-8)
Fakta 2 SA



kun 1/4 angiver søvnighed som hovedproblem
(3/4 manglende energi, motivation og
udmattelse)
mænd har højere risiko for ulykker end kvinder
med samme AHI
AHI og søvnighed, AHI og u-risiko hænger ikke
sammen
(Young T, Blustein J, Finn L, Palta M: Sleep-disordered breathing and motor vehicle accidents
in a population-based sample of employed adults. Sleep. 1997;20:608-13)
Kørselsforbud AHI- relateret?

Danmark:
”Hvis ansøger lider af søvnapnø i middelsvær til
svær grad (dvs. AHI >15), er fast natlig
behandling med CPAP/BiPAP en forudsætning
for at Sundhedsstyrelsen sædvanligvis kan
anbefale kørekort...”
USA
”lapse of consciousness”
UK
”excessiv daytime sleepiness”
Tyskland
”messbare auffällige Tagesschläfrigkeit”
søvnighed: vurdering

anamnese

egenvurdering: EPWORTH, Stanford-skala


reaktionstid: hurtige, nemme test (ca.15 min)
med referenceværdier, gratis på nettet, f.eks.

Psychomotor Vigilance Task (PVT)

Trail- Making- Test (TMT)

Wiener Testsystem
EEG baserede, tidskrævende us. (24 h):

MSLT, MWT
USA (CA) – UK – D
USA 1994: ad hoc
American Thoracic Society:
”Sleep Apnea, Sleepiness, and Driving Risk”
mht. kørselsforbud (KF):

lægens situation uoverskuelig og utryg

lægen bør ikke være myndighedernes værktøj

kategoriske løsninger anbefales ikke
USA 1994: ad hoc
”INTERACTIVE MODEL OF RESPONSIBILITIES”

læge + patient + kørekortkontor (KKK)

læge: detaljeret information, kontroller

patient: viser forståelse og ansvar

KKK: udtaler sig om evt. kørselsforbud, evt.
videregående us.
High risk driver (1994)
”...being that person with severe daytime
sleepiness accompanied by historic evidence of
an unintended motor vehicle crash”

alvorlig søvnighed i dagtimerne

utilsigtet trafikuheld i fortiden

behandles og kontrollers efter 2 måneder

ved non-compliance indberettes pt.
USA: situation i dag

50 delstater = 50 forskellige ordninger

permissive, funktionelle og kategoriske

lægen informerer pt.

juridiske konsekvenser

indberetter evt. til KKK

KKK afgør kørselsforbud
California 2012
California Code of regulation § 2806





(a) “... lapses of consciousness”...involve:
(1) a loss of consciousness or a marked reduction of alertness
or responsiveness to external stimuli; and
(2) the inability to perform one or more activities of daily living;
and
(3) the impairment of the sensory motor functions used to
operate a motor vehicle
(b) Examples of medical conditions that do not always, but may
progress to the level of functional severity described in
subsection (a) ... include... sleep apnea...”
California 2012
CCR § 2810

”...a physician and surgeon shall notify the local
health officer within seven (7) calendar days of
every patient 14 years of age or older, when a
physician and surgeon has diagnosed a
disorder characterized by lapses of
consciousness (Section 2806) in a patient...”
California 2012: KKK



No action
Medical probation Type II
(efter 3-5 måneder)
Medical probation Type III
(efter 6 måneder, gentages)

Suspension (tidsbegrænset, revurdering)

Revocation (for altid)
UK 2011 - Drive and Vehicle
Licensing Agency DVLA
”At a glance – for medical practitioners”
”SLEEP DISORDERS
Including Obstructive Sleep Apnoea syndrome causing excessive daytime /
awake time sleepiness
GROUP 1 (personbiler m.f.)
Driving must cease until satisfactory control of symptoms has been attained
GROUP 2 (lastbiler, busser m.f.)
Driving must cease until satisfactory control of symptoms has been attained,
with ongoing compliance with treatment, confirmed by consultant / specialist
opinion. Regular, normally annual, licensing review required. ”
UK 2011: Hvem har ansvaret ?
“1.The driver is legally responsible for informing the DVLA about such a
condition or treatment. However, if a patient has such a condition, you should explain to the
patient:
(a) that the condition may affect their ability to drive (if the patient is incapable of understanding this
advice, for example, because of dementia, you should inform the DVLA immediately), and
(b) that they have a legal duty to inform the DVLA about the condition.
2. If a patient refuses to accept the diagnosis, or the effect of the condition on their ability to drive,
you can suggest that they seek a second opinion, and help arrange for them to do so.
You should advise the patient not to drive in the meantime.
3. If a patient continues to drive when they may not be fit to do so,
you should make every
reasonable effort to persuade them to stop. As long as the patient agrees, you may
discuss your concerns with their relatives, friends or carers.
4. If you do not manage to persuade the patient to stop driving, or you discover that they are
continuing to drive against your advice, you should contact the DVLA
immediately and disclose any relevant medical information, in confidence, to the medical
adviser.
5. Before contacting the DVLA you should try to inform the patient of your decision to
disclose personal information. You should then also inform the patient in writing once you have
done so.”
UK 2011- kørselsforbud
”On receipt of all the required medical evidence...
a licence is accordingly issued or
revoked/refused.
The Secretary of State in the person of DVLA’s
medical advisers alone can make this decision.”
Tyskland 2007

Fahrerlaubnisverordnung (bilag 4):
SA
ubehandlet
SA
behandlet
KK personbiler
nej, hvis der er målbare
påfaldende søvnighed i
dagtimerne til stede
KK lastbiler
nej, hvis der er målbare
påfaldende søvnighed i
dagtimerne til stede
ja, hvis der er ikke
længere målbare
påfaldende søvnighed i
dagtimerne
ja, hvis der er ikke
længere målbare
påfaldende søvnighed i
dagtimerne;
regelmæssige kontroller
Tyskland 2007

hvordan målbar ?

hvad mener ”påfaldende” ?

hvilken kontrol og hvornår?

tavshedspligten tillader ikke indberetning

ingen revurdering af kørekort

ergo: diagnose SA faktisk uden konsekvens
resume
KF AHIbaseret
DK
hvem
hvem
kontrolperiode
pålægger KF indberetter SA
ja (>15)
læge (KKK)
ingen (læge)
6 måneder
nej
KKK
læge
min. 3 mån.
GB
nej
KKK
patient
ikke fastlagt
D
nej
(KKK)
ingen
ikke fastlagt
USA
(CA)