Diabetes and driving: towards equitable, evidence‐based decision‐making

MacLeod, Kenneth M.

doi:10.1046/j.1464-5491.1999.00069.x

Cited by 35 publications

(23 citation statements)

References 36 publications

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“…Whether this actually leads to a higher incidence of car accidents has been controversial (6 -9,15-17), and the discussion on drivers licensing in insulin-dependent diabetic subjects is continuing (18,19). In our population-based dataset covering highrisk groups for traffic accidents, we could not confirm an excess mortality.…”

Section: Causes Of Death Among Diabetic Subjectsmentioning

confidence: 78%

Mortality in Childhood-Onset Type 1 Diabetes

2005

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OBJECTIVE -To describe the age-and sex-specific mortality in a cohort of young type 1 diabetic patients and to analyze the causes of death with special focus on suicide, accidents, and unexplained deaths.RESEARCH DESIGN AND METHODS -A population-based incident childhood diabetes register, covering onset cases since 1 July 1977, was linked to the Swedish Cause of Death Register up to 31 December 2000. The official Swedish population register was used to calculate age-and sex-standardized mortality rates (SMRs), excluding neonatal deaths. To analyze excess risks for specific diagnoses, case subjects were compared with five nondiabetic control subjects, matched by age, sex, and year of death. Death certificates were collected for all case and control subjects. For case subjects with an unclear diagnosis, hospital records and/or forensic autopsy reports were obtained.RESULTS -Mean age-and sex-SMR was 2.15 (95% CI 1.70 -2.68) and tended to be higher among females (2.65 vs. 1.93, P ϭ 0.045). Mean age at death was 15.2 years (range 1.2-27.3) and mean duration 8.2 years (0 -20.7). Twenty-three deaths were clearly related to diabetes; 20 died of diabetic ketoacidosis. Only two case subjects died with late diabetes complications (acute coronary infarction). Thirty-three case subjects died with a diagnosis not directly related to diabetes; 7 of them committed suicide, and 14 died from accidents. There was no significant difference in traffic accidents (odds ratio 1.02 [95% CI 0.40 -2.37]). Obvious suicide tended to be increased but not statistically significantly so (1.55 [0.54 -3.89]). Seventeen diabetic case subjects were found deceased in bed without any cause of death found at forensic autopsy. Only two of the control subjects died of similar unexplained deaths.CONCLUSIONS -In a well-developed health care system, there is still a significant excess mortality in young type 1 diabetic patients. We confirm a very large proportion of unexplained deaths in bed, which should be further studied. There is no clear excess death rate caused by suicide or traffic accidents among young diabetic subjects. Diabetes Care 28:2384 -2387, 2005A lthough the main part of excess mortality in type 1 diabetes is due to long-term complications, an excess death rate has also been reported from several countries in case subjects with short duration without signs of long-term complications (1-4). Except for the mortality caused by onset ketoacidosis or diabetic ketoacidosis after onset, part of the excess mortality has been unexplained deaths in bed (3).It has been made clear in experimental studies that car driving skills may be affected by hypoglycemic episodes (5). Restrictions are also put on driver's licenses, especially type 1 diabetic subjects in Europe. The epidemiological evidence of accidents in general or traffic accident incidence among diabetic compared with control subjects has been controversial (6 -9).In the present study, we studied survival of children who were diagnosed with diabetes at age 0 -14 years during the period of 1 J...

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Section: Causes Of Death Among Diabetic Subjectsmentioning

confidence: 78%

Mortality in Childhood-Onset Type 1 Diabetes

2005

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“…Several studies have investigated the impact of diabetes on driving (5-7). The conclusion from two reviews was that drivers with diabetes receiving insulin therapy have a slight but statistically significant increased risk of moving vehicle violations (8,9). Both reviews, however, emphasized that intensive insulin therapy is associated with more frequent hypoglycemia.…”

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confidence: 99%

Diabetes and Driving Mishaps

et al. 2003

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OBJECTIVE -The intensive treatment of diabetes to achieve strict glycemic control is a common clinical goal, but it is associated with an increased incidence of hypoglycemia. Becoming hypoglycemic while driving is a hazardous condition and may lead to a greater incidence of driving mishaps. This study investigated whether diabetes is associated with increased risk of driving mishaps and correlates of such a relationship.RESEARCH DESIGN AND METHODS -During routine visits to diabetes specialty clinics in seven U.S. and four European cities, consecutive adults with type 1 diabetes, type 2 diabetes, and nondiabetic spouse control subjects (n ϭ 341, 332, and 363, respectively) completed an anonymous questionnaire concerning diabetes and driving.RESULTS -Type 1 diabetic drivers reported significantly more crashes, moving violations, episodes of hypoglycemic stupor, required assistance, and mild hypoglycemia while driving as compared with type 2 diabetic drivers or spouse control subjects (P Ͻ 0.01-0.001). Type 2 diabetic drivers had driving mishap rates similar to nondiabetic spouses, and the use of insulin or oral agents for treatment had no effect on the occurrence of driving mishaps. Crashes among type 1 diabetic drivers were associated with more frequent episodes of hypoglycemic stupor while driving, less frequent blood glucose monitoring before driving, and the use of insulin injection therapy as compared with pump therapy. One-half of the type 1 diabetic drivers and three-quarters of the type 2 diabetic drivers had never discussed hypoglycemia and driving with their physicians.CONCLUSIONS -Type 1 diabetic drivers are at increased risk for driving mishaps, but type 2 diabetic drivers, even on insulin, appear not to be at a higher risk than nondiabetic individuals. Clinical and treatment factors appear to increase risk, e.g., more frequent hypoglycemia while driving, method of insulin delivery, and infrequent self-testing before driving. Physicians are encouraged to talk to their type 1 diabetic patients about hypoglycemia and driving. Diabetes Care 26:2329 -2334, 2003M ost western countries impose some restrictions on the commercial driving licenses of drivers who have diabetes. The side effects from the treatment of diabetes (principally hypoglycemia) and the potential risk imposed by developing complications (mainly to vision) render diabetes a prospective disability with respect to medical fitness to drive. Impaired awareness of hypoglycemia and recurrent severe hypoglycemia may place drivers at higher risk for driving mishaps. Research studies have demonstrated neuropsychological and driving simulation impairments at modest levels of hypoglycemia (3.6 mmol/l) (1-3). However, the ecological validity, or relevance, of such laboratory findings to routine daily functioning is unclear (4). Several studies have investigated the impact of diabetes on driving (5-7). The conclusion from two reviews was that drivers with diabetes receiving insulin therapy have a slight but statistically significant increased risk of mo...

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Section: Driving and Employment Issuesmentioning

confidence: 99%

“…Despite this, most studies suggest hypoglycaemiarelated road traffic accidents are rare events. 19 A responsible, collaborative approach between patients, healthcare professionals and licensing authorities is needed to make decisions appropriate to an individual's risk of hypoglycaemia and type of driving (long-distance, shift, night-time etc).Diabetes consultations, particularly with patients on insulin, should emphasise that the privilege of driving goes hand-in-hand with the responsibility of appropriate self-management. Similarly, there should be individual assessment of the risk of work in hazardous roles or environments.…”

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confidence: 99%

Hypoglycaemia in diabetes

MacLeod

2004

Clinical Medicine

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Why is hypoglycaemia important?The achievement and maintenance of blood glucose concentrations as near normal as possible are major targets of modern diabetes care. 1,2 Unfortunately, this increases the frequency of hypoglycaemia, so people with diabetes are all too familiar with insulin acting at the wrong time or intensity. 3 Hypoglycaemia, the most common acute complication of type 1 diabetes, usually develops rapidly. Its effects range from mild symptoms to brain damage or death. 4 Alarmingly, severe hypoglycaemia may occur with no perceived symptoms. In elderly people, it can mimic stroke. A young person with type 1 diabetes presenting with a seizure has a hypoglycaemia-induced convulsion unless proven otherwise.Hypoglycaemia is important because it limits therapeutic efforts to attain normoglycaemia and protect against long-term complications. It embarrasses, frightens and injures people with diabetes so that fear of hypoglycaemia can dominate their own and their families' lives. How common is hypoglycaemia?Major hypoglycaemia was experienced by 27% of patients with intensively treated type 1 diabetes in the Diabetes Control and Complications Trial (DCCT) but by only 2% of those in the UK Prospective Diabetes Study (UKPDS) of type 2 diabetes despite broadly similar levels of glycaemic control. 1,5 Thus, the rates of severe hypoglycaemia in type 2 diabetes are substantially lower than those seen in type 1 diabetes (of the order of 10% lower). 6 When it does occur, however, severe hypoglycaemia may have more serious consequences than in type 1 diabetes because older people have more comorbidities (Table 1). In the UKPDS study over the first 10 years, major hypoglycaemia rates varied with treatment modality: 2• diet treated patients: 0.5% • chlorpropamide: 0.4% • glibenclamide: 0.6% • insulin: 2.3%. Hypoglycaemia-associated autonomic failureThe pursuit of normoglycaemia in diabetes is bedevilled because 'hypoglycaemia begets hypoglycaemia' . 8 Indeed, the single most significant risk factor for severe hypoglycaemia is previous severe hypoglycaemia. In insulin deficient diabetes, (exogenous) insulin-levels do not decrease as glucose levels fall so the integrity of counter-regulatory hormonal responses assumes greater significance. The glucagon response to hypoglycaemia is blunted with increasing duration of type 1 diabetes so the catecholamine response becomes the critical defence mechanism. The epinephrine response is itself progressively blunted by antecedent hypoglycaemia, as is awareness of hypoglycaemia. The coexistence of deficient glucagon and epinephrine responses constitutes a major breach in counter-regulatory defence. The combination of defective glucose counter-regulation and impaired awareness of hypoglycaemia due to antecedent hypoglycaemia is termed hypoglycaemia associated autonomic-failure (HAAF) (Fig 1) Prediction and preventionThe symptoms of hypoglycaemia are idiosyncratic, non-specific and variable, even within an individual. The most important aspect of prevention is for patients to have...

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Diabetes and driving: towards equitable, evidence‐based decision‐making

Cited by 35 publications

References 36 publications

Mortality in Childhood-Onset Type 1 Diabetes

Mortality in Childhood-Onset Type 1 Diabetes

Diabetes and Driving Mishaps

Hypoglycaemia in diabetes

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