Fitness-to-drive recommendations in post-stroke patients: a retrospective study.

BACKGROUND: Stroke sequelae can have an impact on daily life activities such as driving. French legislation stipulates that post-stroke patients should undergo a multi-professional fitness-to-drive assessment before being allowed to drive again. This retrospective study aims to explore the determinants of multi-professional fitness-to-drive recommendations. METHODS: Sixty-six post-stroke patients assessed for fitness to drive in the Kerpape Center, France in 2019 were included. Favorable or unfavorable driving recommendations were attributed to patients following a joint decision by a multi-professional team. Individual characteristics obtained from medical records were compared. RESULTS: Findings showed that 64% of stroke patients received a favorable fitness-to-drive recommendation. Across all demographic, clinical, and driving characteristics, the time interval between stroke and assessment was significantly longer for patients designated as unfit to drive than for those designated as fit to drive (P = .004). Furthermore, the proportion of instrumental sequelae was higher in patients designated as unfit to drive than in those designated as fit to drive (P = .022). Stepwise logistic regression showed that the presence of instrumental sequelae, mainly aphasia, was the best predictor of fitness-to-drive recommendations. CONCLUSIONS: The post-stroke time interval and the presence of instrumental sequelae explained the difference between patients recommended as fit-to-drive and unfit-to-drive. Furthermore, aphasia was found be the best predictor of a fitness-to-drive recommendation. It is possible that aphasia impacts the understanding of instructions during on-road testing. These findings emphasize the need for a standardized multi-professional fitness-to-drive assessment, since the determinants of fitness-to-drive recommendation differ between studies.

[Impact of cardiovascular diseases on fitness to drive: mobility limitations in the elderly]. / Einfluss kardiovaskulärer Erkrankungen auf die Fahreignung: Mobilitätseinschränkungen im Alter.

The prevalence of cardiovascular diseases increases with age. Common symptoms such as dyspnea, chest pain, dizziness, or syncope can impact driving fitness. Due to a growing number of private drivers aged 65 and older and an increasing prevalence of cardiovascular diseases, questions regarding driving fitness restrictions for cardiological patients are gaining prominence in clinical settings. This article aims to summarize current recommendations for driving fitness in the context of cardiovascular diseases. The basis for the guidelines includes the Driving License Ordinance, the expert assessment guidelines of the Federal Highway Research Institute, and the guidelines of the German Society of Cardiology on driving fitness. Original literature on this topic is limited.Emphasizing an individualized assessment, clear guidelines for driving fitness in cardiac diseases or their symptoms and treatments are formulated. Regardless of the cardiac condition, the symptoms and likelihood of sudden loss of consciousness play a leading role in driving fitness assessment. Resulting impairments can range from a few weeks to a complete revocation of driving fitness. Regular examinations and differentiated assessments by medical professionals are prerequisites for maintaining driving fitness.The driving fitness of older private drivers is a significant and practical topic in cardiology. Current guidelines support the treating physicians in providing appropriate recommendations.

[Reduced mobility in the elderly due to medication, alcohol, and cannabinoids]. / Einschränkungen der Mobilität von älteren Verkehrsteilnehmern durch Medikamente, Alkohol und Cannabis.

Many diseases are accompanied by symptoms that can impair the ability to perform complex everyday tasks, such as active participation in road traffic. If a cure is not possible, the aim of drug therapy is to alleviate the symptoms to such an extent that the patient no longer has any restrictions in everyday life. However, around 20% of the approximately 100,000 medicines licensed in Germany have traffic-relevant side effects that can also lead to driving impairment.It is assumed that the effect of a drug is at least partially responsible for one in four traffic accidents and that one in ten victims of fatal road accidents has taken psychotropic drugs before driving. In addition to alcohol and drugs, medications from the benzodiazepine, opioid, and antidepressant groups are suspected of impairing driving safety in particular. The effects of these substances on young people have been described many times, but this review deals specifically with the traffic-relevant (side) effects of various classes of drugs on elderly people (aged 65 and over).Older people in particular often have to take different medications, which are metabolized differently compared to younger people due to underlying diseases and can also interact with each other. It was found that (1) older people often react more sensitively to substances, (2) not all representatives of a drug class have the same effect on driving safety, and (3) a general assessment of a drug's safety is not possible, since the effects also depend on other factors such as underlying diseases, treatment regimen, and the time of day the medication is taken.

[Checking the fitness to drive of senior citizens under German law-pending corrective measures to ensure road safety]. / Die Überprüfung der Fahreignung von Senioren nach deutschem Recht ­ Anstehende Korrekturbedarfe zur Gewährleistung der Verkehrssicherheit.

German driving licence law takes a reactive approach to dealing with suitability deficiencies of senior citizens. If the driver is no longer fit to drive and nevertheless participates in traffic, an administrative offence has been committed. If this endangers or injures other people or causes significant damage to property, it may even be a criminal offence. In addition to prosecuting these offences, the driving licence authority may restrict or even withdraw the licence issued. In this respect, senior citizens have a high degree of personal responsibility when assessing their fitness to drive. This article presents the current driving license law and discusses the need for changes.Legally, various corrections are required to the current Driving Licence Ordinance and its annexes. At present, there is no clear regulation regarding the general reduction in performance in old age for an event-related assessment of fitness to drive. In addition, in the event of doubts about fitness to drive, the driving licence authority should be expressly granted the power to order standardised driving tests. Furthermore, the legislator must take preventive measures to ensure road safety. He must no longer ignore the current accident situation. In view of the fact that senior citizens aged 75 and over are disproportionately involved in traffic accidents with personal injury in terms of their culpable behaviour, it is important to impose moderate restrictions on the personal responsibility of driving licence holders. This is especially true for sensory abilities, which are particularly important in road traffic. Seniors should therefore be required to undergo eye tests from the age of 75. From this age onwards, it also seems sensible to introduce compulsory advice on fitness to drive, preferably from your family doctor.

The Impact of Age, Sex, and Position on Visual-Motor Processing Speed and Reaction Time as Measured by the Vision CoachTM.

Occupational therapists are in a unique position to screen and evaluate fitness to drive with both visual-motor processing speed and reaction time being important factors to consider when determining fitness to drive. This study uses the Vision CoachTM to investigate the differences in visual-motor processing speed and reaction time across age and sex of healthy adults. It also explores whether the position of sitting or standing made any difference. The results showed no difference between male/female or standing/sitting positions. However, there was a statistically significant difference between age groups, with older adults demonstrating slower visual-motor processing speed and reaction times. These findings can be used for future studies to explore the impact of injury or disease on visual-motor processing speed and reaction times and its relation to fitness to drive.

Skin temperature as a predictor of on-the-road driving performance in people with central disorders of hypersomnolence.

Excessive daytime sleepiness is the core symptom of central disorders of hypersomnolence (CDH) and can directly impair driving performance. Sleepiness is reflected in relative alterations in distal and proximal skin temperature. Therefore, we examined the predictive value of skin temperature on driving performance. Distal and proximal skin temperature and their gradient (DPG) were continuously measured in 44 participants with narcolepsy type 1, narcolepsy type 2 or idiopathic hypersomnia during a standardised 1-h driving test. Driving performance was defined as the standard deviation of lateral position (SDLP) per 5 km segment (equivalent to 3 min of driving). Distal and proximal skin temperature and DPG measurements were averaged over each segment and changes over segments were calculated. Mixed-effect model analyses showed a strong, quadratic association between proximal skin temperature and SDLP (p < 0.001) and a linear association between DPG and SDLP (p < 0.021). Proximal skin temperature changes over 3 to 15 min were predictive for SDLP. Moreover, SDLP increased over time (0.34 cm/segment, p < 0.001) and was higher in men than in women (3.50 cm, p = 0.012). We conclude that proximal skin temperature is a promising predictor for real-time assessment of driving performance in people with CDH.

A Systematic Review of the Risks of Motor Vehicle Crashes Associated with Psychiatric Disorders.

OBJECTIVE: Psychiatric disorders and their treatments have the potential to adversely impact driving skills. However, it is unclear to what extent this poses a public health risk by increasing the risk of motor vehicle crashes (MVCs). The aim of this systematic review was to synthesize and critically appraise evidence on the risk of MVC for drivers with psychiatric disorders. METHOD: We conducted a systematic review of the MVC risk associated with psychiatric disorders using seven databases in November 2019. Two reviewers examined each study and extracted data. The National Heart, Lung, and Blood Institute Quality Assessment tools were used to assess each study's quality of evidence. RESULTS: We identified 24 studies that met the inclusion criteria, including eight cohort, 10 case-control, and six cross-sectional designs. Quality assessment ratings were "Good" for four studies, "Fair" for 10, and "Poor" for 10. Self-report or questionnaires were used in place of objective measures of either MVC, psychiatric disorder, or both in 12 studies, and only seven adjusted for driving exposure. Fifteen studies reported an increased risk of MVC associated with psychiatric disorders, and nine did not. There was no category of disorder that was consistently associated with increased MVC risk. CONCLUSION: The available evidence is mixed, not of high quality, and does not support a blanket restriction on drivers with psychiatric disorder. An individualized approach, as recommended by international guidelines, should continue. Further research should include objective assessments of psychiatric disorders and MVC risk and adjust for driving exposure.

Analysis of Part 1 of the latest Austroads Guidelines, June 2022.

The Austroads Fitness to Drive Guidelines were updated in 2022. Most of the focus to date has been on Part 2 of the Guidelines, which provide guidance as to specific medical conditions. Less attention has been paid to Part 1 of the Guidelines, which cover a medical practitioner's ethical and legal obligations. This paper addresses the imbalance by considering and amplifying the obligations discussed in Part 1 of the Guidelines.

Fitness-to-drive after adult civilian traumatic brain injury: protocol for a systematic review and meta-analysis.

Traumatic brain injury (TBI) poses significant challenges for assessing fitness-to-drive (FTD) and determining the appropriate timing for return-to-driving (RTD) in civilian adults. This systematic review and meta-analysis protocol is designed to offer a comprehensive assessment of RTD timelines post-TBI, examining the effects of injury severity as well as demographic and clinical factors that influence driving capabilities. In response to gaps identified in previous literature-namely, the absence of recent systematic search strategies and thorough quality assessments-this study employs rigorous methodologies for literature search, data extraction, and evaluation of study quality. Our approach aims to provide reliable estimates and detailed analyses of subgroups within the TBI population. The findings aim to support clinical decision-making, inform RTD readiness, and potentially impact policy and driving assessment protocols. Ultimately, this review seeks to contribute to public safety measures, reduce traffic-related harm, and improve life outcomes for individuals recovering from TBI, thereby filling a vital research niche in neurotrauma rehabilitation.

Effectiveness of a time to fixate for fitness to drive evaluation in neurological patients.

We present a method to automatically calculate time to fixate (TTF) from the eye-tracker data in subjects with neurological impairment using a driving simulator. TTF presents the time interval for a person to notice the stimulus from its first occurrence. Precisely, we measured the time since the children started to cross the street until the drivers directed their look to the children. From 108 neurological patients recruited for the study, the analysis of TTF was performed in 56 patients to assess fit-, unfit-, and conditionally-fit-to-drive patients. The results showed that the proposed method based on the YOLO (you only look once) object detector is efficient for computing TTFs from the eye-tracker data. We obtained discriminative results for fit-to-drive patients by application of Tukey's honest significant difference post hoc test (p < 0.01), while no difference was observed between conditionally-fit and unfit-to-drive groups (p = 0.542). Moreover, we show that time-to-collision (TTC), initial gaze distance (IGD) from pedestrians, and speed at the hazard onset did not influence the result, while the only significant interaction is among fitness, IGD, and TTC on TTF. Obtained TTFs are also compared with the perception response times (PRT) calculated independently from eye-tracker data and YOLO. Although we reached statistically significant results that speak in favor of possible method application for assessment of fitness to drive, we provide detailed directions for future driving simulation-based evaluation and propose processing workflow to secure reliable TTF calculation and its possible application in for example psychology and neuroscience.

Fitness to Drive: It is Time for Evidence-Based Consensus and Italian Guidelines for Medical Driving Assessment.

European Union (EU) and non-EU countries have adopted different medical procedures for the issuance and renewal of a driver's license showing relevant matters of concern. In Europe, EU directives have been only partially supplemented with national laws, and there is a paucity of evidence-based criteria and methods for fitness-to-drive assessment. For instance, there is no agreement on standards for establishing which is the competent authority charged with the medical examination. Furthermore, license conditions, restrictions, or vehicle modifications, which appear as "limited use" codes on the driver's license are not regulated. This may generate confusion and deformity when it comes to the medico-legal evaluation, with potential ethical implications due to lack of transparency and equity and legal disputes between citizens and competent authorities. In this article, Italian experts on fitness-to-drive medical assessment highlight some major issues concerning the medical driving assessment activity in the EU. The Italian experience is shown as a case study, which is representative of other EU member states, for launching a call for evidence-based consensus documents and scientific guidelines on this topic, which may be helpful to international regulators and medico-legal stakeholders.

Comparing objective wakefulness and vigilance tests to on-the-road driving performance in narcolepsy and idiopathic hypersomnia.

Patients with narcolepsy or idiopathic hypersomnia (IH) are at increased risk of driving accidents. Both excessive daytime sleepiness, i.e. unwanted sleep episodes during the day, and disturbed vigilance are core features of these disorders. We tested on-the-road driving performance of patients with narcolepsy or IH coming in for a routine driving fitness evaluation and examined: (1) correlations between driving performance and the Maintenance of Wakefulness Test (MWT), Sustained Attention to Response Task (SART) and Psychomotor Vigilance Test (PVT) as objective tests; (2) the predictive power of the MWT and SART for increased risk of impaired driving; (3) the best set of objective predictors for increased risk of impaired driving. Participants were 44 patients (aged 18-75 years) with narcolepsy type 1 (NT1), type 2 (NT2) or IH. They completed the MWT, SART, PVT, a subjective sleepiness questionnaire, and a standardised on-the-road driving test. The standard deviation of the lateral position (SDLP) was used as outcome measure of driving performance. The MWT had low correlation with the SDLP (ρ = -0.41 to -0.49, p < 0.01). The SART and PVT had low correlations with SDLP (ρ = 0.30 and ρ = 0.39, respectively, both p < 0.05). The predictive power of MWT for an increased risk of impaired driving was significant, but low (area under the curve = 0.273, p = 0.012), and non-significant for SART. We conclude that in our present group, none of the tests had adequate ability to predict impaired driving, questioning their use for clinical driving fitness evaluation in narcolepsy and IH. Real-time monitoring of sleepiness while driving seems more promising in these patients.

Strong evidence for age as the single most dominant predictor of medically supervised driving test-mini mental status test outcomes provide only weak but significant moderate additional predictive value.

BACKGROUND: With age, medical conditions impairing safe driving accumulate. Consequently, the risk of accidents increases. To mitigate this risk, Swiss law requires biannual assessments of the fitness to drive of elderly drivers. Drivers may prove their cognitive and physical capacity for safe driving in a medically supervised driving test (MSDT) when borderline cases, as indicated by low performance in a set of four cognitive tests, including e.g. the mini mental status test (MMST). Any prognostic, rather than indicative, relations for MSDT outcomes have neither been confirmed nor falsified so far. In order to avoid use of unsubstantiated rules of thumb, we here evaluate the predictive value for MSDT outcomes of the outcomes of the standard set of four cognitive tests, used in Swiss traffic medicine examinations. METHODS: We present descriptive information on age, gender and cognitive pretesting results of all MSDTs recorded in our case database from 2017 to 2019. Based on these retrospective cohort data, we used logistic regression to predict the binary outcome MSDT. An exploratory analysis used all available data (model 1). Based on the Akaike Information Criterion (AIC), we then established a model including variables age and MMST (model 2). To evaluate the predictive value of the four cognitive assessments, model 3 included cognitive test outcomes only. Receiver operating characteristics (ROC) and area under the curve (AUC) allowed evaluating discriminative performance of the three different models using independent validation data. RESULTS: Using N = 188 complete data sets of a total of 225 included cases, AIC identified age (p < 0.0008) and MMST (p = 0.024) as dominating predictors for MSDT outcomes with a median AUC of 0.71 (95%-CI 0.57-0.85) across different training and validation splits, while using the four cognitive test results exclusively yielded a median AUC of 0.55 (95%-CI 0.40-0.71). CONCLUSIONS: Our analysis provided strong evidence for age as the single most dominant predictor of MSDT outcomes. Adding MMST provides only weak additional predictive value for MSDT outcomes. Combining the results of four cognitive test used as standard screen in Swiss traffic medicine alone, proved to be of poor predictive value. This highlights the importance of MSDTs for balancing between the mitigation of risks by and the right to drive for the elderly.

Driving ability in patients with dizziness: a systematic review.

PURPOSE: The aim of this systematic review was to identify and evaluate studies dealing with driving performance of dizzy patients or patients with a vestibular disorder. METHODS: A systematic review was performed according to the preferred reporting items for systematic reviews and meta-analysis guidelines. (1) PubMed, Embase, and Cochrane library. (2) Study selection: articles about driving ability and reported driving difficulties in patients with dizziness, or a diagnosed vestibular disorder, were included. (3) Data extraction was performed by two independent authors using predefined data fields: patient's characteristics, diagnostic criteria, sample size, and type of evaluation of driving ability and outcome of the study. RESULTS: Eight out of 705 articles matched the inclusion criteria but varied widely regarding the study population, study design, and outcome measures. The majority of studies reported a negative impact of dizziness and/or vestibular disorders on self-reported driving ability and car accidents. Yet several studies could not identify any impairment of driving ability. CONCLUSIONS: Driving ability was negatively affected by dizziness or a vestibular disorder in the majority of included studies with low risk of bias. This systematic review revealed a significant heterogeneity in studies reporting driving performance and contradictory results. We were, therefore, unable to identify a causal relationship between dizziness and driving ability. There is a need for prospective studies in populations with different vestibular disorders using subjective and objective outcome measures that have been validated to evaluate driving performance.

Effectiveness of an intervention to reduce accidents in bus drivers.

BACKGROUND: Medical incapacity at the wheel is a small but significant factor in accident causation. To mitigate against this, in July 2017 a UK-based bus operator changed its medical assessment policy, requiring all future medicals to include a request to the General Practitioner (GP) for information about any conditions in the medical record which could affect fitness to drive. AIMS: To evaluate the impact of the change in policy on accident rates. METHODS: Accident data were obtained over a 5-year period, with information on age and length of service of drivers, from three bus depots. Monthly accident rates, before and after the change in policy were compared with the Wilcoxon matched pairs test, and a line of best fit/R2 obtained via a scatter graph. RESULTS: Although a general downward trend in accident rates was seen, there was no statistically significant difference between the overall accident rates in the 12 months before and after the policy change in July 2017 (P-value = 0.519, significance level P < 0.05). CONCLUSIONS: The downward trend in accident rates observed over the study period could not be attributed to the change of policy. However, this intervention warrants further scrutiny due to the potential consequences of passenger service vehicle accidents. Evidence suggests that professional awareness of the UK Driver and Vehicle Licensing Agency fitness to drive standards can be limited, so requesting GP input into driver medicals may raise awareness of these standards from an occupational health perspective.

Fitness to Drive: A Smartphone Application for Doctors, Patients and the Driver Licensing Authority.

Medical fitness to drive in Victoria is currently governed by the Austroads Fitness to Drive Guidelines. Doctors are expected to review the 188-page document and advise patients in relation to their unique medical condition. Patients must then report themselves to the driver licensing authority if they are unfit to drive. Despite multiple recommendations from coroners, there is no mandatory reporting system in Victoria, as mandatory reporting is disliked by both doctors and patients. Research has shown that binary decision trees are more accurate than doctors in determining fitness to drive. This article proposes a phone application implementing yes-no decision trees for each condition in the guidelines to increase accuracy and documentation rates and protect doctors from liability.

Emotion Recognition and Traffic-Related Risk-Taking Behavior in Patients with Neurodegenerative Diseases.

OBJECTIVES: Neurodegenerative diseases (NDDs), such as Alzheimer's disease, frontotemporal dementia, dementia with Lewy bodies, and Huntington's disease, inevitably lead to impairments in higher-order cognitive functions, including the perception of emotional cues and decision-making behavior. Such impairments are likely to cause risky daily life behavior, for instance, in traffic. Impaired recognition of emotional expressions, such as fear, is considered a marker of impaired experience of emotions. Lower fear experience can, in turn, be related to risk-taking behavior. The aim of our study was to investigate whether impaired emotion recognition in patients with NDD is indeed related to unsafe decision-making in risky everyday life situations, which has not been investigated yet. METHODS: Fifty-one patients with an NDD were included. Emotion recognition was measured with the Facial Expressions of Emotions: Stimuli and Test (FEEST). Risk-taking behavior was measured with driving simulator scenarios and the Action Selection Test (AST). Data from matched healthy controls were used: FEEST (n = 182), AST (n = 36), and driving simulator (n = 18). RESULTS: Compared to healthy controls, patients showed significantly worse emotion recognition, particularly of anger, disgust, fear, and sadness. Furthermore, patients took significantly more risks in the driving simulator rides and the AST. Only poor recognition of fear was related to a higher amount of risky decisions in situations involving a direct danger. CONCLUSIONS: To determine whether patients with an NDD are still fit to drive, it is crucial to assess their ability to make safe decisions. Measuring emotion recognition may be a valuable contribution to this judgment.

Physicians' attitudes toward driving by persons with epilepsy in Korea: 2009 versus 2017 survey.

PURPOSE: This study compared physicians' attitudes toward the fitness of persons with epilepsy to drive between 2009 and 2017 in Korea. METHODS: A questionnaire focusing on physicians' opinions about driving issues for persons with epilepsy was developed from literature reviews. Korean physicians were then surveyed anonymously via the online questionnaire in 2009 and in 2017. RESULTS: The numbers of valid respondents were 118 in 2009 and 160 in 2017. The majority of respondents were neurologists. The preferred criterion for eligibility to drive in both surveys was 2 years free from seizure (41.5% in 2009 and 45.6% in 2017). However, the minimum seizure-free criterion for driving eligibility declined between 2009 and 2017. The changes in attitudes toward driving were significant only among physicians who had more than 10 patients with epilepsy per week. However, the proportion of physicians who agreed with 6-month seizure freedom as a criterion for fitness to drive was lower in 2017 than in 2009. CONCLUSIONS: Although the preference of a 2-year seizure-free period as a criterion for fitness to drive did not change between 2009 and 2017, the minimum criterion for the seizure-free period did decline, particularly among physicians who had more than 10 patients with epilepsy per week in their clinic. The data support sustained efforts to promote education regarding aspects of epilepsy related to driving.

Caregiver Prediction of Driving Fitness in Older Adults with Dementia.

Objectives: To determine whether caregiver opinion of fitness to drive and the level of assistance needed for functional activities are useful in determining the need for a Comprehensive Driving Evaluation.Methods: This study examined a sample (N = 179) of drivers with dementia. Caregivers completed a questionnaire that included caregiver opinion of driving fitness and the Functional Assessment Questionnaire (FAQ). A univariate simple logistic regression model was used to examine the relationship of road test failure with caregiver opinion of driving fitness and FAQ scores. From the significant predictive variables from the univariate test, multiple logictic regression models were used to examine possible combination of variables as predictors of road test failure.Results: The combination of caregiver opinion of driving fitness and the FAQ sub-item for memory were found to have modest ability in predicting failure on a standardized on-road driving assessment (AUC 0.727).Conclusions: Caregiver opinion of driving fitness and most individual higher order activities of daily living were found to be independent predictors of failure on a standardized road test.Clinical Implications: Caregiver opinion of driving fitness and ratings of functional activities may be useful for families and clinicians in considering whether an adult with dementia should be more carefully assessed for fitness to drive.

Excessive daytime sleepiness in obstructive sleep apnea: implications for driving licenses.

PURPOSE: Excessive daytime sleepiness (EDS) while driving is a major international public health issue resulting in a more than doubled risk of motor vehicle accidents (MVAs). Obstructive sleep apnea (OSA) is the most frequent medical cause of EDS. Therefore, the European Union Directive 2014/85/EU determined that "untreated moderate to severe OSA coincident with EDS constitutes a medical disorder leading to unfitness to drive." The paper aims are to provide a brief review of sleepiness and its implications for driving safety, as well as to describe the subjective and objective methods to accurately evaluate EDS in order to assess fitness to drive in patients with OSA. METHODS: We examined databases including PubMed, Medline, and EMBASE using the search terms "sleepiness at the wheel, excessive daytime sleepiness, sleepiness measure, sleep-wake cycle, obstructive sleep apnea, driving license, fitness to drive." RESULTS: Significant interindividual variability in EDS exists in patients with comparable severity of OSA. Objective methods of measuring EDS are too expensive and time consuming to be suitable for the certification of driving licenses. The reliability of subjective methods depends upon the clinical setting and subjective tools assess only limited aspects of EDS. Objective measures, such as biochemical biomarkers, must, therefore, support subjective methods. CONCLUSIONS: Extensive data have supported different subjective and objective methods for the appraisal of EDS in patients with OSA depending upon the clinical and experimental setting. Challenges remain to determine an appropriate tool for the evaluation of fitness to drive.