to undertake safety critical if necessary, activities and for the individual to declare that they are unfit if that be the case. that's about having a just or a right culture as part of the safety culture. so it's non-punitive. it is there for the safety of the operation and for the safety of the individual to make that declaration and would then allow the supervisor or operator to look for somebodiality flat to undertake that task. >> i would see just the basic elements of journey management put into place where you obviously can't do the questioning, the need for travel, because travel is imperative. but of course i'm sure you look at alternative modes that may be safer, alternative to driving. again, having someone who is

aware of the trip and the conditions for the trip. i believe you generally work in teams, so there's the opportunity for individuals to work together to monitor fatigue, to self-regulate and also to work together to mitigate fatigue. there's also with shift work certainly, or extended work hours, there has to be some kind of accommodations to not have to drive back home, to be able to stay overnight, to be able to extend a trip, either as a planned element of the journey or if you are fatigued with being you should have the flexibility to say "i'm too tired" or "i don't see well at night" or "i into edneed to stop overnight before continuing

home." >> dr. pratt, do you have a sense of how widespread it's becoming with companies to have fatigue management plans and addressing fatigue as a risk factor? >> i don't. although i would say that, from my interactions with different industry groups industries such as oil and gas are -- it's much more prevalent within those industries, then also of course within transportation industries which would be a given. i think in oil and gas the consequences of something going wrong on the operational side are so potentially catastrophic that it just becomes natural to look at assessing and managing most any risk in the environment. i will say that some industries or occupations where driving is

an integral part, yet it's not really part of -- it's not really looked at as an important part of the work environment. the vehicle isn't really looked at as a piece of work equipment, that there are significantly left robust fatigue management plans, and there may not even be a plan it just may be some general advice about, you flow, make sure you get enough sleep, don't get tired, drink caffeine, and those tend to be companies that do look at managing certain elements of driving but think of transport industries as the ones that are the most susceptible to fatigue, and they don't seem to be as comfortable always to talk about -- talk to employees about their individual choices and to account for their behaviors and to be responsible for their

behaviors. i think that in many settings where you have a risk like driving that's such an every day risk, we all get in our wbnéçcars it is such a familiar, comfortable risk, that we all take just about every day, that when a vehicle is used for work purposes, there's not necessarily the sensitization to that as a really significant workplace risk because it is such -- it is something we don't even think about. >> how do we deal with the kind of concept -- you talked about it a little bit with the police officers -- that their duty is so important that they just need to fight through fatigue. >> well i think -- in my view,

i think the biggest blockade if you will and policing is the. >> caller: tur of the occupation. if we could dent the culture, we could probably do a lot better. but it is so engrained from tradition and it is so engrained in firefighters, for example, and police officers that we can do it without sleep. we can do all of these things and we don't need to get the sleep. we need to break through that. we need to look more at the sociology of that culture. the culture that doesn't want to be changed. that's the only thing i can think of with these occupations. >> in occupations such as sales forces, there isn't necessarily the orientation of the sales

manager or the supervisor to be coming a driving coach. so what happens is that when those things start to become incorporated into their programs, they don't know how to make those -- manage those types of encounters. they are so used to looking at sales performance as the main performance measure for individuals and they're not necessarily attuned to thinking of driving as part of safety. >> so it would be great if this panel can help us create a model drowsy driving program. so dr. pratt dr. flower, i don't just want the bp one. but start at this end. what would your first top three elements of a model program be? we'll let each of you have

three. unfortunately, can't use the other person's three. doctor, my/poll giz, it apologies to your end of the table. right now let's go down and if we're going to make a list, your top three core element programs, elements of a model drowsy driving program for a workplace. dr. pratt. >> okay. i think my number one would be flexibility in terms of empowering the employee to make assessments as to their own level of fatigue and then to allow them to get overnight accommodations or travel the day before in response to that. i also think another element would be picking up on dr. flower's comment about the checklist, i think collecting

data on the incidences of drowsy driving and not near-misreporting, which is part of empowerment. but then also collecting detailed information, doing incident reviews on events that do happen, and then using that information to guide countermeasures. thirdly, i think sending -- i think it's cultural sending the message throughout the organization, not just the top management articulating it as a core value but then having that information trickle down to the line manager level so that everybody sees it as part of the organization and part of the safety culture of the organization so that it's not just some here today, gone tomorrow type of thing where you have a few e-mail blasts, newsletters and that's the end

of it. it has to be part of the safety management system for the organization. >> great. so dr. flower, we're paying attention. very comprehensive program. but if you had to pick three more to build on what dr. pratt just started, what would your three be? >> just picking up on the last point, making it a part of the safety management system is -- it's about operationalizing it so it is the way that that company does business. it is a risk that they consider. so that embeds it within the organization. i think it's about recognizing what fatigue is that the business can say it's good business, we should be doing this. but unless the employee, the individual who is at risk recognizes what it means to them, then they're not going to pay attention to it. and so it was mentioned earlier about the australian videos,

they are brutal they are hard hitting. i use them every single time i speak. it gets people's attention. they realize what the issue is and what the end result can be. so i think it is about education and it is about education and it is about education. it's about reinforcing that at every opportunity through journey management through the tool box talks, at the start of business meetings where people are just commuters. they may not be business drivers but they're just commuters. but with the changing way that we work and the increasing distances that people often travel to work, commuting now is a very significant risk. so i think that's important. and again, going into the way that the business handles fatigue, it's about having that culture that allows someone to put their hand up and say "i am fatigued. i can't do this. it would not be safe either for me or for the organization for me to do this." and to have a culture that

enables that to be done which then as dr. pratt says gives them the free will to stop to take a nap, reschedule their appointment, book into a hotel, whatever it may be to ensure that they are fit to do their job when they're required. >> thank you. doctor, he just took your culture one. so if you have three more that you would put into our model program. >> three e'5more. okay. i vote for education. i vote for changing attitude. along with that comes behavior in this particular culture. i vote for assessment. i think sleep apnea, for example. i mentioned this before. it is one of those factors that's important. voluntary screening for apnea or any sleep disorders by people at the beginning of their career where it makes a difference should be done. lastly, i think on a voluntary basis i would try some programs

that have been tried. one is controlled napping. i really think that works to allow maybe 15 or 30-minute naps during certain times of the shift to allow the body to catch up a little bit. but this needs to be controlled in a formal way. it has worked. i know there are a lot of industries that do use this and it's rather controversial in some other industries but i think it is a good idea to start using some of the knowledge that people have gotten from the great research they've done and applying it instead of just talking about it. >> thank you. that was a great close for that particular because you are the one that brought up the workplace apnea q-issues, the controlled rest, which is a strategy out there. great. now i'm curious just for any one of you -- all of you don't have to answer -- what data is available either internally or in a peer reviewed pub accomplished way to show us any

of these drowsy driving programs are actually effective? dr. flower? >> i think internally, as we've seen when we look at behavior of our drivers, fatigue was generally the second -- number two after situational awareness of their areas of concern when they're driving. but as we saw in the causation of accidents when we investigated those accidents last year, it was number seven in the causation. so i think recognition and ultimately what's the causation of the accidents is saying that it's having some impact. it's not removed it completely but fortunately none of those accidents were caused by drowsy driving. it was implicated in the -- as one of the behavioral factors within the accident or the incident. so i think that's a demonstration internally. small numbers i admit, but it is a demonstration internally. >> my recollection is with the

development of the north american fatigue management program, that that went through quite a bit of testing, i mean many years and even some field studies perhaps. i'm quite sure that there were some of those conducted in both the united states and in canada. so i think that in that case we can look to that as if not representing something that has been completely shown to be effective in the field, it certainly, at the very minimum, would represent a best practice from a lot of people who know a lot coming doth to develop a xree lensive program. >> great. so we've got internal numbers, to some extent, to a program that's widely available that has been studied in the field as well. doctor, you looked like you had something to contribute as well? >> i was just going to xlent on our own research. we're finding associations between fatigue and lack of

sleep and injuries especially on night shifts to a greater degree than occur on day shifts. and this data suggests to us that people are tired, the officers are tired. and when you're tired, your ability to make quick decisions in your job, and in your driving, is really impaired. we think that's what's happening here. also, we did apnea screens and we are finding that about 30% to 35% of the officers screened for apnea -- we haven't done actually testing yet but we are going to get to that. i think a doctor who will speak this afternoon has done a lot of research in this area and his research is very good. i think if i were to go through a source i'd probably go there for additional research. >> i think what i'm highlighting here though which is a note for us to pay attention to there is no question about the issue, there is no question there is a variety of things you can do about it. i guess my question goes to do

we know what the model or other programs that are in place, how effective they really are by safety standards. i'm asking that question, and right now i'm kind of getting the sense that there may be a gap there for us to kind of understand the data. because you do the investigations to feed it back to get some improvement. last pressure and no question but this question is right before the break, so timely. what about required versus guidance? so a lot of challenges for workplace is when people come in and say, thou must as opposed to guidance. so for example, the faa has new rules out all large commercial airlines have a requirement for fatigue risk planningment. but that's not for all aviation. transportation, oil and gas, et cetera. just makes -- anybody want to make a comment about requirements addressing this issue as opposed to guidance.

anyone? >> well, first of all, i'm thinking in terms of who's going to require this for a non-commercial motor vehicle fleet because osha doesn't exercise its jurisdiction on the highway. so there would be the question of how this would operationally happen. certainly it can be guidance for any industry but in practical terms i don't see it happening unless it would happen within the context of the transportation industry the d.o.t. regulated fleets. >> at the company level when we introduce the driving safety standard back in 2004, that was an absolute requirement and if you failed to adhere to it, then potentially that was an issue that could face discipline. in fact, since then, the driving

framework has become voluntary but actually the requirement to be well rested and not fatigued has been elevated to the code of conduct. it's actually applicable now to everybody coming to work, whether you are driving or not driving, are you fit to do your job because you're well rested and not fatigued. so the requirement for fatigue management has been elevated to one of the most fundamental requirements of the organization. >> fatigue management has to do not just with driving for work but it has to do with occupational injuries during the work day non-driving injuries. >> we're focused on drowsy driving here but clearly a lot of this extends beyond to the actual work. >> i would vote for required. i think it is essential that training required not only at the beginning of a first responder occupation but also an in-service trainings which are probably held every year every two years. additionally, i think the big stick in the mud here is what will happen to you if you don't

participate. i think it shouldn't be punitive but i think in many cases it may be in these occupations. but that's the issue that has to be addressed with unions and so forth. >> thank you. that's a very difficult challenge for many places and i appreciate the candor. dr. bruce, thanks for your leadership on this particular panel. panelists, great job, again. really appreciate it. we know the workplace is a risk factor for a lot of drowsy driving crashes that we see so thanks very much for doing that. we're going to take a break until 11:15 and come back for our third panel on novice drivers. we are adjourned until 11:15.

more from the national transportation safety administration's summit on the dangers of driving drowsy. this panel focuses on the adolescent brain and why sleep deprivation is more acute in teens than adults. the panelists discuss the link between a later school start time and a decrease in adolescent traffic accidents. this is just under an hour. >> welcome back, everybody.

we're here for our third panel which mr. bragg is going to lead for us. if you didn't notice, we've expanded the audience and sitting in the back there, everybody, is a group from the national organization for youth safety. noise. there ya go. what perfect timing because our next panel is specifically on novice drivers. so mr. bragg, whenever you are ready. >> thank you member rosekind. as a reminder for our panelists, please push the button on the microphone to activate. bring it close to you. once again our next panel is on concerns for novice drivers. our panelists dr. nate watson, president elect of the academy

of sleep medicine and co-director of sleep centers at the university of washington. >> thank you. thank you very much for the invitation to speak here today. thank you, member rosekind. and thank you for making some noise back there. i'm very excited that high school students are here this morning for my presentation. because i'm going to be talking about why teens are susceptible to driving fatigue and what's happening to them that's making them susceptible. so i'm going to talk about the biology of teen sleep and what's going on duringed a less accidented a sent sleep what's going on during sleep as well as societal restrictions, and what's going on with teen driving and sleep. the biology of sleep, when we

talk about the regulation of sleep biology, we talk about two systems. one is the circadian timing system, and the other the sleep/wake static system. both of these systems undergo changes during the adolescent years so the circadian timing system just a reminder what we're looking at here in the context of sleep pressure is this 24-hour pattern of higher and lower sleep pressure as a function of the internal biology of our daily clock. what happens to that daily clock during adolescent development. one way of looking at it is asking what is the -- how are you timing your sleep when you don't have anything else going on in the day. and so weekend sleep timing if we look at the mid point of that, you can see on the

verticalvert vertical axis, the mid points ranging from 2:30 a.m. in 10 year-olds and rising to as late at 5:00 a.m. in 20 year-olds. so this second decade, the adolescent phase is where we see a rapid delay in this marker of the biological system. we can also look at it by measuring the biology itself. so by looking at the timing of the hormone that marks the start of the biological night each day. so we've done that and looked at this. it's called the onset phase of melatonin secretion. if you look at it as a function of the stage of puberty -- so the high school students in the back of the room here are probably at puberty stage 5. so the latest progression on this, you can see clearly a pattern that the more mature an

adolescent is the later is the timing of this biological signal. so just a quick summary then. the timing of the rhythms get later across adolescents and as a result, sleep is favored later in the day. of course waking up is favored later in the morning as well but we'll see. there is a problem for adolescents on that end side of the program. so the second part of the system is the sleep/wake homeostatic drive. so the longer you are awake, the sleep pressure rises and, as we sleep, this sleep pressure falls, is dissipated recovers from being awake. so we have again this pattern that's occurring on a daily basis, although we alter this significantly many times. we measure this by looking at the type of sleep in a qualitative way, just assessing

the brain wave patterns. we can also measure and quantitatively look at this by lookingality alityality alityality at the slow wave activity. this one one child prepubertal the first time she was studied and a mature adolescent the second time she was studied. the amount of slow wave sleep declined markedly and the amount of power of the slow wave activity during sleep also declined markedly. what didn't change, however, was this decay of the sleep pressure across the night. and we can look at it in this light in a different way where model systems are given showing that across puberty, this recovery process is not changed. but the rate that sleep pressure builds slows down in the more mature adolescent. so we look at that it sort of

jibes nicely, from some perspective, with the circadian processes. we see that recovery process doesn't change. so one interpretation of that is that the need for sleep stays the same in a 10-year-old and a 17-year-old. but the pressure builds a little slower in the 17-year-old so it is a little bit easier to stay awake longer. again, the result of this is that late nights are favored. here now in a per missive way, more than driven, as we saw in the circadian system but the key point is the same amount of sleep is needed. so what else is going on with teens. yes, we have the biology but there is a lot of other stuff that happens during adolescent development. there is a psycho/social

context. we could go around the room and everybody could give a point on this. but we see one of the major goals of adolescent development is establishment of autonomy in behaviors and in regulating your lives. there are a lot of adolescents who have jobs. a lot of adolescents who are using all kinds of substances, caffeine being a major one, one of my mantras is that no child needs caffeine or should need caffeine, but we see much caffeine used in adolescents. now in the 21st century, screen time at night has become a big deal. social networking is also now very highly available and available at night. of course one of the major things that happens during adolescent developments are romantic attachments and the loss of those attachments. and there is a ton more things. but one of the key parts of the psycho/social context is the context that society puts on adolescents with the school

schedule. so the school start time is a major issue and a major thorn in the side of adolescent sleep. schools in the u.s. start early. . middle schools, grade 6 through 8, more than half start before 8:00 a.m. high schools looking at different school districts we see, again more than half starting before 8:00 a.m. this is a problem when sleep is delayed due to the biology of the system. and here's a view of that problem. so this slide is showing that tenth-graders -- so these are our young people on the verge of getting their driving licenses, in a school that started at 7:20 in the morning the kids were sleeping about seven hours a night. and we monitored that.

we can see when we had them in the lab, sleeping that amount at night, and we tested how fast they fall asleep in the morning that at 8:30 a.m. which would be second period in their school they're falling asleep in under five minutes. and some of them were falling asleep essentially when their head hit the pillow. recently, in august of this year the american academy. pediatrics actually has now acknowledged that the school start time is a problem in adolescents. i've just highlighted here one of the comments and recommendation of this group was that most school districts, middle and high schools, should aim for a start time of no earlier than 8:30 a.m. if kids are not getting adequate sleep, there are many consequences. i've highlighted some here from a study by my colleagues showing

that the reduction of sleep leads to a number of things that could be thought of as risk taking activities. and so you see in these slides from texting while driving to drinking in excess, or drinking at all. i guess at this age in the united states drinking at all is excess. but there are problems and there are consequences for behavior as teens get less and less sleep. we've also seen some data showing that school start time changes have an impact on driving crashes in teens. not necessarily directly attributed to drowsy driving, but sort of statistically attributed to the school start change. so in lexington county, kentucky, one of the first such

studies showed that in the year after the school district changed their start time from 8:00 a.m. to 9:00 a.m., the crash rate in teenagers went down 16.5% and in the rest of kentucky, the crash rate in teenagers went up nearly 8%. another study looked at two towns in southeastern virginia that were very similar. in this study one of the towns the school started at 7:25. the teen crash rate was 65 almost 66 crashes per 1,000 drivers. in another town, chesapeake, with a school start time of 8:40 to 8:45 the crash rate was significantly lower. less than 50 crashes per 1,000 drivers. new data coming out from work that was done by kyla walstrom's group for the cdc showed again that in school districts where the start time was shifted to a

later time in general the crash rate was reduced. you can see in the minnesota and wyoming school districts, it was incredibly big shift in the crash rate for teen drivers. so a, many teens don't get enough sleep. i didn't emphasize this but a recent poll by the national sleep foundation showed that the average amount of sleep in grades 11 and 12 in the united states on school nights was seven hours or less. that's the average. so if you think about it that means many teens are well below seven hours a night. this means they're fatigued. they're especially fatigued in the early morning after school and late at night. and the short sleep and fatigue has many consequences that include consequences for driving

safety safety. >> thank you. our next presenter is nate washington from the american academy of sleep medicine and university of washington. dr. watson. >> mr. bragg, member rosekind and the board of the national transportation safety board, i want to thank you for inviting me today to be here to speak with you on this important topic. my golda is to be a representative of the american academy of sleep medicine to let you know about some of our concerns in regards to novice drivers, drowsy driving, and to present to you a proposal that we're going to be undertaking in regards to how we are going to address this problem. so i wanted to share with you our vision and mission. you can see here that clearly when you look at our vision that if we achieve optimal health through better sleep, we make people more alert. if people are more alert they're going to be more alert behind the wheel and we're going

to have safer roadways. if you look at our mission we focus on a broad range of areas including advocacy, education strategic research and practice standards. so i think this really summarizes our strengths that we bring to the table as we work together to overcome dangers of drowsy driving. i'd also like to let you know that we're currently engaged in a five-year grant from the cdc with multiple other stakeholders shown here to help advance the agenda of the four sleep health objectives from healthy people 20 2020. one of those objectives is to reduce the rate of drowsy driving accidents for 100 miles traveled. this forum today and the efforts that we'll be putting forth dovetail nicely with the agenda that we have for this healthy sleep awareness project. as we got to work on that project, we decided to focus much of our efforts on teen

drivers, because we acknowledge that accidents are the leading cause of death among teens and motor vehicle accidents are the leading cause of these accidental deaths. this represents over one-third of deaths to all teenagers. so as a result we want to tailor or messaging to teenage drivers. you can see here as an example of what we feel is some effective messaging that will resonate with teenagers. this is from the utah teen driving task force. they highlight what they call thely behaviors. you can see drowsy driving is included here, as well as impaired driving distracted driving, and reckless or aggressive driving, along with seatbelt use. as we go forward with this talk, what i'll be bringing up again and again is the fact that none of these things are happening in a vacuum that there's substantial overlap between all of these factors when we consider safety on the roadways with our novice drivers.

we also want to focus on novice drivers because we know from research that drowsy driving prevalence is highest amongst younger drivers. so you can see here, this is a 24-year age group. it is also highest among some male drivers. as we move forward and consider about lou to tackle this problem, i think we get the most traction if we gear our message towards teen boys and young men as the primary target but clearly we will be addressing driving issues in all teenagers. one of the other things that we need to acknowledge as we try to tackle this problem is the fact that the teenage brain is not yet fully developed. i think anybody here who has a teenager will probably -- this will resonate for them. but we know that through the teenage years, in an area ever the brain called the prefrontal cortex, there's ongo-going

developmental processes to develop this brain area and this area is really crucial to aspects of judgment, decision making and moderation of social behavior. so if it's not fully developed then what you have is that teenagers are more apt to not really be able to correctly assess risk and perhaps engage in more risk taking behavior than adults would. another challenge is the fact that teenagers and young adults are baltimore susceptible and more vulnerable to sleepyiness. so here is a study by fitness in 2012. on your left, you can see what they did was they sleep deprived these individuals to five hours the night before a simulated driving task that took two hours. the younger age group had an average age of 23 years pmp the older age group had an average age of 67 years. you can see that there were substantially more episodes where all four tires would go out of the intended lane in the

younger age group than the older age group. this is after the same amount of sleep deprivation. on the right you can see they were measuring the electro entesten encephalogram. they found, you can see in the younger age group, more what we call power in alpha and theta ranges. really that means a greater propensity to fall asleep and more sleep occurring in the younger age groups. so there is another challenge as we try to address this in the younger group. teenagers are also prone to distraction and risky behaviors, and here on the left is some ntsa data that showed that for crashes in teenagers that are 15 to 18-year-old drivers, that driver error was the cause in more than 95% of crashes. what i'd like you to appreciate is that, recognition errors, decision errors and performance errors make up most of this.

so actually falling asleep only made up 1.2% of critical teen driver errors resulting in accidents. however, this study did not assess crashes occurring between midnight and of6:00 a.m. which may have artificially reduces that number. recognition errors involving things like distracted driving or inattention. decisional errors involve driving too fast or aggressive driving. those things clearly can be influenced by sleep deprivation and drowsiness. so i think that that's a big issue. on the right, you can see a survey of -- population-based survey of over 500 young licensed drivers showed an increase odds ratio of crash involvement in two conditions. one was being a current smoker. the second was driving drowsy while alone. there's also overlap between drowsy driving and driving while impaired. that's highlighted here. when 11th grade students were

surveyed, 13% admitted to driving while impaired at least once in the past 30 days. 24% admitted to riding while impaired, at least once in the past year. you can see if you look at the odds ratios that the odds are increased over eight-fold of driving while impaired if you were sleepy or drowsy. you can also see that driving after midnight also increased the odds substantially of driving while impaired. not only that, we also have evidence that individuals and teenagers that are using cell phones while they're driving, either texting or on the phone are more apt to drive while drowsy as well. so i'd like to turn our attention now to the american academy of sleep medicine strategy to try to address this issue. we're going to mostly do this through advocacy and education. we recognize the widespread prevalence of drowsy driving and its association with fatal motor vehicle accidents especially

amongst novice drivers. what we're going to be doing is creating a transportation safety task force in order to address this issue. education is a big part of this. we know that it can be effective. here is a study out of yale from last year which utilized a quick computer-based educational program about risky driving behaviors in emergency rooms and showed that when you assess these individuals one month later, you find that all of these risky driving behaviors were reduced, as well as drowsy driving being reduced by 16%. so at the core of our educational initiative will be efforts to partner with states to promote standardized evidence-based drowsy driving education within the local driver education system. we've done a preliminary assessment and found that at least 17 states currently include drowsy driving education in their curricula. what we have found is that there is high variability in the quality of the content.

one exemplar is montana which has power point presentations videos, and faqs sheets. we'd like to access this space and improve it where we can. we are also looking at state drivers manuals. we have found that 48 jurisdictions out of 51, including washington, d.c. currently have information about drowsy driving in their drivers manuals. only iowa south carolina and hawaii do not currently have this. so it is fairly prevalent. however, what we find is that the quality of what's there often can vary quite a bit. some of it is fairly superficial. here's an example of what's in the park arc state drivers manual. we will address this by drafting model language that states can adopt and include in their manuals to equip drivers with more comprehensive information about drowsy driving. we also want to address state

driver's license examples and ensure that not only is the content being taught but it's also being tested. and so here's an example of a practice question from new york. but what we'll propose to do is write questions and then offer them to states to include in their driver's license examples related to the perils of drowsy driving. another approach that we plan to take will be to engage with another important stakeholder which is the insurance industry. and what we see is that when we've looked at this space, that there is some things being done, particularly by state farm to try to address this issue with their celebrate my drive and steer clear discount program, if young drivers go through these modules, they can actually save money on their insurance rates. and so we're going to seek to partner with auto insurers to

make droudy driving education a part of their existing discount programs or collaborate and develop new discount programs that address drowsy driving. as part of our national healthy sleep awareness project we'll have a public safety campaign and we have to be mindful that if we want to get some traction with teenage drivers that we have to have messaging that is going to resonate with them. these are some examples of messaging that is from the utah teen driving safety task force that we think will resonate with younger drivers and be compelling and be something that might motivate behavior change. so this forum is happening at a very advantageous time. it is actually teen driver safety week 2014. transportation safety is really an issue that can unite a diverse coalition of interest groups from both the public and private sectors. the academy's transportation safety task force and our healthy sleep project will seek to develop strategic partnerships with a variety of

stakeholders, including federal and state agencies safety foundations, medical institutions professional societies, insurers, driving educators, and the auto industry. i want to finish with an example of success. this is the state graduated driver's license laws that are out there. this shows how strategy and targeted initiatives can lead significant improvements in driver safety. so all states and the district of columbia have a three-stage gdl system which really gives young drivers the opportunity to develop the expertise andw competency to drive while keeping them away from situations that would be unsafe. one of the major tenets is limiting driving hours so they are not driving at night. also limit being the number of passengers that can be in the car and whether or not they can have their cell phones with them when they are in the car. and this initiative has been tremendously successful. you can see here on the right

that the change in per capita fatal crash rates by driver age has reduced substantially, over 70%, in the 16-year-old age group. so this is a true example of success. however, we have to be mindful that there's work still to be done. the overall teen crash rates remain elevated compared to middle aged drivers. so in summary what the academy is going to be doing is convening the aasm transportation safety task force. we're going to be assessing driver's education clickurriculacurricula, drowsy driving material for examples. we want to ensure there is accuracy and consistency in the content of the materials. we'll develop and eninsure a discount program. some elements of a drowsy driving campaign being targeted to the novice driver. research without action is

merely an academic pursuit. thank you. >> thank you, dr. watson. dr. watson touched on this briefly and we have young people here so i'd like to expand on it. would you discuss how prolonged chronic sleep deprivation affects the cognitive development of adolescents. >> how it affects their cognitive development? >> yes. >> well there's not a lot of data on how it affects the development but it is clear that sleep deprivation affects thinking in a lot of different ways. it also affects learning and the ability to learn. you think about it on three levels we have it now. if you're too sleepy you have trouble with the acquisition phase of learning. paying attention, not being distracted, being motivated to get the information in. so we hear education education, education. well, if you're too sleepy

you're not going to be absorbing the education. secondly, sleepiness is going to impact how one retrieves the information information. so you can acquire the information, but then you have to be able to use it. so if you're too sleepy, too tired, distracted unmotivated that's a problem as well. and the third factor in the last decade or so we've learned a huge amount about is that sleep itself helps to substantiate those things you learn during the daytime. it actually improves learning. so the students who get plenty of sleep get a bonus in their learning purely from having a good night's sleep. and one of the things particularly maybe related to driving is the motor skills learning is particularly

advantaged by having a good night's sleep. and a lot of what we do when we drive is sort of repeated motor skills. oh you press this pedal and do you this turn and you turn that. quality and quantity of sleep are affecting the learning and the ability to perform at a number of different levels. >> i ask that question briefly too. i think that there's some research out there in animal models that show that sleep deprivation request affect cells in the brain which are involved in -- the axons. getting back to frontal lobe development it would be a possibility i suppose is yet unproven that there could be some effect there, as well. and we also know that you know, sleep is important for many things, clearly but, that sleep is a time when the by-products

of neurotransmission get cleared out of the brain and so if you're not sleeping, that's not happening, and there's some suggestions that that can create some issues with the protein deposition in the brain. >> thank you. are adolescents as likely to become aware as adults? >> no. the short answer is no. you know, the adolescent brain is just wired differently as has already been alluded to. and the part that's turned on seems fully functional is the emotional part. and it's that executive part that's not turned on and not helping to gauge situations, and keep you aware of what's going on. one of my colleagues has alluded to this situation in adolescent as, since we're at a driving

forum, as the accelerator is fully engaged, but the brake is not. and so, you have this part of adolescent brain development where all of the emotional regulate -- all the emotional activity is there but the regulation of that activity, the foresight, the controls are not fully engaged yet. >> another comment i'd like to make, so we do something in sleep medicine called the maintenance of wakefulness test which tests a person's ability to stay awake in an environment where they may be prone to fall asleep. and what researchers have shown that if you ask individuals to press a button and younger individuals to press a button, as they get introducier, as they feel sleep is imminent that 60% of the time they fall asleep without pressing the button. and even if you incentivize it you still get a substantial percentage of individuals that

just fall asleep without signaling it. so i think that quite often people -- they cannot judge how sleepy they are. they cannot judge that sleep is imminent. and obviously that has implications for transportation safety. >> okay dr. lawson as a parent of a child that by some measures is now an adult when i think back to how he was learning to drive and i try to do all these things to make him safe it never really occurred to me to think about drawsy driving. my question is are we doing enough to teach parents about sleep health so we can convey that to the children? >> i would argue we're not doing enough to teach parents about sleep health. i think sleep iq in this country is low right now and i think that, you know that's one of our great challenges, is to get people to reprioritize sleep in their lives in a forum such as this is one way to get the

message out. because really ultimately you know, the sleep habits that these children develop when they're in homes with their parents are going to be the ones that are going to carry throughout their lives. in some sense having parents that enforce bedtimes, that get technology out of the bedroom you know that limit caffeine use parental involvement is crucial to good sleep health and good sleep habits in the youth of this country. you know sleep education is not only limited to the general public, but unfortunately it's also limited within the medical schools of our country at the academy we've been trying for years to increase sleep education but haven't had a lot of success because curricula are already stuffed with so many other things. but we find that many medical schools only have two or three hours worth of sleep medicine education, and unfortunately we end up with many physicians out in the world that never think of

sleep illness or sleep problems when their patients come to see them. that's also a problem. >> i think one of the really nice points of the american academy of pediatrics comments on school start time was also advice to pediatricians to get involve edd in this issue of adequate sleep for teenagers. it's the pediatricians who can help empower the parents to help guide and put limits on the sleep and the electronic activities of teenagers. and younger children, as well. >> thank you, have nothing else. >> fascinating presentations as a mom of a middle schooler i'm listening very carefully. so speaking of parents, and because we have a lot of youth leaders in our audience today,

dr. carskadon you mentioned the concept of school start times and i'd like to know if you have any advice or suggestion to people who may be trying to advocate for later school start times? any kind of words of wisdom for those individuals? >> it's a challenge. in the united states, there are thousands of school districts. every town every you know, village, has its own school district. and every school district has its own organizational style, and own, you know catchment area for students. some may have a commute of five minutes. some may have a commute of an hour or more. so, theh individual for each district. there are things to help though. those who are advocating. there are actually some nice websites now that have, where parents have put together materials that are useful.

the national sleep foundation also has modules on how to go about advocating for later school start times. and i think one of the big flags that thank you can be waved, since august 25th, 2014, is that advice from the american academy of pediatrics which is backed up by another paper which includes the data that supports this move. so it's a hard task but what's always fascinated me has been in school districts that make the change, the commitment that they show to the health and well-being of the teenagers in their schools is just staggering to me. i mean, it really is so impressive that what they do, how they arrange it the steps that they take to bolster the situation, are just so impressive. and that tells me that it really does take a commitment in a big

way to the health, the safety, and the educational needs of teenagers for schools to make this kind of change. >> you know i'm in seattle, and there have been a group of concerned parents and professionals, that have been working to try to get a later school start time now for about a year and a half. and as you know observing that process, i think that what i've seen is like dr. carskadon is saying, it's really about education. and you need to educate the school board about the issue. and what we find is that once you begin to do that i mean the argument that you make is so strong that, because you're talking about their well-being you're talking about their being prepared to learn when they show up to school, that it's really hard to be opposed to it once you understand the issue. >> thank you. that's very helpful. my final question is just a bit

of a curiosity thing. i read recently this term that i thought was very interesting it was central jet lag and the concept being that even people who aren't using you know going on long-distance air travel can have circadian disruption or dysrhythmia just by their lifestyles. it strikes me adolescents, even well intentioned adolescents on school nights might have very different schedules on weekends. i wondered if you observed that in your work and if you can comment on that. >> it's really a huge issue especially for adolescents because there's this biological pressure for them to stay up later. so it's almost as if they are jet lagged all week long, and then on the weekend they can sleep at their biologically appropriate time. another way to think of it is we're also making them into shift workers. getting them up a totally inappropriate biological time and having them at school when

their brain is really biologically prepared to be on the pillow at home. so social jet lag is a major, major issue in adolescents who are sleeping at one time during the week, and then a totally different time on the weekend. and it isn't good for them. >> thank you both. dr. malloy? >> and as a father of a young man in high school, whose county is actually considering moving the start time back an hour which i would like when i'm waking my son up to get him ready. unfortunately the cost has made it somewhat the school board would like it, the cost is too great. are there any studies that look at the costs associated with not moving the school time? that the -- we've seen the crash rates are higher, learning -- you've mentioned learning.

is there anything that can quantify that? >> there's one paper that comes to mind that was written in a -- the psychological economics journal about comparing improvements in middle schoolers' test performance by changing the school start times an hour later, the cost of that, versus getting the same improvements in their test taking by reducing the class size. and it was a 7 to 1 difference. so it costs 7 times more to get the same you know bang for your buck in terms of the performance outcomes by reducing class sizes, as by changing the school start time.

so, yes, there are economic costs, but there are also ways to work around it. and you know, it is a complex situation, and a complex issue. but part of what's gone on is we've decided that the little children can't ride on the same buses as the big children. which, i was at one forum where some high school students said, but those are our little brothers and sisters. what's the problem? and i think, you know there are some -- some interesting thinking on these things that maybe need to be readjusted. >> i think when you consider costs, you know, similar question was asked of dr. dr. flowers in his panel, and you know i'm just thinking in a similar way to him that, you know, this is really a social issue. and how do you figure up the cost of the, you know the safety of our children their learning preparedness their mental health, you know all

these things that are at stake here. i think cost is obviously an important argument but i think that there are many elements of this that clearly go beyond the cost assessment. >> dr. rosekind. >> thank you. i'd have three questions i'd like a comment from each of you, so we'll try to stay focused. starting in the last panel even before that, there's been a lot of discussion about culture and a lot of need for changing attitudes and behaviors. it seems a lot of, since it's education, education, education here, not just about drowsy driving but all these issues seems like there's a real generational opportunity here by focusing on teenagers. and dr. watson you started on that a little bit but i'd like each of you to kind of comment. if we want 2015 to be the year there's no more sleep problems it's not going to happen. it's going to take us awhile. and it seems like this focus on teenagers may be driving is part of the hook gives us this generational opportunity to

really see some of the cultural change that we keep talking about. could both of you make a comment about that? >> well, dr. rosekind what was most exciting for me today was to see these youth leaders in the audience here. and i think you know we can, as grown-ups, can talk till we're blue in the face, and talk at these young people, but it's the leaders of the i think, who really have the opportunity to get these messages across to their fellow teenagers. and to really have some impact. i think you know if we can convince those young people that get their parents on board, get the pediatricians on board, get the school districts on board and really shift the mind-set to where sleep is no longer the forgotten country, but part of

our health behaviors, it's going to take work it's going to take time, as you say i've been trying to send this message for decades now, and it really seems like our society may be at a point where the commitment is there to do the things that will push this message forward. and the younger we can get it into the family life, the better we will all be. to start at teenagers, i think is hard for many parents. if they haven't started in their 9 and 10-year-olds, and keep the bedtime setting, and keep, you know thinking about planning for sleep. not just letting sleep be the last thing in the day it's so much easier to keep that going as the kids get a little older. >> you know i think deliberate or not, there are some powerful

interests that don't want us to sleep in this country. there's some that i refer to as the caffeine industrial complex out there. and i'm from seattle. but, you know if you look at what the stock has done on starbucks, you don't have to look very far to see that when there's a need for caffeine, that there's an economic benefit that's out there. you know, you also can't consume things when you're sleeping. so, you know i think that we have to acknowledge these challenges that we have. but yet you know, we also have to also propose the -- you know what the value of sleep is to teenagers. and you know i mean they're pretty savvy and i think they'll hear the message. you know, when we let them know that there's a lot of experimental and epidemiological studies showing an association between sleep deprivation and obesity those kinds of things will get their attention.

hat we also see in teenagers is obviously they're embracing technology, and there's lots of sleep health focused technology that's out there that i think is a real opportunity in order to engage people. what that tells me is that people are interested in their sleep. they want to know more about their sleep. and i think if we could just take it a step further you know, to say -- to encourage them to get more of it, then we'll definitely be making progress. so, you know, i think it's going to be an educational effort. i think you know, we need to convince people on a case by case basis to prioritize their sleep and see how they feel. i do that in clinic all the time. and it's a simple experiment you can do on yourself by prioritizing sleep for a few weeks. and you know going to bed when you're sleepy and waking up spontaneously when you're rested. and then gauge how you feel during the day. and compare that. and you know, get people to focus on the quality of their

wakefulness experience rather than the quantity of their wakefulness experience. and if we keep trying to get those messages out there i think eventually they'll resonate. >> thank you both. just briefly you have one bullet dr. carskadon on screen time. but if each of you could make a brief comment about technology. it seems to be part of creating the risk, and maybe part of the solution. but if you could just sort of give us a little bit more about the role of technology again both as part of the problem but also maybe in helping us out. >> well, part of the problem, there's a paper i have in my bag now that just came out showing that if you block the light from a technology in the evening you actually will have better melatonin onset phase so the signal of night time is established better. but you know, the problems with

technology, i think all of us can commonsense those. well, if you're using your technology, you're not asleep. if you have it in bed with you and your phone is ringing or pinging, you're not going to be able to sleep as well. so that's very clear. to the extent that apps are made, or you know -- well my fantasy for technology was always a rolling blackout of the internet. for people whose brains are of a certain age. and you know that's obviously not going to happen anymore. it's something we have to live with, and something we have to begin to understand better, and begin to use thoughtfully, and not -- and not use it so much so late to avoid sleeping. >> yeah.

you know this is a really difficult issue. because like you say, is it the solution, or is it the problem? i mean technology has been interfering with sleep ever since the invention of the alarm clock. so, in my ideal world nobody -- everybody wakes up spontaneously now. that's clearly not the world that we live in. but, you know i do think that, you know as a sleep medicine practitioner that it's really important to have good sleep hygiene and a part of that is to have, you know, regular habits, and have a wind-down period of time where you're, you know you allow your body to prepare for sleep. and you know, i think we have problems when people view sleep as something that they need to do. those are the people that have trouble. the people that sleep well are the ones that let it happen in the right circumstances. and so in generally speaking i think we need to keep technology out of the bedroom and really

kind of preserve the bedroom environment for sleep. >> so this is the last issue i'd like both of you to address, and that is, when you think of the conversation around start time of schools, a lot of that is about learning. dr. sizeler's done a lot of work with medical interns and residents and that's around hours of work for learning. and yet in both situations, we can also focus on the car crashes. so we're here at the national transportation safety board health well-being, but we're all about safety. and we're focused on this because lives get lost and people injured. and it seems that that piece and you showed the data that when you change the start time of schools crashes go down, safety improves, and i'm just wondering how much again there's been a lot of health and well-being especially focused on the learning part but really one of the, at least equally important hook here is the safety for all of these individuals at any level of our

educational system and for all of us generally to be focusing on how the safety element of this needs to be as included as health, well-being or learning anything else we want to be talking about here. >> well, you know i think that we're really going to enact change through education here. you know, i -- you know i listen to the radio. i commute by ferry. i listen to the radio quite a bit. i hear so many public health announcements from nhtsa in regards to distracted driving and impaired driving. i'd like to hear some about drowsy driving. you know, i think that you know, the academy through its national healthy sleep awareness project is going to be getting the word out but i think that, you know we -- there's going to come a point where everyone will be aware of this. i don't think we're there yet. but we have to keep knocking on the door, in order to get our message heard. >> i think that there has to be

a way to incentivize young people to get better sleep for their health and for their safety. and for the safety of their friends. and people they don't know on the roads. one of the first stories i ever heard about a teen fall-asleep crash is you know is a tragedy that is repeated many, many times in this country. and we just -- we aren't)t&g hearing them. we're not listening to them. we're not telling our children about them. this first crash is a young man who was, you know, well on his way to college he had gone to visit a college that he wanted to attend. he had stayed up late. he had driven too early in the morning. and he fell asleep, his car drifted, and crashed head-on with a car of another teenager killing both of them. i mean, it's just that kind of story, and that kind of, you

know, again it's the let's wake them up by telling them the worst that can happen. because they're not hearing that. they're not seeing that. and they're not, you know, it's just not part of what is the message that they're getting. that might help implement some change. >> great. thank you both for a great panel. mr. bragg your leadership, with just keeping at this high quality level of excellence here. to all of our safety leaders in the back. dr. carskadon didn't know you were coming but you made her day. if you didn't notice she was talking to all of you directly basically. so we're hoping you not only got some information to be educated but we may have saved the life and prevented an injury there with our folks that are here. we're about to break for lunch. i'm just going to take a little prerogative. i took it out of my opening remarks but i'm going to do it now. one of the things you just heard about dr. carskadon discuss was a sleep latency test which was

objective fizzological way to measure how sleepy people are. took two stanford professors to figure that out. i mention this because i was her first post doc out of gradual school, first one when she moved to brown, and it means do i know sleepiness alertness to that test, i know it extremely well. i mention this because part of my career was working at nasa and running something called the countermeasures program and the first call was from dr. carskadon saying mark what's this fatigue stuff? nobody knows sleep alertness better than you do. i'm bringing this up because our conversation was around specifically how people talk about sleepness, alertness drowsiness fatigue, et cetera. so i notice fatigue was in your title of your talk today. and the doctor was going to include this. you're going to hear a lot of words today fatigue drowsiness, sleepiness alertness. we're all talking about the same thing. we do not want to get pulled into a acceptantic discussion because we're really talking

about the same thing. but we've already heard those words used differently through the day and i just want to highlight whether it's fatigue, sleepiness drowsiness they're all dangerous and they're all part of this we're talking about now. we're going to adjourn for lunch. we will see you back here starting at 1:15. the 114th congress gavels in this tuesday at noon eastern. watch live coverage of house on c-span and the senate live on c-span2. and track the gop-led congress and have your say as events unfold on the c-span networks. c-span radio and c-span.org.

new congress, best access on c-span. >> we can join the conversation on what congress should focus on over the next two years on our facebook page. today's question is, your top issues for the 114th congress. here are a couple of the comments so far. carol brown suggests rebuilding our country, our infrastructure is falling apart around us. we're starting to look like a third world country. and dave russell writes, attack the 18 trillion dollar debt. even if it means a government shutdown. there isn't an election for nearly two years. and what do you think? let us know your thoughts at facebook.com/cspan. >> more from the national transportation safety summit on the dangers of driving drowsy. this panel focuses on sleep disorders and health issues like sleep apnea. experts say 85% of people with sleep apnea remain undiagnosed. this is about an hour and 15 minutes.

we are going to begin our fourth panel of the day. and the chair of that is dr. mary pat mckay. whenever you're ready. >> thank you very much member rosekind. as a reminder for the panel when you push the button on the microphone a green light will indicate the microphone is on. when speaking bring your microphone close to you and when finished please turn off the mic. in this panel, we'll discuss health issues. our panelists are dr. maurice ohayon, chief of mental health and population sciences at stanford university. dr. indira gurubhagavatula,

associate professor in the division of sleep medicine at the university of pennsylvania and the director of the sleep disorders clinic at the philadelphia veterans administration medical center. and finally dr. ronald farkas lead medical officer in the division of neurology products at the u.s. food and drug administration. dr. ohayon. >> member rosekind thank you very much to have invited me to this forum. so i will speak today about drowsy drivers in our generic population. so this data is coming from the survey that was realized in 2013. this study is very recent, and i am trying -- i will try to

present you what are the results we found about the drowsy driver and a link with the sleep disorder, the mental disorder, and also the medical condition. so in fact from where we are coming a number on drowsiness and accidents. generally speaking, they are coming from three reports, from transportation and safety agency. from insurance report. from clinical study for specific disease. all with numbers that are focusing on accidents, also sleepiness, but generally speaking with few number inside and rarely from population studies. the way to collect the data is

the correlation with the death toll are higher because, in fact, we find for example in the general population only the people that are alive and for just reason. the population survey representative of the general population are difficult to do, but are one of the best way to assess sleepiness at wheel without any consequences with the police, or with any kind of physical implication. the people are spontaneously reporting what is happening and like that we can see the impact on traffic accidents marginally. so the present study is based on a large representative sample of the american general population. i will go very fast on it. this study has two main objective to determine how many individuals experience sleepiness while at the wheel. of the motor vehicle.

to identify what are the characteristics of this individual in term of sociodemographic characteristics of their medical condition. secondly the treatment that are very important for these people sleepy at wheel. so the sample, the size of the sample is more than 19,000 people. we have a participation rate i give the participation rate only to say how much could be the results that we are presenting, 83.2% participation rate. the age range is between 18 and 100 years. the location, 15 states. we took 15 states and for each state we are representative according to the --

we have 13,300 individuals reporting driving motor vehicles at the moment. so it is 83.8% of the sample, and the results that we present you will see are for these people in majority. only to put the program with sleeping at wheel let me say that according to all the general population study the american population is sleeping around 6 hour 45. this number that repetively found inside of the population. so comparatively the duration of sleep in europe is around 7 hours. with one exception in uk where we found a number around 6 hour 50 minutes.

28% of the general population of america is experiencing daytime sleepiness. everyone is really a big number putting sleepiness as the first reason to have an accident. but also, something that is concerning the social relationship, familial at work, et cetera. so the consequence of all of that is that in our study we were needing to collect more information about the sleepiness we have a sleep disorder diagnosis according to the compound.

sleepiness at wheel by age and gender. i think that i have no pointer unfortunately but i can tell you that the difference between men and women is important at any kind of age. and generally speaking we find 10% of the general population for the men that is concerned when for the women is practically half. the traffic accident by age and gender i don't say sleep at wheel. i am saying only traffic accident by age and gender and you see that for the category of age between 18 and 24 we have the highest prevalence as the previous speaker was saying. we have after -- and peak at 35,

24, for the rest is comparable is no significant difference between all the group. the traffic accident with or without sleeping at the wheel in the past year as you see in red, i have sleeping at wheel. in gray, i have without sleeping at wheel. if you look at our -- our graph, you have inside the men and the women, and you see that the men have more traffic accidents in the past year than the women. and you see that without sleeping at the wheel so in red is sleeping at the wheel you see that we are practically for the men around 15% and we go with the women, around 10%, and you have comparatively the accident without sleeping at the wheel. sleeping at the wheel by the time of the accident very

interesting thing inside of the general population of america you see the number are for night time. like the previous speaker was saying, night time is really the biggest problem. and i must add that we found that the early morning is practically concerned. i have not put the bar here but we will come back on the next slides. the sleeping at wheel by night time sleep duration that is something that everyone have said i will go very fast on this saying that less -- more you sleep, less you have sleeping at the wheel. so this is very interesting thing, is only a confirmation that what the previous speaker was saying. sleeping at the wheel -- sleepy at the wheel by fatigue

severity, this is more interesting, and you see that we have many significant difference between the group and you see we have mild, we have moderate and we have severe and you see that we have a lot of people that are concerned, around 15%. the prevalence of sleeping at the wheel, and accident by automatic vehicle -- automatic vehicle we mean that the people are driving without taking care of anything they are in automatic pilot. they are going totally lucky for computer was going there. but is the responsible for a lot of accidents like you can see. we have there the frequency of the people that are concerned by that. you see 15% for the people that are sleepy.

and we have the car so accident in gray. so you see that sleepiness is not totally recovering the car accidents. we have practically something like i would say half more of sleepy people inside of the general population, and these people are driving. they are not all accidents. so to appreciate the -- the frequency, and the prevalence of sleeping at wheel, you must keep that in your mind. everyone have not an accident is why the police can be only under estimate. excuse me. the prevalence of sleepiness at the wheel by sleep disorder, and here is very interesting, because we have sleep apnea with

great strength and you see we have always the same kind of design for the bar in red the presence of the disorder. the absence of disorder when you have sleep apnea you see you have around 18% that are concerned, and you see on the side in gray, without sleep apnea. and you have the same for insomnia. and you see that insomnia sles powerful than sleep apnea to give sleeping at the wheel. surprisingly is doing more problem of sleepiness that insomnia inside of this sample but here the difference is not significant. the prevalence of sleepiness at the wheel by mental disorder. and you see that the disorder is exiting, and exiting in

comparison of the people without sleeping disorder bipolar disorder is also coming. and anxiety disorder could be there. but again, what is really without any discussion is a depressive disorder. the prevalence of sleepiness at the wheel by alcohol consumption, and here you see if you take -- with the number of drinks that the people are taking you will say, oh, i see six drinks is not so much difference, is because in my opinion, they are in the bed and they are not moving anymore. if you look at the category it's small that we have. for the prevalence of sleepiness at the wheel by medication. and here some big surprise, anti-arhythmic agents are

exiting strongly, and the anti-psychotic also and something very surprising but not so surprising i suppose for the people of the fda is otc drugs because of the presence of anti- -- inside the project i verify is really this project that are responsible of that. the antidepressant you see, they have a participation, but, not so high. so what is the best predictor of sleepiness at wheel for men 35 years old? you see, here we have the fact to take daily alcohol, the fact that you are fatigued and the fact that you have sleep apnea. this is explaining 47% of the

variance. when we are taking the best predictor for the people the men more than 35 here you find a lot of explanation, so the sleep disorder are there. they are ordered by frequency, and this is explaining 48% of the variance. to respect the time, i must go faster. best predictor of sleepiness at wheel for women and you see that also there we have for example something that is more present for the women, the otc, and this is explaining all this four factors are explaining, 46% of the variance. we have for the best predictor for the women more than 35 and here also we have sleep apnea that is exiting with 45% of the variance. again sleep apnea has a big

presence in all these best predictors that we can find for this population. the best predictor of traffic accident, that is interesting, i hope hope, so sleep you have again sleep apnea, and you see that 41.8% of the variance is explained. again this predictor are very strong. and best predictor of traffic accident for men more than 35 years old. i will go through directly to the conclusion to finish in time. so sleepiness, while driving is relatively frequent affecting 9% of men and 4.3% of the women, representing and that is a big number 13.4 millions of american drivers. the sleepy individual at the wheel have nearly two times more chances to be enrolled in the traffic accident in the past

year and that clearly knows the population. the factor associated with sleepiness at the wheel are numerous sleep deprivation, fatigue, insomnia, sleep apnea, depression, anxiety disorder alcohol and medication including otc. thank you very much. >> thank you. dr. g. >> hi member rosekind doctors price and mckay, thank you for the invitation. i appreciate the opportunity to be here. so, i'm going to be talking diseases and health conditions that lead to daytime sleepiness and i'm going to begin by reiterating the process that dr. carskadon illustrated so beautifully in her talk. what determines how alert we are at any given 24 hour period, our alertness fluctuates over the course of the day.

and it's determined by two different processes. one is called the home yo static process, or process h. and that's indicated by the downward pointing arrows on the top of the slide. and what that says is that the longer we are awake as the day goes on the greater the drive to fall asleep. and after we fall asleep the longer we've been asleep, the less our drive to continue to sleep. now that process is counterbalanced by another process which is an alerting inging process that's driven by an androgynous pacemaker and that has us be the most alert late in the day and in the early evening. there is a dip in the middle afternoon. that's our siesta time. but that process also drives the incredible sleepiness that we feel in early morning hours. and of course, our behavioral capability, our ability to operate a motor vehicle varies according to our level of sleepiness. and in real life things are never this clean and easy. there are always other factors that can modify our level of alertness. they can be internal to us or

external to us. so whether we're feeling stressed or anxious, whether the situation is urgent, we're highly motivated about something then we'll be more alert. and if we've consumed alcohol or taken certain types of medications or if we're being sedentary, then we may be less alert. so the disorders that cause sleepiness can impact any of these processes. there can be disorders that increase the amount of time we're awake. patients with insomnia have a hard time falling asleep. patients with sleep hygiene issues, there can be circadian rhythm disorders like shift work, sleep disorder or jet lag. and then there's a group of disorders that directly impacted duration and quality of sleep. that includes sleep apnea restless legs as dr. ohayon alluded to certain medical disorders such as heart failure, emphysema that can cause gasping or breathing difficulties at

night, certain psychiatric disorders like anxiety or ocd where people have a hard time staying asleep. and certain think some medications. i'm going to focus on sleep apnea and it's epidemiological hugely important problem. it has a very important association withdrawsyness while we drive. so i'm going to cover what it is, who is likely to have it, how common is it, what are the usual symptoms, what are the consequences, can we zieg know us quickly at low cost. and does it make sense economically. let's go so i have 11 minutes. here we have an airway. the blue arrows represent air moving down the wind pipe and into the lungs. so this when we are awake we're breathing getting plenty of air. so sleep apnea does not happen when we're awake it only happens when we're asleep. and there the upper airway actually collapses, and it blocks the progress of air into

the throat and down into the lungs. so why does that happen when we're asleep? what's different? well, people with sleep apnea can have an airway that's narrowed. it can be narrowed because of excess fatty tissue that's built up in the upper airway. and by far obesity is the strongest risk factor for sleep apnea. not saying all patients with apnea are obese, but it definitely is one of the strongest risk fatters that we know of. airways can also be crowded with large tonsils, or if there's a large tongue or if the jaw is recessed and set back like don knotts instead of jay leno. heredities and other factors, and airways can be floppier as we get older. everything kind of gets floppier as we get older and the airway is no exception. men are also at higher risk, and women after entering menopause. nasal congestion can contribute to sleep apnea. we would have to suck harder to get the air in past a blocked airway so we can suck the airway

shut. alcohol and sleeping pills can block the nerves that control the upper airway muscles and make it easier for the muscles to collapse. so what happens when those walls collapse together is they start to vibrate. and that's when the bed partner tells you to go sleep on the couch because they hear the snoring. and other times the air can be blocked completely, and that's what's known as an apnea. and sometimes it can be partially blocked. so some air gets in but not the full flow and that's called a hypopnea. the brain has a sensor for this and sends a signal for the muscles to wake up just enough to reopen the airway. and that signal is usually a burst of adrenaline which we all know is a stress hormone. now during those few seconds when the airway is closed it's not like your heart and brain get to take a break and go work for someone else. they continue to work. but they're just doing it without oxygen. so that alerting signal the adrenaline, causes those muscles to reopen, and for air flow to

get re-established. and once that happens it's now the coast is clear and we can go back to sleep but as soon as we do the airway closure happens again. and this can continue like this all night long. and when i ask my patients how do you think you feel the next day after spending a night like this, their usual response is, the way i feel right now. and the most important thing for them to know at that point is that when you feel like that the most dangerous thing you can do some rate a motor vehicle. there are 18 studies in car drivers as well as two in truck drivers that were reported in this analysis that was commissioned by the fmcsa that show that the odds of a crash in people with sleep apnea range from 1.21 to 4.89 which means there's at least a 21% chance higher chance of having a crash up to a 4.9-fold increase. so what happens at night in a person with sleep apnea is that they may snore, they may choke they may gasp they may have to get up and urinate frequently

because of the pressure swings in the chest which fool the body into thinking that there isn't enough fluid, and that can cause some fluid imbalances and increased urination. a lot of times they're not even aware they're doing any of this and they're told by a bed partner. so, these events that are associated with low oxygen and surges of adrenaline which over the long run can contribute to the development of hypertension heart disease, stroke, pre-diabetes and even death. each of these events is terminated by an arousal, and frequent arousals can lead to daytime sleepiness and increased crash risk. but can also lead to mood disturbances irritability sadness, forgetfulness, difficulty with focusing difficulty with sustaining attention and with executive decision making which dr. carskadon referenced. reaction time, if someone were to cut them off on the road can take longer. they can often experience morning headaches, impotence and also there are studies linking sleep apnea to reduced

productivity at work and absenteeism. and all of this gets worse as people gain weight. now, as a country, we're facing a huge obesity epidemic. and a recent analysis looked at what would happen to current prevalence estimates of sleep apnea. we know that 9% of men and 4% of women had at least moderate to severe apnea in 1994 when those data were applied to current rates of obesity the numbers almost tripled. so the way we identify this disorder was traditionally by using something called in-lab sleep study. this required patients to come in and get hooked up and they would have hires taped to the head that measured brain waves, and also eye movement and chin and leg muscle active if is and all of that taken together told us whether they were asleep or not. we alsotsv'ñ used chest and abdominal belts to measure breathing air flow and snoring sensors to tell us is the air flow decreasing or is it completely absent even though there's ongoing

respiratory effort, and did the oxygen level drop by using a finger clip. and with this technology, we know that 85% of cases of sleep apnea remained undiagnosed. now, what's really encouraging is the development recently of what are called portable sleep studies, and there there's no usually no eeg monitoring. instead we just use the chest and abdominal effort belts air flow snoring and oxygen sensors. there are variations to this type of a model. but the beautiful advantage of this type of a device is that a patient can assemble it themselves in their own home, and they're much more convenient for people who are shift workers, who sleep away from home a lot, and they've really increased the accessibility. so once its diagnosed can we treat sleep apnea? and i tell my patients think of your airway like a tire. when you were a kid and you had a bicycle and you had a flat tire, what would you do? you would blow it up with air. and we have this device called a continuous positive airway pressure machine and they've

become so sophisticated now that we don't need to bring patients back in in most circumstances to repeat the sleep study to determine the pressure level. these machines have automatic sensors that can determine for you. directly in the home. and there are so many dozens of different masks, full face mask for mouth breathers masks that let you sleep on your side or on your back. and these machines, it's just a flow generator that measures -- that blows air into the throat and keeps that airway open when the patient sleeps. and with an open airway it's now possible to have a continuous flow of oxygen and with oxygen, patients can finally sleep. and get a break from all that adrenaline. and we know with randomized trials, they've shown that cpap lowers crash risk it improves alertness in as little as one night of use and performance in a driving simulator can improve in as little as two to seven days. we also have randomized control trials that show that people just feel better. their blood pressure is lower. their heart disease and stroke

risk, even their mortality, all improve. and we know that they spend less money on health care. there are other therapies including oral appliances and upper airway surgeries. the body of evidence that supports the use of cpap is so enormous that that usually tends to be the first line therapy. we also recommend that patients lose weight, that they limit alcohol, sleeping pills narcotics to the lowest amount that they can get away with. avoid tobacco smoke, which can otherwise increase upper airway swelling and make the airway more collapsible. and also to keep the nasal passages open by controlling nasal congestion. and if they need surgery then we'll advise surgery to correct any deviated septum in the nose so they can col rate cpap more efficiently. now we also can monitor is someone using their cpap. these devices have not only sd cards but they have modems that snap onto the back of the machine, and it allows us to

track night to night how many hours that they use it what was the pressure level, is there still apnea going on and was the mask leaking? so we can address these issues as we go. and this is an example of such a download, and the green color indicates that the person used it for at least four nights. and you can see night after night, and on the fifth night they skipped it, so it was blank. so in summary i would say that sleep apnea is extremely common. it's definitely been linked to sleepiness, and to crashes as well as major economic and health outcomes. and importantly, it can be diagnosed in the home. cpap treatment is inexpensive, it's accessible, it's been shown to lower crash risk. it improves many health conditions. lowers health care costs. and can be tracked in realtime. thank you. >> thank you very much. our final panelist will be dr. ronald farkas of the food and drug administration. dr. farkas? >> hi, i'm ron farkas i'm a

clinical team leader in the division of neurology products in the center for drug evaluation and research at the food and drug administration. i'd like to thank the ntsb for inviting the fda here to talk. and i'm going to start with a slide that first says that the views i'm going to express are those -- that are mine and not necessarily of the fda. but one of the discussion questions that will come up soon is what the fda is saying to patients to help them understand the risks from drugs as regards introduciness and regards driving. so in this presentation, there are -- it's a little hard to see but there's yellow only on my screen i guess it's hard to see. there's yellow highlights around some text and that text is from web pages that the fda has that help patients to understand risk from drugs, and also the picture on the right is from a pamphlet that's available to patients who

would like to learn more about the effects of drugs on driving. so, the fda is really trying to communicate very clearly the risks that can occur from prescription and over-the-counter drugs to use very clear language and make very clear recommendations. so like you see here, fda, and actually working with the nhtsa and ntsb and other sister agencies warns patients that both prescription and over-the-counter medications can make it unsafe to drive. and one important way that the fda judges the acceptability of risk of drugs, all drugs have risk, but what's an acceptable risk, and we actually look to examples like introducey driving or examples like drunk driving like driving under the influence of alcohol to try to understand

society's tolerance for risks from drugs. so one of the things that we look at is the legal definition. not to give legal advice, but to warn patients about, well, if if you take this particular drug would you be impaired to the same degree that you might be from alcohol at the legal limit for driving, and i think, too, that normally when you think of adverse events from drugs, you think about, you know, injury to your liver or skin reactions, and that kind of thing but certainly crashes are a serious adverse event and even the whole -- even if it's notnln illegal, being stopped by the police, that would certainly be something that patients would be interested in avoiding. so car crashes are kind of right

in the middle of frequent events and rare events so if you give somebody a drug and they get into a car crash, well, they're frequent enough so that you can't say necessarily that the drug caused the car crash, and yet they're rare enough so that if you do a normal sized clinical trial of an experimental drug, you only see a few car crashes and you don't really have the statistical power to determine most of the time if the drug increased the risk of the car crash and studies could be designed randomized controlled trials could be designed to investigate the increased risk of a car crash from a drug but they'd have to be very large and most of the time that's not practical, and also, there is some ethical considerations that if you have a suspicion that a drug would cause an increased risk of car crashes, then it would be problematic to enroll patients and expose them to that

risk, and again, looking to examples from alcohol and from drowsy driving, one approach that we've been looking at at the fda is the effect that drugs have on driving skills and this is very helpful because drugs are -- i mean certainly sleep is complicated but drugs are extremely complicated, a drug for insomnia, of course, when the blood level's high. of course it's dangerous to drive, but then the question becomes well how many hours after taking the drug would it be safe to drive again, and so some of these kinds of detailed questions about drug levels or individual patient variability, that is much easier to address in a controlled trial, in a laboratory, with a driving simulator, and an instrumented car. so this, again, is an image from

the fda website, and stressing that knowing how your medications, and importantly any combination of them affect your ability to drive is a safety an important safety measure that involves the patient their passengers and others on the road, and in fact, the sign here, the traffic sign shows a whole list of problems that could be caused by drugs that could affect your ability to drive, in addition to sleepiness, you know, some of the others are more straightforward in terms of the patient perceiving the problems to like blurred vision or fainting, one of the things that's been talked about today is that patients are often unaware of drowsiness and other effects on their thinking and

so that it's less reliable to judge ability to drive after you've taken a medicine based on if you feel awake and feel alert. there's a tremendous complexity to trying to understand the effects of drugs that are mixed together. already, it's difficult to understand the effects of drugs in different people who have different blood levels after taking the same dose who eliminate the drug at different rates, and so one thing the patients need to be aware of is that combinations of drugs like two drugs that cause sleepiness can have a far greater effect than taking one drug alone and there's really a very large number of drugs that cause sleepiness, and they increase that risk in placebo controlled trials and we often see things like 10% of patients who take the drug are sleepy during the

day versus 3% of the people on placebo and it's a randomized sample, and they have the same disease, so we know about that kind of increased risk and this is represented in the label for drugs, and the website for the fda gives a kind of a long list of categories and we would recommend that people, of course, check with their health care provider and with the pharmacist and read the drug labels and information that comes with the drugs and this list just shows how a very large variety of drugs can cause sleepiness, drugs for anxiety, some antidepressants, drugs containing codeine narcotics some cold remedies, allergy products tranquilizers, sleeping pills, and then at the bottom, it lists diet pills, and one thing that we're also concerned about is that there's the possibility of an increased

risk of crashes from sleepiness but some drugs might affect a person's judgment and even if they're awake, that that could lead to problems with decision-making or aggressive driving, if you will, and so that's one characteristic of stimulants that we're interested in evaluating. so when thinking about what should be assessed, this line here is says safety concerns may differ depending on the drug and patient population, and i think really to say it most clearly that is that the drugs have different effects on different people and right now i think doctors and the fda are struggling a little bit with how to identify patients, you know, just the individual patient who might be more at risk or let

risk from a particular drug, but that's really the ideal place to look. lot of patients can take a drug safely and some patients are at risk, and the goal would be to try to identify those patients who are sleepy from the drug. we've taken a lot of guidance from some work done by nhtsa, with ntsb. there have been meetings and expert panels and i apologize that this is small, but it's really kind of a framework for the fda that we've been using to evaluate drugs. up in the left-hand corner there's really the basic pharmacology of drugs what receptor are they binding to what neurotransmitter systems in the brain are they affecting. that can give a strong indication if a drug is going to be impairing, benzodiazepine, often used for sleep or anxiety, those generally cause a great deal of sleepiness.

then up to the right there's epidemiological evidence so there is evidence that drugs that can make people sleepy do increase the risk of traffic accidents, and then down at the bottom is this focus on standardized studies, taking a look at neuropsychological tests, measuring alertness and arousal, kind of going through actually all the important brain functions, the brain functions are important for driving certainly arousal, sleepiness is very important but it would even go on to things like executive function and in the setting of studies for drugs, again, we can ask drug developers to enroll patients or healthy volunteers and do randomized placebo-controlled trials have positive controls,

and get a really good idea of skills important for driving like being able to stay within the lane of the highway. so at this point, we were i think changing to a more sophisticated analysis of drugs. previously we were collecting of course a lot of data about patient's complaint of sleepiness and representing that in the label and now more recently we have labels, three are listed here where they go into some detail about the kinds of driving studies that were done and the kind of results and then we make recommendations about the dose and as the dose increases, again some of these drugs, these are involving sleep, at the highest dose sometimes we will seeay

essentially that unless the physician and patient know that the patient isn't impaired not just that they don't feel sleepy, it might not be a good deal to drive or maybe there's another, better drug to are that patient. thank you. oh, no, one more i'm sorry. so the risk mitigation really as it was talked about earlier today. in some cases probably in many cases, patients aren't aware that they're sleepy from a drug or that it has effects on their judgment. certainly if they do feel sleepy or do feel impaired, they shouldn't drive but that should be paired with again from the fda website learning to know how your body reacts to the medicine, and a lot of this gets back to the pharmacology really, to the dose to taking the lowest