The decision not to drive during hypoglycemia in patients with type 1 and type 2 diabetes according to hypoglycemia awareness

Sugar and stops in drivers with insulin-dependent type 1 diabetes

BACKGROUND

Diabetes is a major public health challenge, affecting millions of people worldwide. Abnormal physiology in diabetes, particularly hypoglycemia, can cause driver impairments that affect safe driving. While diabetes driver safety has been previously researched, few studies link real-time physiologic changes in drivers with diabetes to objective real-world driver safety, particularly at high-risk areas like intersections. To address this, we investigated the role of acute physiologic changes in drivers with type 1 diabetes mellitus (T1DM) on safe stopping at stop intersections.

METHODS

18 T1DM drivers (21-52 years, μ = 31.2 years) and 14 controls (21-55 years, μ = 33.4 years) participated in a 4-week naturalistic driving study. At induction, each participant's personal vehicle was instrumented with a camera and sensor system to collect driving data (e.g., GPS, video, speed). Video was processed with computer vision algorithms detecting traffic elements (e.g., traffic signals, stop signs). Stop intersections were geolocated with clustering methods, state intersection databases, and manual review. Videos showing driver stop intersection approaches were extracted and manually reviewed to classify stopping behavior (full, rolling, and no stop) and intersection traffic characteristics.

RESULTS

Mixed-effects logistic regression models determined how diabetes driver stopping safety (safe vs. unsafe stop) was affected by 1) disease and 2) at-risk, acute physiology (hypo- and hyperglycemia). Diabetes drivers who were acutely hyperglycemic (≥ 300 mg/dL) had 2.37 increased odds of unsafe stopping (95% CI: 1.26-4.47, p = 0.008) compared to those with normal physiology. Acute hypoglycemia did not associate with unsafe stopping (p = 0.537), however the lower frequency of hypoglycemia (vs. hyperglycemia) warrants a larger sample of drivers to investigate this effect. Critically, presence of diabetes alone did not associate with unsafe stopping, underscoring the need to evaluate driver physiology in licensing guidelines.

CONCLUSION

This study links acute, abnormal physiologic fluctuations in drivers with diabetes to driver safety based on unsafe stopping at stop-controlled intersections, providing recommendations for clinicians aimed at improving patient safety, fair licensing guidelines, and targets for developing advanced driver assistance systems.

Diabetes and driving safety: A survey among health care professionals in Saudi Arabia

AIMS

Diabetes mellitus may impair an individual's fitness to drive. In this study, we explore health care providers' (HCPs) knowledge of problems associated with diabetes and driving, and evaluate the consistency of counseling on driving safety for patients with diabetes.

METHODS

We conducted a cross-sectional survey-based study among HCPs in Saudi Arabia. We designed a web-based questionnaire to collect demographic data, assess HCPs' knowledge of driving and diabetes and their compliance with driving safety regulations, and meet Diabetes Canada's and the British Driver and Vehicle Licensing Agency's recommendations. Data were analyzed using descriptive statistics and chi-square analysis.

RESULTS

We received 389 responses to the questionnaire. The majority of the respondents were consultants (38.8%), worked in governmental institutes (72.2%), and managed more than 30 patients weekly (34.4%). Only 5.7% of HCPs correctly answered all the driving safety questions. Diabetes educators and general practitioners had the fewest correct answers (p-value 0.03). About 12.6% of HCPs stated that they always counseled their patients about driving safety strategies.

CONCLUSION

HCPs' education in problems associated with diabetes and driving should be improved to ensure quality counseling for their patients.

Age-Related Diseases and Driving Safety

Due to demographic changes, the number of older drivers is steadily increasing. Mobility is highly relevant for leading an independent life in the elderly. It largely depends on car driving, which is a complex task requiring a multitude of cognitive and motor skills vulnerable to age- related functional deterioration. The almost inevitable effects of senescence may be potentiated by age-related diseases, such as stroke or diabetes mellitus. Respective pharmacological treatment may cause side effects, additionally affecting driving safety. The present article reviews the impact of age-related diseases and drug treatment of these conditions on driving fitness in elderly drivers. In essence, we focus on diseases of the visual and auditory systems, diseases of the central nervous system (i.e., stroke, depression, dementia and mild cognitive disorder, and Parkinson's disease), sleep disorders, as well as cardiovascular diseases, diabetes mellitus, musculoskeletal disorders, and frailty. We will outline the role of functional tests and the assessment of driving behavior (by a driving simulator or in real traffic), as well as the clinical interview including questions about frequency of (near) accidents, etc. in the evaluation of driving fitness of the elderly. We also address the impact of polypharmacy on driving fitness and end up with recommendations for physicians caring for older patients.

Type 2 diabetes can undermine driving performance of middle-aged male drivers through its deterioration of perceptual and cognitive functions

It has been widely agreed that it is risky for patients with diabetes to drive during hypoglycemia. However, driving during non-hypoglycemia may also bring certain safety hazards for some patients with diabetes. Based on previous studies on diabetes-related to early aging effect, as well as gender differences in health belief and driving behavior, we have hypothesized that middle-aged male drivers with type 2 diabetes, compared with the control healthy ones, may experience a decline in driving performance without awareness. And the decline is caused by impaired perceptual and cognitive driving-related functions. To verify these hypotheses, we recruited 56 non-professional male drivers aged between 40 and 60 (27 patients with type 2 diabetes and 29 healthy controls) to perform a simulated car-following task and finish behavioral tests of proprioception, visual search, and working memory abilities during non-hypoglycemia. They also reported their hypoglycemia experience and perceived driving skills. We found that the patients had equal confidence in their driving skills but worse driving performance as shown in larger centerline deviation (t = 2.83, p = .006), longer brake reaction time (t = 3.77, p = .001) and shorter minimum time-to-collision (t = -3.27, p = .002). Such between-group differences in driving performance could be fully mediated by proprioception, visual search ability, and working memory capacity but not by hypoglycemia experience. Regarding the effect sizes of the mediation, the visual search ability played the most important role, and then followed the working memory and the proprioception. This initial study provides original and first-hand evidence demonstrating that the middle-aged male drivers with type 2 diabetes have deteriorated driving performance, but they are unaware of it. We will also discuss the possible measures to identify people of the highest risk and improve their safety awareness by using the findings of the current study.

Hypoglycemia, diabetes therapies and driving categories in type 2 diabetes

OBJECTIVE

To assess the experiences of hypoglycemia in drivers with type 2 diabetes according to types of diabetes treatment; to determine experiences in different driving groups; and to ascertain whether UK-based Driving and Vehicle Licensing Agency (DVLA) guidance concerning hypoglycemia and driving is understood. Research, design, and methods: An online questionnaire was sent to UK drivers with type 2 diabetes between June and September 2014. Study limitations included selection bias inherent in online surveys, and lack of validation of the definition of hypoglycemic symptoms by an expert patient group.

RESULTS

The survey was completed by 1569 (457 social, 590 commuters, and 522 business/work) drivers. Vocational drivers were more likely to be treated with an insulin secretagogue (sulfonylureas and glinides) (52%) than diet alone (18%), a non-insulin secretagogue (26%) or insulin (16%). Symptoms of hypoglycemia (both mild and severe) were reported by 62% of the total cohort in the past year. Risk was greatest in those with poor diabetes self-management behavior and those receiving an insulin secretagogue. Among the 1112 respondents commuting or driving for a living, 16.8% had poor, 49.6% average, and 33.6% good diabetes self-management. Poor self-management was more frequent among vocational drivers and those receiving insulin secretagogues. Following a hypoglycemic episode, only 24% of insulin-secretagogue-treated drivers and 39% of insulin-treated drivers would discontinue driving for the DVLA-recommended 45 minutes. Insulin-treated drivers were best informed about diabetes and driving. Healthcare providers were the preferred source of information on driving and diabetes for 78% of drivers.

CONCLUSION

Hypoglycemia risk is highest among drivers with poor diabetes self-management, those commuting or driving for a living and those taking insulin secretagogues. There is an educational need for all drivers concerning driving and hypoglycemia.

Driving and diabetes: problems, licensing restrictions and recommendations for safe driving

Driving is a complex process that places considerable demands on cognitive and physical functions. Many complications of diabetes can potentially impair driving performance, including those affecting vision, cognition and peripheral neural function. Hypoglycemia is a common side-effect of insulin and sulfonylurea therapy, impairing many cognitive domains necessary for safe driving performance. Driving simulator studies have demonstrated how driving performance deteriorates during hypoglycemia. Driving behavior that may predispose to hypoglycemia while driving is examined. Studies examining the risk of road traffic accidents in people with insulin-treated diabetes have produced conflicting results, but the potential risk of hypoglycemia-related road traffic accidents has led to many countries imposing restrictions on the type and duration of driving licenses that can be issued to drivers with diabetes. Guidance that promotes safe driving practice has been provided for drivers with insulin-treated diabetes, which is the group principally addressed in this review.

Interventions That Restore Awareness of Hypoglycemia in Adults With Type 1 Diabetes: A Systematic Review and Meta-analysis

OBJECTIVE

Impaired awareness of hypoglycemia (IAH) increases the risk of severe hypoglycemia (SH) sixfold and affects 30% of adults with type 1 diabetes (T1D). This systematic review and meta-analysis looks at the educational, technological, and pharmacological interventions aimed at restoring hypoglycemia awareness (HA) in adults with T1D.

RESEARCH DESIGN AND METHODS

We searched The Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, Social Sciences Citation Index, PsycINFO, and CINAHL from inception until 1 October 2014. Included studies described HA status at baseline. Outcome measures were SH rates, change in HA, counterregulatory hormone responses, and glycemic control.

RESULTS

Forty-three studies (18 randomized controlled trials, 25 before-and-after studies) met the inclusion criteria, comprising 27 educational, 11 technological, and 5 pharmacological interventions. Educational interventions included structured diabetes education on flexible insulin therapy, including psychotherapeutic and behavioral techniques. These were able to reduce SH and improve glycemic control, with greater benefit from the latter two techniques in improving IAH. Technological interventions (insulin pump therapy, continuous glucose monitoring, and sensor-augmented pump) reduced SH, improved glycemic control, and restored awareness when used in combination with structured education and frequent contact. Pharmacological studies included four insulin studies and one noninsulin study, but with low background SH prevalence rates.

CONCLUSIONS

This review provides evidence for the effectiveness of a stepped-care approach in the management of patients with IAH, initially with structured diabetes education in flexible insulin therapy, which may incorporate psychotherapeutic and behavioral therapies, progressing to diabetes technology, incorporating sensors and insulin pumps, in those with persisting need.

Transport, driving and ageing

Transport is the invisible glue that holds our lives together, an under-recognized contributor to economic, social and personal well-being. In public health terms, the medical profession had previously allowed itself to focus almost exclusively on the downsides of transport. However, the research basis for transport, driving and ageing is steadily evolving and has important academic and practical considerations for gerontologists and geriatricians. For gerontologists, teasing out the critical role of transport in the health and well-being of older people is an imperative, as well as the key challenges inherent in transitioning from driving to not driving. The safe crash record of a group with significant multi-morbidity allows us to focus on the remarkable strategic and adaptive skills of older people. From a policy perspective, strictures on older drivers are an exemplar of institutionalized ageism. For geriatricians, a key challenge is to develop strategies for including transportation in our clinical assessments, formulating effective strategies for assessment of medical fitness to drive, incorporating enabling techniques, giving due consideration to ethical and legal aspects, and developing and promoting multi-modality and alternative transportation options.

The influence of new European Union driver's license legislation on reporting of severe hypoglycemia by patients with type 1 diabetes

OBJECTIVE

We test the hypotheses that the implementation in Denmark of new, stricter European Union (EU) legislation on driver's licensing, with the purpose to improve traffic safety in January 2012, has reduced the self-reported rate of severe hypoglycemia in a routine clinical setting and that anonymous reporting results in higher event rates.

RESEARCH DESIGN AND METHODS

A cohort of 309 patients with type 1 diabetes was recruited in the outpatient clinic at Nordsjællands University Hospital Hillerød, Denmark. Yearly numbers of severe hypoglycemic events defined by need for treatment assistance from another person were retrieved from medical records in the years 2010 to 2012 and retrospectively reported in an anonymous questionnaire. Data from medical records in 2012 were compared with those from 2010 and 2011 and with data from the questionnaire.

RESULTS

Reported rates of severe hypoglycemia in the medical records were reduced by 55% in 2012 compared with the prior years (P = 0.034). The proportion of subjects reporting recurrent episodes was grossly reduced from 5.6 to 1.5% (P = 0.014). Compared with anonymous reporting in the questionnaire, the rate of severe hypoglycemia in 2012 was 70% lower (P < 0.001).

CONCLUSIONS

Reporting of severe hypoglycemia by patients with type 1 diabetes is significantly reduced following implementation of EU driver's licensing legislation that implies withdrawal of driver's licensing in case of recurrent episodes within 1 year. The resulting burden of concealed severe hypoglycemia may impair the safety of affected patients and unintentionally paradoxically reduce the general traffic safety.

Recurrent Hypoglycemia Increases Anxiety and Amygdala Norepinephrine Release During Subsequent Hypoglycemia

Recurrent hypoglycemia (RH) is a common and debilitating side effect of therapy in patients with both type 1 and, increasingly, type 2 diabetes. Previous studies in rats have shown marked effects of RH on subsequent hippocampal behavioral, metabolic, and synaptic processes. In addition to impaired memory, patients experiencing RH report alterations in cognitive processes that include mood and anxiety, suggesting that RH may also affect amygdala function. We tested the impact of RH on amygdala function using an elevated plus-maze test of anxiety together with in vivo amygdala microdialysis for norepinephrine (NEp), a widely used marker of basolateral amygdala cognitive processes. In contrast to findings in the hippocampus and prefrontal cortex, neither RH nor acute hypoglycemia alone significantly affected plus-maze performance or NEp release. However, animals tested when hypoglycemic who had previously experienced RH had elevated amygdala NEp during plus-maze testing, accompanied by increased anxiety (i.e., less time spent in the open arms of the plus-maze). The results show that RH has widespread effects on subsequent brain function, which vary by neural system.

Diabetes and driving

The principal safety concern for driving for people treated with insulin or insulin secretagogues is hypoglycaemia, which impairs driving performance. Other complications, such as those causing visual impairment and peripheral neuropathy, are also relevant to medical fitness to drive. Case control studies have suggested that drivers with diabetes pose a modestly increased but acceptable and measurable risk of motor vehicle accidents compared to non-diabetic drivers, but many studies are limited and of poor quality. Factors which have been shown to increase driving risk include previous episodes of severe hypoglycaemia, previous hypoglycaemia while driving, strict glycaemic control (lower HbA1c) and absence of blood glucose monitoring before driving. Impaired awareness of hypoglycaemia may be counteracted by frequent blood glucose testing. The European Union Third directive on driving (2006) has necessitated changes in statutory regulations for driving licences for people with diabetes in all European States, including the UK. Stricter criteria have been introduced for Group 1 vehicle licences while those for Group 2 licences have been relaxed. Insulin-treated drivers can now apply to drive Group 2 vehicles, but in the UK must meet very strict criteria and be assessed by an independent specialist to be issued with a 1-year licence.

Hypoglycemia in patients with diabetes who are fasting for laboratory blood tests: the Cape Girardeau Hypoglycemia En Route Prevention Program

OBJECTIVE

Patients with diabetes are routinely asked to fast for laboratory tests. If not properly prepared, they may be at risk for hypoglycemia, which may result in traffic accidents while driving en route to and from laboratory facilities. We undertook this study to evaluate the magnitude of this overlooked problem, and to evaluate the effectiveness of a prevention program implemented in our clinic.

METHODS

A retrospective study consisting of chart reviews and telephone interviews of consecutive hypoglycemic events (blood glucose level < 70 mg/dL). The study cohorts, A and B, were extracted from our central laboratory database. Cohort A (from January 2008-September 2009) consisted of patients prior to--and cohort B (from October 2009-June 2011) subsequent to--the implementation of a prevention program involving blood glucose monitoring and adjustment of antidiabetic medications. Duration of each cohort was 21 months. For the purpose of this article, we use the acronym FEEHD (fasting-evoked en-route hypoglycemia in diabetes) to describe this overlooked form of hypoglycemia.

RESULTS

Of a total of 1801 blood glucose test results retrieved, cohort A included a total of 55 hypoglycemic events in 51 patients (4 patients with 2 events each). Cohort B included a total of 23 hypoglycemic events in 22 patients (with 1 patient sustaining 2 events) out of a total of 2561 blood glucose test results retrieved. In cohort A, of 35 patients on antidiabetic medications who recalled fasting or probably fasting, there were 39 hypoglycemic events (2.2% frequency), compared with 18 events (0.7% frequency) in 17 patients in cohort B. This indicates a 68% risk reduction. The frequency of critical hypoglycemia (< 50 mg/dL) was more significantly reduced, from 11 events (0.6%) to 2 events (0.07%), indicating a risk reduction of 88%.

CONCLUSION

This study showed a 68% risk reduction of FEEHD with implementation of the prevention program, and an 88% reduction of severe FEEHD (blood glucose level < 50 mg/dL). Reporting on the first prevention program of its kind, this is the first study to evaluate an overlooked safety problem in diabetes management. Clinicians should consider if fasting laboratory tests are in fact necessary, and when ordered, clinicians should properly instruct their patients on adequate blood glucose monitoring and adjustment of antidiabetic medications. We present the guidelines that proved effective in our program to help patients with diabetes and their clinicians avert this potentially harmful complication.

Survey of migraine sufferers with dogs to evaluate for canine migraine-alerting behaviors

OBJECTIVES

Anecdotal reports suggest that changes in dog behavior might be used to predict impending migraine episodes. This survey was designed to investigate how companion dogs react to migraines that occur in their owners.

DESIGN

Online survey was available from January 4-31, 2012.

SETTINGS/LOCATION

Survey was conducted through SurveyMonkey, with links to the survey posted at Migraine.com and promoted through social media.

SUBJECTS

Adults ≥18 years old who experience migraine episodes and live with a dog were eligible to participate.

INTERVENTIONS AND OUTCOME MEASURES

Participants completed an 18-question online survey that asked about participant demographics, migraines, and their dog's behavior before or during migraine episodes.

RESULTS

The survey was completed by 1029 adult migraineurs (94.9% women), with migraines typically occurring ≤8 days per month in 63.4% of participants. A recognized change in the dog's behavior prior to or during the initial phase of migraine was endorsed by 552 participants (53.7%), most commonly unusual attentiveness to the owner (39.9%). Among the 466 participants providing details about their dog's behavior with their migraines, 57.3% were able to identify dog alerting behavior before symptoms of a migraine attack would typically begin, with changes usually noticed within 2 hours before the onset of initial migraine symptoms. The dog's behavior was considered to be often or usually linked with the development of a migraine for 59.2% of migraineurs, and 35.8% of migraineurs endorsed beginning migraine treatments after the dog's behavior was recognized and before migraine symptoms had started. Participant demographics, migraine frequency, and breed of dog in the home were similar between the 470 participants with no alerting behavior endorsed and the 466 participants providing detailed alerting information.

CONCLUSIONS

About one in four migraineurs living with a companion dog endorsed recognizing a change in their dog's behavior before recognizing initial symptoms of a migraine attack.

Harvesting experiential expertise to support safe driving for people with diabetes mellitus: a qualitative study evaluated by peers in a survey

BACKGROUND

Hypoglycemia is a frequent phenomenon in people being treated for diabetes mellitus, which can acutely disrupt driving performance. For the benefit of personal and public traffic safety, we decided to identify successful diabetes-related (SDR) behaviors to support safe driving for people with diabetes, from the perspective of experiential experts with diabetes mellitus. Experiential experts are people who can manage their own illness and conditions by developing expertise relevant to maintaining health and countering illness, and who are able to use this expertise to the benefit of peers.

OBJECTIVE

The aim of our study was to objectify and systematize experiential expertise in terms of SDR behaviors, based on reports by experiential experts, to support safe driving for people with type 1 and type 2 diabetes mellitus. The emphasis was on preventing hypoglycemia as a short-term complication during driving.

METHODS

We performed a mixed-methods study involving (i) semi-structured in-depth interviews with 33 experiential experts with diabetes mellitus from the Dutch Diabetes Association (DVN; Diabetesvereniging Nederland), in order to identify SDR behaviors regarding safe driving, and (ii) a validation study by means of a survey among a panel of 98 experiential experts (peers) from the DVN, to determine the extent to which they agreed with the communicability, importance, and feasibility of these behaviors for drivers with diabetes mellitus.

RESULTS

We identified a comprehensive set of 11 SDR behaviors, differentiated into seven general and four specific behaviors, to support safe driving. The general behaviors concern the following topics: (i) acquiring knowledge and information; (ii) acquiring and using self-measuring of blood glucose (SMBG) equipment; (iii) knowing one's physical response pattern; (iv) obtaining knowledge about the medication used; (v) preventing long-term eye complications; (vi) influencing factors that can affect blood glucose; and (vii) renewal procedure for driving license. The four specific behaviors refer to the following topics: (i) measures to be taken before driving; (ii) responding effectively to hypoglycemia while driving; (iii) informing and instructing passengers; and (iv) preventing hypoglycemia in drivers with type 2 diabetes mellitus not using SMBG equipment. Key factors for safe driving proved to be the ability of drivers to anticipate and respond effectively to hypoglycemia while driving and to inform and instruct fellow passengers. Participants of the validation survey agreed to a considerable degree with the communicability, importance, and feasibility of these behaviors to support safe driving for people with diabetes mellitus.

CONCLUSIONS

This study resulted in the identification and description of SDR behaviors to support safe driving. It proved possible to operationalize experiential expertise in terms of such behaviors. The next step is to have these behaviors validated by professional care providers in the field of diabetes, followed by translation into recommendations in self-management programs.

Exploring the meaning of hypoglycaemia to community-dwelling Singaporean Chinese adults living with type 2 diabetes mellitus

This study aimed to explore how community-dwelling Singaporean Chinese adults diagnosed with type 2 diabetes mellitus experience hypoglycaemia. A qualitative interpretive research design was employed. Semi-structured interviews were conducted with six participants from a Singaporean diabetes specialist outpatient clinic, transcribed verbatim and analysed using qualitative manual thematic analysis. Eight major themes emerged: experiencing symptoms, knowing hypoglycaemia is manageable, using acute measures, using preventative strategies; applying knowledge, identifying causes of hypoglycaemia, forming relationships and working with health-care professionals. Participants underestimated the impact of hypoglycaemia mainly due to their experiencing mild and infrequent episodes, and knowledge deficits. Health-care professionals' roles were limited to information providers, and they were perceived as detached and impersonal. Theimplications are that health-care professionals need to provide more client-focused education, and improve the quality of their interpersonal relationships to ensure shared decision-making with their clients.

The impact of hypoglycaemia on quality of life and related patient-reported outcomes in Type 2 diabetes: a narrative review

As a common side effect of insulin treatment for diabetes, hypoglycaemia is a constant threat and can have far-reaching and potentially devastating consequences, including immediate physical injury as well as more pervasive cognitive, behavioural and emotional effects. Moreover, as a significant limiting factor in achieving optimal glycaemic control, exposure to hypoglycaemia can influence diabetes self-management. Although hypoglycaemia is known to occur in Type 2 diabetes, its morbidity and impact on the individual are not well recognized. The aim of the current review is to examine published evidence to achieve a synthesis of the scope and significance of the potential detriment caused by hypoglycaemia to individuals with Type 2 diabetes. The implications of these observations for treatment and research have also been considered. A narrative review was performed of empirical papers published in English since 1966, reporting the effect of hypoglycaemia on quality of life and related outcomes (including generic and diabetes-specific quality of life, emotional well-being and health utilities) in Type 2 diabetes. Research demonstrates the potential impact of hypoglycaemia on the lives of people with Type 2 diabetes, from an association with depressive symptoms and heightened anxiety, to impairment of the ability to drive, work and function in ways that are important for quality of life. Few studies consider hypoglycaemia as an explanatory variable in combination with quality of life or related primary endpoints. As a consequence, there is a pressing need for high-quality research into the overall impact of hypoglycaemia on the lives of people with Type 2 diabetes.

Effects of dexamphetamine with and without alcohol on simulated driving

RATIONALE

In party circuits dexamphetamine is frequently used in combination with alcohol. It is hypothesized that co-administration of dexamphetamine to alcohol might reduce the sedative effects of alcohol, but may potentiate risk-taking behaviour.

OBJECTIVES

The study was aimed at assessing the effects of alcohol, dexamphetamine and the combination of both on simulated driving and cognitive performance.

METHOD

Eighteen subjects participated in a randomized, crossover, placebo-controlled study employing four conditions: 10 mg dexamphetamine, 0.8 g/kg alcohol, 10 mg dexamphetamine + 0.8 g/kg alcohol, and placebo. Fundamental driving skills and risk-taking behaviour were assessed in a driving simulator. Subjects also completed vigilance and divided attention tasks, and subjective ratings.

RESULTS

Mean BAC levels during simulated driving were between 0.91‰ and 0.64‰. Subjects using alcohol showed a significantly larger mean standard deviation of lateral position and shorter accepted gap time and distance. Use of alcohol or dexamphetamine + alcohol was associated with a higher frequency of red light running and collisions than the dexamphetamine or placebo conditions. Performance of vigilance and divided attention tasks was significantly impaired in the alcohol condition and, to a lesser degree, in the dexamphetamine + alcohol condition.

CONCLUSION

Single doses of 0.8 g/kg alcohol increased risk-taking behaviours and impaired tracking, attention and reaction time during a 3-h period after drinking when BACs declined from 0.9 to 0.2 mg/ml. The stimulatory effects of co-administration of dexamphetamine 10 mg were not sufficient to overcome the impairing effects of alcohol on skills related to driving.

Acute consequences of hypoglycaemia in diabetic patients

Strict glycaemic control is a major concern in many people with diabetes, hypoglycaemia being the most limiting factor in the daily management of patients with diabetes. Acute consequences of hypoglycaemic attacks are not precisely evaluated. Acute cardiovascular (CV) complications as myocardial ischaemia or stroke seem to be rare, but possibly ignored mainly in older frail patients. Recent large trials in type 2 diabetic patients have not shown the anticipated mortality benefits of strict glycaemic control, and reported a higher frequency of severe hypoglycaemia in the intensive treatment arms with an excess of CV deaths. The authors of these trials persist to deny a direct link between CV deaths and hypoglycaemia. In young type 1 diabetics "dead in bed" syndrome represents a rare but devastating consequence probably due to arrhythmia and prolonged QTc interval. Driving mishaps represent another complication but with a controversial frequency. Neurologic syndromes are frequent during severe hypoglycaemia but usually reversible. Major brain damages are scarce, but cognitive defects or dementia should be underestimated in older and frail type 2 diabetics. Thus, iatrogenic hypoglycaemia due to insulin or sulphonylureas may cause recurrent morbidity in type 1 and type 2 diabetic subjects, and should be prevented by a reevaluation of glycaemic targets in some patients, patient education and the use of new antidiabetic drugs without hypoglycaemic risk.

Hypoglycemia and safe driving

The lack of awareness of the effects of hypoglycemia on safe driving is a real issue for diabetic patients and a challenge for health care providers. Taking the form of questions and answers, this review addresses the issue of road traffic accidents and drivers with type 1 diabetes mellitus. While there is little evidence showing higher accident rates among diabetic drivers, there is research indicating that hypoglycemia compromises driving performance, resulting in slower response times and reduced cognitive function. Unawareness of an early fall in plasma glucose is another important issue that affects some diabetic drivers. The driver with type 1 diabetes is obliged to check their blood glucose before driving. The physician's duty is to familiarize the patient with the risk of hypoglycemia. If hypoglycemic unawareness is present, the physician should advise the patient to stop driving until the condition is reversed. The doctor should consider informing authorities if he concludes there is a risk and the driver cannot be persuaded to stop driving.

Neurocognitive Differences Between Drivers with Type 1 Diabetes with and without a Recent History of Recurrent Driving Mishaps

OBJECTIVE: A subset of drivers with type 1 diabetes mellitus (T1DM) may be at significant risk of hypoglycemia-related driving collisions and moving vehicle violations due to acute and chronic neurocognitive impairment. The present study compared drivers with T1DM with and without a recent history of multiple driving mishaps on a neurocognitive battery during euglycemia, progressive mild hypoglycemia, and recovery from hypoglycemia, to determine whether neurocognitive measures differentiate the two risk groups. We hypothesized that drivers with a history of multiple recent hypoglycemia-related driving mishaps would demonstrate greater psychomotor slowing, both during hypoglycemia and euglycemia. STUDY DESIGN: Partcipants were 42 adults with T1DM and were assigned to one of two groups: those reporting no driving mishaps in the last year (-History) and those reporting two or more (+History).Neurocognitive testing was conducted before and repeated during a hyper-insulinemic clamping procedure. RESULTS: Not surprisingly, all drivers demonstrated a decrease in functioning across all neurocognitive tasks during hypoglycemia. However, in contrast to the common belief that neurocognitive functions return slowly and gradually following hypoglycemia, baseline neurocognitive functioning immediately recovered upon return of BG to euglycemia for all subjects. Between-group analyses revealed that subjects with a recent history of driving mishaps consistently demonstrated poorer performance on tasks measuring working memory. CONCLUSION: Working memory is a potential neurocognitive indicator that may help differentiate adults with T1DM with and without a history of driving mishaps, predict future risk for driving mishaps, and provide targeted intervention programs to address this critical public health issue.

Driving with diabetes in the future: in-vehicle medical monitoring

The motor car is a ubiquitous feature of modern life, and most of us spend significant amounts of time in a car, behind the wheel. Driving a vehicle requires complex coordination of cognitive, motor, and sensory skills. All of these aspects can be affected adversely by diabetes per se, with hypoglycemia being the main concern for people with diabetes who drive. Here we introduce the concept of using the motor vehicle as a device to collect and deliver physiological and clinical information, which, in turn, may enable more people to drive more safely by reducing the chances of medical mishaps behind the wheel. This is particularly relevant for people living with diabetes who are at risk from a number of medical conditions that have the potential to have an impact on safe driving. The development of in-vehicle medical monitoring presents a new opportunity for novel collaborations between two industries, which have safety as a core value.

Motor vehicle crashes in diabetic patients with tight glycemic control: a population-based case control analysis

BACKGROUND

Complications from diabetes mellitus can compromise a driver's ability to safely operate a motor vehicle, yet little is known about whether euglycemia predicts normal driving risks among adults with diabetes. We studied the association between glycosylated hemoglobin (HbA1c) and the risk of a motor vehicle crash using a population-based case control analysis.

METHODS AND FINDINGS

We identified consecutive drivers reported to vehicle licensing authorities between January 1, 2005 to January 1, 2007 who had a diagnosis of diabetes mellitus and a HbA1c documented. The risk of a crash was calculated taking into account potential confounders including blood glucose monitoring, complications, and treatments. A total of 57 patients were involved in a crash and 738 were not involved in a crash. The mean HbA1c was lower for those in a crash than controls (7.4% versus 7.9%, unpaired t-test, p = 0.019), equal to a 26% increase in the relative risk of a crash for each 1% reduction in HbA1c (odds ratio = 1.26, 95% confidence interval 1.03-1.54). The trend was evident across the range of HbA1c values and persisted after adjustment for measured confounders (odds ratio = 1.25, 95% confidence interval 1.02-1.55). The two other significant risk factors for a crash were a history of severe hypoglycemia requiring outside assistance (odds ratio = 4.07, 95% confidence interval 2.35-7.04) and later age at diabetes diagnosis (odds ratio per decade = 1.29, 95% confidence interval 1.07-1.57).

CONCLUSIONS

In this selected population, tighter glycemic control, as measured by the HbA1c, is associated with an increased risk of a motor vehicle crash.

[Hypoglycemia as a limiting factor in the management of type 1 diabetes]

Type 1 diabetic patients frequently present hypoglycemic episodes during their insulinotherapy, which, besides the discomfort and constrains does not allow the ideal glycemic control. Further, hypoglycemic events lead to the deficiency of the counter-regulation mechanisms in the subsequent episode, with a decrease in the release of epinephrine and the symptoms of warming, with great risk of severe hypoglycemia. The occurrence of hypoglycemia during some risky activities, specially driving, could result in accidents with the patient and /or third parts including property damage, stressing here the need to advise diabetics against having the necessary caution while driving. Generally the connective recovery is total after correcting a hypoglycemic coma. However when these episodes are repetitive, particularly in children, they could result in definitive cognitive disturbances. Hypoglycemic events without a warning signal (hypoglycemic unawareness) are difficult to reverse, thus it is necessary to prevent their occurrence, adjusting the treatment with glycemic targets, using continuous glucose monitoring at home and teaching them how to have an early recognition of hypoglycemia.