driving and · pdf filedriving and epilepsy • significance of driving for people with...
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Driving and Epilepsy
Allan Krumholz, MD
VA Maryland Health Care System
Department of Neurology
University of Maryland School of
Medicine
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Driving and Epilepsy
• Significance of driving for people with epilepsy
and others
• History of restrictions on driving by people
with seizures
• Driving risk of seizures
• Laws and regulations governing drivers with
seizures
• Physician’s role
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USA: Importance of Driving
• More cars and trucks than people of driving age.*
• In 1969, 30% of two adult households had two or more cars; in 1990 it was up to 76%*
• Only 8% of US households have no vehicles*
• Of workers, 73% drive themselves to work and 13% carpool (only 5% use public transport.)*
• Of 180 million Americans licensed to drive, 700,000 have epilepsy
*Bureau of Transportation Statistics-2003
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Driving and Epilepsy: Affects
• People with epilepsy and seizures
• State and federal regulators
• Health Providers (Physicians)
• Public
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Epilepsy and Driving: Patient
Concerns Social
function
Employment
Psychological
function
(self-
esteem)
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Driving: major listed concern of
people with epilepsy
Gilliam et al, Epilepsia, 1997
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Epilepsy and Driving: Physician
Concerns
• Advisors to patients
• Information for
regulators
• Consultants to
regulators
• Legal jeopardy
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Epilepsy and Driving: the
Dilemma
How to protect the public’s
safety while still providing
reasonable opportunities for
people with controlled seizures
to drive?
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History of Driving and Epilepsy
• Late 1800s – Automobiles introduced
• 1906 – First automobile crash and death due to a seizure
• Therefore when licenses become obligatory for driving a car, people with epilepsy or seizures are excluded.
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History of Driving and
Epilepsy -2 • 1940s- With introduction
of the EEG and phenytoin, epilepsy better understood and potentially “curable”
• 1949 –Wisconsin is the first state to permit some people with controlled seizures drive an automobile.
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History of Driving and Epilepsy -3
• 1970s – All US states grant licenses to some
people with epilepsy or seizures
• 1980s to today – Trend to liberalize restrictions
on driving and epilepsy in the US and
worldwide.
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Driving and Epilepsy-2014
• USA- all states permit driving by some people
with epilepsy, but standards and rules vary
widely.
• European Union- has adopted the standard of
an one year seizure-free interval
• India, Brazil, and Russia- prohibit driving for all
with epilepsy
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Risk of Driving with Seizures
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Risk of Driving with Seizures
and Epilepsy • Seizures while driving*
• Crashes due to seizures while driving*
• Deaths due to seizures while driving*
• Sedative effects of antiepileptic
medications impairing driving
• Crash rates in drivers with epilepsy**
** Most data available * Some data available
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Risks
• “Acceptable Risks” are hard to agree upon
(e.g.) Prior to the hurricane Katrina, the risk
of New Orleans’ levees failing was 1 every 200
years or more and it was accepted, but in 2005
when it really happened, it was an
unacceptable risk.
• “Accepted Risks” are part of our lives and can be
measured and compared, even when they may
seem unacceptable.
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The Bubble Boy – Motion Picture Film 2001
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Risk Assessment
• Situation Motorcycling Smoking Influenza Auto driving (UK) Leukemia Drinking (1btl wine/day) Struck by auto Taking contraceptive pills Floods Earthquake (California) Lightening (UK) Release from a nuclear reactor
• Death/Person/Year(Odds) 1 in 50 1 in 200 1 in 5,000 1 in 5,900 1 in 12,500 1 in 13,300 1 in 20,000 1 in 50,000 1 in 45,000 1 in 588,000 1 in 10 million 1 in 10 million
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Risk of Driving with Seizures
and Epilepsy • Seizures while driving*
• Crashes due to seizures while driving*
• Deaths due to seizures while driving*
• Sedative effects of antiepileptic
medications impairing driving
• Crash rates in drivers with epilepsy**
** Most data available * Some data available
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Comparative Risk of Driving Accidents for
People with Epilepsy* (~2X expected)
02468
1012141618
Epile
psy
Vas
c
Dia
betes
Men
tal i
llnes
s
Expected
Observed
*Known to MVA as drivers with epilepsy complying with rules
Majority of crashes related to driver error and not medical impairment
Hansiota et al., NEJM 1991
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Crash Rates by Age and Sex for
Epileptic Drivers
(per 100 drivers over 10 years)
0
10
20
30
40
50
60
70
15-25yrs 25-45 yrs 45-65yrs >65yrs
All Male
All Female
Male/Epilepsy
Female/Epilepsy
Washington State 1967-1976
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Risk of Driving with Seizures
and Epilepsy • Seizures while driving*
• Crashes due to seizures while driving*
• Deaths due to seizures while driving*
• Sedative effects of antiepileptic
medications impairing driving
• Crash rates in drivers with epilepsy**
** Most data available * Some data available
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Comparative Risks
(Traffic Accidents)
• 1/10,000 related to epilepsy*
• 1,000/10,000 related to alcohol*
• 6/10,000 related to sudden cardiac death
behind the wheel
*Van der Lugt, Epilepsia 1975
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Risk of Crashing Due to Seizures* • Of 367 patients with intractable seizures
presenting as candidates for epilepsy surgery, 115 (31%) had driven in the last year and 237 (65%) had ever been licensed to drive.
• 144 (39%) had a seizure while driving and 98 (27%) had a crash due to a seizure
• Of drivers with crashes due to seizures, 80% reported only 1; 10%, 2; and 10%>3.
• 94% of crashes involved property damage; 32% moderate or severe medical injuries to the driver; and 20% moderate or severe injuries to others; no deaths
*Berg et al., Neurology 2000
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Risk of Driving with Seizures
and Epilepsy • Seizures while driving*
• Crashes due to seizures while driving*
• Deaths due to seizures while driving*
• Sedative effects of antiepileptic
medications impairing driving
• Crash rates in drivers with epilepsy**
** Most data available * Some data available
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Comparative Risks
(Traffic Deaths)*
• 1 per 10,000 related to epilepsy
• 4,000 per 10,000 related to alcohol
*Van der Lugt, Epilepsia 1975
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Problems and Risks of
Restricting Drivers with Epilepsy
• Loss of employment
• Social consequences
• Psychological consequences
• Noncompliance with regulations
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Noncompliance with Driving
Regulations • 40% to 60% of patients with epilepsy who
drive do not report this condition to authorities.
Harsher restrictions = Lower compliance
Less harsh restrictions = Higher compliance
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French Seizure Clinic Study of 400 Drivers
with Epilepsy*
• > Weekly seizures reported by 23% of drivers
• > Monthly seizures reported by 46% of drivers
• 33% report a seizure while driving
• 17% reported a crash due to a seizure while driving
• 2 deaths due to seizure related crashes
*Gastaut and Zifkin, Neurology 1987 (study conducted at a
time that driving by people with epilepsy was severely
restricted in France)
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Sometimes
risk
is predictable
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Factors Predictive of Seizure
Recurrence Risk • Recent history of seizure control
• Type of seizures or epilepsy
• Total number of seizures
• Associated neurological deficits
• EEG abnormalities
• MRI/CT lesions
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Conclusion: Epilepsy and Driving
• Public safety risks not unacceptably high
• Individual risks elevated but similar to other less regulated medical disorders, and much less than alcohol
• Seizure-related crashes potentially predictable and preventable
• Restricting drivers with epilepsy is appropriate, but optimal restriction have not prospectively validated
Krumholz, JAMA 1991
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Rules for Driving with Epilepsy
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Rules Determining Driving for
the Person with Epilepsy in the
USA • Federal laws
• State laws*
• State Motor Vehicle Department
regulations*
• State policies, procedures, and practices
• State or Federal case or common law
Krumholz et al., JAMA 1991
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Varied State Rules and
Regulations • Seizure-free interval*
• Physician mandatory reporting
• Physician immunity for reporting or
advising motor vehicle administration
• Mitigating circumstances (e.g. – physician
recommended reduction of meds or 1st sz)
• Commercial intrastate drivers
Krauss, Ampaw, Krumholz, Neurology 2001
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Seizure-free restrictions for non-commercial driving: U.S. states
Seizure free requirement 3 months 6 months 12 months Flexible restriction
2002
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Seizure-Free Requirement (# of
States in USA)
0
2
4
6
8
10
12
14
16
3
months
6
months
1 year > 1 year Variable None
Based on 2001
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Crash risk decreases progressively
with longer seizure-free intervals
85%93%
57%
> 3 mo > 6 mo** >12 mo**
Seizure Free Interval
% R
ed
uced
Ris
k
Note: seizure-free cutoffs are from separate multivariate models of crash odds
**p<0.05
Krauss, Krumholz et al., Neurology, 1999
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Potential tradeoffs: seizure-free intervals*
*
1 yr sz-free = eliminates 80% of crashed
drivers but also 50% not crashing lose
driving privilege
3 mos sz-free = eliminates 50% of
crashed drivers and only 25% not
crashing lose their driving privilege
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Months of seizure free interval
.01
.02
.03
.04
.05
.06
.07
.08
.09
.1
.11
.12
.13
.14
rates
0 3 6 12
0 = uncertain period
3 = 3 months of restrictions
6 = 6 months of restrictions
12 = 12 months of restrictions
Rates of
fatal
crashes
per
100,000
pop/year
Whisker-box plots for rates of fatal crashes according to months of seizure free intervals
required for driving laws in different states in US. 0 indicates no particular requirement.
Seth, 2004
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Noncompliance with Driving
Regulations • 40% to 60% of patients with epilepsy who drive
do not report this condition.
Harsher restrictions = Lower compliance
Less harsh restrictions = Higher compliance
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AAN, AES, EF Consensus on
Driving and Epilepsy (1991)* • A seizure-free interval should be stated: 3
months is preferred.
• Both favorable and unfavorable modifiers modifiers could alter this interval (individualized determinations)
• Physicians should not be required to report patients to the DMV (physician immunity)
• Patients should be responsible to self-report
Epilepsia, 1994
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Mandatory Physician Reporting
States • California
• Delaware
• Nevada
• New Jersey
• Oregon
• Pennsylvania
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Give it to me straight Doc. How
long do I have to ignore your driving
advice?
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Mandatory Reporting of
Epilepsy or Seizures • Not clear that mandatory reporting
reduces crash risk, but some recent
evidence supports that it does for many
medical conditions - not just epilepsy*
• Even in jurisdictions with mandatory
reporting, it may be inconsistent
• Interferes with patient/physician
communication, honest reporting of
seizures, and optimal treatment
* Redelmeier et al,. NEJM 2012;367:1128-36
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Physician warnings for unfit drivers and
the risk of trauma from road crashes*
• Encouraged by Ontario (Canada) financial incentives
($36) to warn and report
• Over 100,000 patients reported followed for 4 years
• 45% reduction in annual crashes in the subsequent 1
year for drivers with alcoholism, epilepsy**, dementia,
sleep disorders, fainting, stroke, diabetes, depression
• Adverse patient effects – 1. significant increase in
depression, 2. compromise doctor/patient relationship,
3. still does not reduce patient crash risk to that of the
general population
* Redelmeier et al, NEJM 2012;367:1128-36
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Consensus Statement (AAN,
AES, EFA) (1991)- Modifiers Favorable:
1. Seizure during medically directed medication change
2. Seizures related to a reversible acute illness
3. Simple partial seizures that do not interfere with consciousness or motor function
4. Seizures with persistent prolonged auras
5. Purely nocturnal seizures
6. Sleep deprived seizures
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Consensus Statement (AAN,
AES, EFA) (1991)- Modifiers Unfavorable
1. Noncompliance with medication, medical visits and/or lack of credibility
2. Recent alcohol or drug abuse
3. Prior bad driving record
4. Prior crashes due to seizures
5. Frequent seizures after seizure-free interval
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Driving and Epilepsy:
Recommendations for MDs • Be familiar with and follow state rules and
regulations
• Notify patient of those rules and their risks
• Document discussion of rules with patient in records
• Refer patients to other resources such as the Epilepsy Foundation for further support and advice
• Support clarification, improvements, scientific study and validation of the systems used and rules applied
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Public Policy Solutions • Improve transportation alternatives to cars for
• impaired drivers- Public Transportation.
• Smart cars and highways (Google)
• Improve and use crash and mortality data systems to monitoring risks and assess effectiveness of rules and regulations