SLEEP
DESIGN FOR AMERICA
STATISTICS/ONLINE RESOURCES
 http://drowsydriving.org/about/facts-and-stats/
 http://www.cdc.gov/features/dsdrowsydriving/
 https://en.wikipedia.org/wiki/Sleep-deprived_driving
 http://www.nhtsa.gov/people/injury/drowsy_driving1/Drowsy.html
 https://www.fhwa.dot.gov/publications/publicroads/99janfeb/effects.cfm
 http://www.discovery.com/tv-shows/mythbusters/about-this-show/tired-vs-drunk-driving/
 http://healthysleep.med.harvard.edu/need-sleep/whats-in-it-for-you/judgment-safety
CONTENTS
 Sleep: An Overview
 Driving and Sleep Deprivation

The Basics
 Short Term Solution: Preventing Sleepiness

Circadian Rhythms
 Long Term Solution: Altering Circadian Rhythms

Sleep Stages

Functions of Sleep

Sleep Disorders
 Measuring Sleepiness
 Sleep Deprivation
 Shift Workers & Sleep
SLEEP: AN OVERVIEW

The Basics

Circadian Rhythms

Sleep Stages

Functions of Sleep

Sleep Disorders
SLEEP: THE BASICS PART 1
 As an organism falls asleep body temperature, heart rate, breathing rate, and energy use all decrease. Brain waves get slower
and bigger.
 Sleep can accrue debt to a certain point (if you skip a night’s sleep, you will sleep longer the next night, but you will not sleep
so long that you make up for the lost sleep completely)
 Sleep consists of 4 stages: Stage 1, Stage 2, Stage 3, and REM

From here on will be referred to as N1, N2, N3, REM

When we sleep, we move through these stages in cycles. Usually like this: N1 → N2 → N3 → N2 → REM

Each full cycle takes approximately 90 minutes

We complete 4-5 full cycles each night (depending on total sleep time)

In the beginning of the night, we spend more time in stages N2 & N3, and less time in REM. Towards the end of the night/morning, we
spend less time in N2&N3, and more time in REM.
SLEEP THE BASICS: CIRCADIAN RHYTHMS
 The need for sleep increases as time from last sleep increases.
 Sleeping times are influenced by: the circadian rhythms, time since last sleep, and desire to sleep/chosen behavior
 Circadian rhythms are influenced by the circadian clock. The circadian clock is ‘located’ in the suprachiasmatic nucleus in the
thalamus, however many tissues have been shown to follow a circadian rhythm independent of the SCN
 Essentially, the body is entrained to match sleep cycles to the sun, where we begin preparing for sleep when the sun goes
down and our body prepares for wakefulness as the sun comes up. This is a ‘natural’ circadian rhythm.
 Even in the absence of light, our bodies follow circadian rhythms. Body temperature and hormones are continually adjusted
by the body, body can still ‘tell time’ without light.
 The most important of these hormones is melatonin, but others such as HGF and cortisol have important implications for
sleep’s impact on health
 Most humans run on a 25 hour cycle, slightly longer than the 24 hour day.

A healthy young adult entrained to the sun will (during most of the year) fall asleep a few hours after sunset, experience
body temperature minimum at 6AM, and wake up a few hours after sunrise.
 Before artificial light, most people slept early, took a brief period of wake in the middle of the night, and then slept again
until sunrise.
SLEEP: THE BASICS PART 3
 Sleeping at the wrong time of day is not as restorative. Timing is correct when the following occur after the
middle of the sleep episode and before awakening: maximum concentration of and minimum core body
temperature.
 People experience two periods of intense sleepiness every 24 hours, about 12 hours apart. This is why some
people feel sleepy in the afternoon and some countries have ‘siesta’. If you usually feel sleepy around 12am, you
will probably also feel sleepy around 12pm. Your circadian clock often overrides this feeling in the afternoon, and
in the morning this sleepiness encourages you to sleep a little longer/reduces change of awakening too early.
 A person’s need for sleep varies by age and individual needs.

Teens need 7-10 hours on average. Some people need more or less.

Adults need 8-9 hours, on average. Some people need more or less.
SLEEP STAGES
 Non-REM Sleep

N1 – the lightest stage of sleep. Participants often shift in and out of N1 and wakefulness at this time. If woken up, they
often do not believe they were asleep. Muscles relax, person may twitch or jerk. Characterized by alpha and theta waves.

N2- characterized by sleep spindles and K-complexes (types of brain activity). People become fully unconscious.

N3- aka deep sleep or slow wave sleep. This stage more than others contributes to feeling “rested”. This is the stage in
which parasomnias occur (sleepwalking, night terrors, etc.)
 REM Sleep

Rapid Eye Movement sleep. The stage in which dreaming occurs. Person’s muscles are paralyzed.
FUNCTIONS OF SLEEP (STILL DEBATED)
 Clearing waste from the brain, including those thought to be related to dementia
 Brain development
 Memory consolidation

N2 & N3 are important for memory for facts and life episodes.

REM is important for procedural/motor memory and complex tasks
 Emotion regulation
SLEEP DISORDERS
 Sleep Apnea: a person will wake frequently during the night because they are having trouble breathing. They are
not aware of their arousals. These arousals prevent them from spending significant time in the deeper stages of
sleep, and can therefore contribute to cognitive deficits
 Insomnia: difficulty falling asleep, staying asleep, or waking too early in the morning. Results in decreased sleep
time against a person’s best efforts
 Delayed Sleep Phase Syndrome: teens often are ‘night owls’. People with DSPS are either extreme night
owls (cannot sleep early and then sleep in late) or they do not grow out of being night owls and it affects their
daily lives negatively
 Non-24 Hour Disorder: people whose natural sleep cycle ‘feels’ like it should be significantly longer than 24/25
hours. These people experience trouble keeping a regular schedule, because every day they don’t feel tired until
several hours later than they went to sleep the previous night. This is especially difficult to live with.
MEASURING SLEEPINESS
MEASURING SLEEPINESS
 An average latency to sleep of between 5 to 10 minutes is considered an intermediate level of sleepiness, and
average latencies greater than10 minutes are considered to represent low levels of physiologic sleepiness. data
from simulated shift work studies suggest that average MSLT sleep latencies are lower during the biologic Night.
Other indicators of physiologic sleepiness include EEG measures of alpha (8–12 Hz) and theta (4–8 Hz) activity,55
slow eye movements,56 or blink duration.
 relation between subjective sleepiness measured with the Karolinska Sleepiness Scale (KSS) and blink duration
(BLINKD) and lane drifting calculated as the standard deviation of the lateral position (SDLAT) in a high-fidelity
moving base driving simulator. Five male and five female shift workers were recruited to participate in a 2-h drive
(08:00–10:00 hours) after a normal night sleep and after working a night shift. significant (P < 0.001) effect of the
KSS for both dependent variables. A test for a quadratic trend suggests a curvilinear effect with a steeper increase
at high KSS levels for both SDLAT (P < 0.001) and BLINKD (P ¼ 0.003). Large individual differences were
observed for the intercept (P < 0.001), suggesting that subjects differed in their overall driving performance and
blink duration independent of sleepiness levels.
MEASURING SLEEPINESS
 Several researchers have investigated the relation between vigilance and ocular variables such as saccade, slow eye
movement, pupil, blink, or eyelid closure. This study was undertaken to find the most effective indicator among
these ocular variables for evaluating short-term (1 min) fluctuation of vigilance, and to investigate the ability of the
most effective ocular variable for predicting deteriorated vigilance during behavioral maintenance of the
wakefulness test (Oxford sleep resistance test: OSLER test). Decreased blink frequency and pupil diameter as well
as increased percentage of eyelid closure time (PERCLOS) and slow eye movement were observed as the
consecutive missed responses increased. Among these variables, PERCLOS showed the highest ability to detect
occurrence of any missed response and three or more consecutive missed responses. Moreover, a missed
response seldom occurred (0.2 ± 0.2/20 trial/min) when PERCLOS was less than 11.5% per minute. Results
suggest that, among the ocular variables, PERCLOS can prevent error or accident caused by low vigilance most
effectively.
 A number of behavioral, physiological, and psychometric tests are being used increasingly to evaluate the impact of
fatigue on driver performance. These include the oculography, polysomnography, actigraphy, the maintenance of
wakefulness test, and others.
SLEEP DEPRIVATION
SLEEP DEPRIVATION
 Sleep deprivation increases sleep propensity- reduces time to fall asleep.
 Partial sleep deprivation occurs in 3 ways:

During sleep fragmentation, the normal progression and sequencing of sleep stages is typically disrupted to varying degrees,
resulting in less time in consolidated physiological sleep, relative to time in bed.

loss of specific physiological sleep stages, and is, therefore, referred to as selective sleep stage deprivation

Sleep deprivation/sleep debt
SLEEP DEPRIVATION
 Sleep deprivation to 6 or 4 hours a night for 2 weeks results in significant cognitive deficits. 4hr condition was
equivalent to 2 nights without sleep. Psychomotor vigilance test, test of working memory, cognitive throughput,
self-reported sleepiness.
 Restricting sleep below an individual’s optimal time in bed (TIB) can cause a range of neurobehavioral deficits,
including lapses of attention, slowed working memory, reduced cognitive throughput, depressed mood, and
perseveration of thought (Banks, 2007)
 Prolonged wakefulness greatly decreases nocturnal driving performance.
SHIFT WORKERS & SLEEP
SHIFT WORKERS & SLEEP
 ¾ of shift workers suffer from disturbed sleep, which is sleep that is less deep and restful, and features more
arousals and periods of wakefulness.
 Driving in the early morning is associated with increased accident risk affecting not only professional drivers but
also those who commute to work.
 Disturbed sleep is #1 predictor of job satisfaction- those with disturbed sleep are less likely to be satisfied with
their job.
 Night shift workers sleep on average 4-6 hours, 1-4 hours less than they sleep during a normal sleep schedule.
 Although some have argued that the main problem in shift working is the changing schedule, others argue that
workers who work the night shift consistently get less sleep than those who are on slowly rotating schedules (at
least 3 weeks per schedule). Rapid, frequent changes in work/sleep schedule are correlated with less overall sleep.
 Sleep loss is primarily stage 2 and REM. Amount of slow wave sleep does not suffer a reduction.
SHIFT WORKERS & SLEEP
 An assumed reason for trouble adjusting to alternate sleep schedule is conflict that occurs when a person is exposed to
external light. Complete control over light can facilitate adjusting to a new schedule.
 Irregular work schedules often results in a disruption of the normal circadian rhythm that can causes sleepiness when
wakefulness is required and insomnia during the main sleep episode.
 Working on a rotating daytime shifts causes significant sleep disturbances. As consequences, these workers are more
likely to feel sleepy at work and are more likely to have work-related accidents and sick leaves.
 strong, acute effects on sleep and alertness in relation to night and morning work. The effects seem, however, to linger
and also affect days off. The level of the disturbances is similar to that seen in clinical insomnia and may be responsible
for considerable human and economical costs due to fatigue related accidents and reduced productivity. The mechanism
behind the disturbances is the sleep interfering properties of the circadian system during day sleep and the
corresponding sleep promoting properties during night work.Various strategies may be used to counteract the effects of
shift work, such as napping, sufficient recovery time between shifts, clockwise rotation
SHIFT WORKERS & SLEEP
 Shift work has been associated with a number of health problems including cardiovascular disease, impaired
glucose and lipid metabolism, gastrointestinal discomfort, reproductive difficulties, and breast cancer.
 Fatigue can be caused by extended on-duty and/or waking periods, inadequate sleep quantity, sleep disturbances,
disruption of circadian rhythms, and difficult work and familial conditions.
 Fatigue-related accidents raise a safety concern for shift workers, especially at the end of the night when the
circadian nadir of alertness interacts with increased time awake.
 Individuals vary greatly in their capacity to adjust to atypical work schedules and their tolerance to circadian
misalignment. Predisposing individual and domestic factors have been identified, such as increasing age, being a
single woman in charge of children, and split sleep patterns, all of which can affect the ability to adjust to atypical
schedules.
SHIFT WORKERS & SLEEP
 The purpose of this study is to describe the prevalence of drowsy driving episodes and the relationship between
drowsy driving and nurse work hours, alertness on duty, working at night, and sleep duration. Almost 600 of the
nurses (596/895) reported at least 1 episode of drowsy driving, and 30 nurses reported experiencing drowsy
driving following every shift worked. Shorter sleep durations, working at night, and difficulties remaining awake at
work significantly increased the likelihood of drowsy driving episodes.
 Shift work, like chronic jet lag, is known to disrupt workers’ normal circadian rhythms and social life, and to be
associated with increased health problems (eg, ulcers, cardiovascular disease, metabolic syndrome, breast cancer,
reproductive difficulties) and with acute effects on safety and productivity
 The aim of this study was to assess the chronicity and reversibility of the effects of shift work on cognition
SHIFT WORKERS & SLEEP
 3232 employed and retired workers (participation rate: 76%) who were 32, 42, 52 and 62 years old at the time of
the first measurement (t1, 1996), and who were seen again 5 (t2) and 10 (t3) years later. 1484 of them had shift
work experience at baseline (current or past) and 1635 had not. The main outcome measures were tests of speed
and memory, assessed at all three measurement times. Results Shift work was associated with impaired cognition.
The association was stronger for exposure durations exceeding 10 years (dose effect; cognitive loss equivalent to
6.5 years of age-related decline in the current cohort). The recovery of cognitive functioning after having left shift
work took at least 5 years (reversibility).
DRIVING AND SLEEP DEPRIVATION
DRIVING & SLEEP DEPRIVATION
 An epidemiological study found an increased incidence of sleep-related crashes in drivers reporting <7 h of sleep
per night on average
 Studies have shown that a large proportion of traffic accidents around the world are related to inadequate or
disordered sleep. Recent surveys have linked driver fatigue to 16% to 20% of serious highway accidents in the UK,
Australia, and Brazil.
 Fatigue as a result of sleep disorders (especially obstructive sleep apnea), excessive workload and lack of physical
and mental rest, have been shown to be major contributing factors in motor vehicle accidents
DRIVING & SLEEP DEPRIVATION
 Additional contributing factors to these crashes included poor sleep quality, dissatisfaction with sleep duration
(i.e., undersleeping), daytime sleepiness, previously driving drowsy, amount of time driving and time of day (i.e.,
driving late at night)
 Studies have also examined the effects of sleep restriction on performance on various driving simulators. It has
been found that driving performance decreased (e.g., more crashes) and subjectively reported sleepiness
increased when sleep was restricted to between 4 and 6 h per night.
 The present study used a driving simulator to investigate the effects of driving home from a night shift. Ten shift
workers participated after a normal night shift and after a normal night sleep. The results showed that driving
home from the night shift was associated with an increased number of incidents (two wheels outside the lane
marking, from 2.4 to 7.6 times), decreased time to first accident, increased lateral deviation (from 18 to 43 cm),
increased eye closure duration (0.102 to 0.143 s), and increased subjective sleepiness.
DRIVING & SLEEP DEPRIVATION
 The objective of this study was to analyze the EEG changes in fatigued subjects while performing a simulated
driving task. After a night of sleep deprivation, eight subjects were given a dose of caffeine to reduce drowsiness.
During about 50 min of continuous driving, car movements and subject behaviors were recorded on video
cameras, and 8 channels of EEG were also recorded. EEG activity was significantly different between groups.
 Twenty human subjects underwent driving simulations with EEG monitoring. Alert EEG was marked by dominant
beta activity, while drowsy EEG was marked by alpha dropouts. The duration of eye blinks corresponded well with
alertness levels associated with fast and slow eye blinks. Samples of EEG data from both states were used to train
the SVM program by using a distinguishing criterion of 4 frequency features across 4 principal frequency ands.
The trained SVM program was tested on unclassified EEG data and subsequently checked for concordance with
manual classification. The classification accuracy reached 99.3%. The SVM program was also able to predict the
transition from alertness to drowsiness reliably in over 90% of data samples. This study shows that automatic
analysis and detection of EEG changes is possible by SVM and SVM is a good candidate for developing pre-emptive
automatic drowsiness detection systems for driving safety.
DRIVING & SLEEP DEPRIVATION
 Thus, countermeasure device is currently required in many fields for sleepiness related accident prevention. This paper
intends to perform the drowsiness prediction by employing Support Vector Machine (SVM) with eyelid related
parameters extracted from EOG data collected in a driving simulator provided by EU Project SENSATION. The dataset
is firstly divided into three incremental drowsiness levels, and then a paired t-test is done to identify how the parameters
are associated with drivers’ sleepy condition. With all the features, a SVM drowsiness detection model is constructed.
The validation results show that the drowsiness detection accuracy is quite high especially when the subjects are very
sleepy.
 This paper describes a real-time prototype computer vision system for monitoring driver vigilance. The main
components of the system consists of a remotely located video CCD camera, a specially designed hardware system for
real-time image acquisition and for controlling the illuminator and the alarm system, and various computer vision
algorithms for simultaneously, real-time and non-intrusively monitoring various visual bio-behaviors that typically
characterize a driver’s level of vigilance. The visual behaviors include eyelid movement, face orientation, and gaze
movement (pupil movement). The system was tested in a simulating environment with subjects of different ethnic
backgrounds, different genders, ages, with/without glasses, and under different illumination conditions, and it was found
very robust, reliable and accurate
 Fatigue can be equally studied in real and simulated environments but reaction time and self-evaluation of sleepiness are
more affected in a simulated environment. Real driving and driving simulators are comparable for measuring line
crossings but the effects are of higher amplitude in the simulated condition. Driving simulator may need to be calibrated
against real driving in various condition.
DRIVING & SLEEP DEPRIVATION
 Sleepiness may be a factor in about 20% of motor vehicle accidents and studies carried out in controlled
environments suggest that the most common changes in driving performance attributable to sleepiness include
increased variability of speed and lateral lane position. Higher-order functions including judgment and risk taking
may also deteriorate.
 Moreover, prolonging wakefulness even by a few hours may produce deterioration in driving performance
comparable to that seen in drivers with blood alcohol concentrations at levels deemed dangerous by legislation.
 The majority of prevention efforts to date have focused on short-term solutions that only mask underlying
sleepiness and it is suggested that more emphasis be directed toward primary prevention efforts such as
educating drivers about the importance of getting sufficient sleep and avoiding circadian performance troughs.
DRIVING & SLEEP DEPRIVATION
 Falling asleep at the wheel is a common cause of road accidents, but little is known about the extent to which
drivers are aware of their sleepiness prior to such accidents. 28 healthy young adult experienced drivers, sleep
restricted the night before drove for 2 h in the afternoon in an interactive real-car simulator incorporating a dull
and monotonous roadway. Lane drifting, typifying sleepy driving, was subdivided into minor and major incidents,
where the latter was indicative of actually falling asleep. A distinction was made between the subjective
perceptions of sleepiness and the likelihood of falling asleep which drivers reported separately. Increasing
sleepiness was closely associated with an increase in the number of incidents. Major incidents were preceded by
self-awareness of sleepiness well beforehand and typically, subjects reached the stage of fighting sleep when these
incidents happened. Whilst the perceived likelihood of falling asleep was highly correlated with increasing
sleepiness, some subjects failed to appreciate that extreme sleepiness is accompanied by a high likelihood of falling
asleep. It was not possible for our subjects to fall asleep at the wheel and have an “accident” without experiencing
a sustained period of increasing sleepiness, of which they were quite aware. There is a need to educate at least
some drivers that extreme sleepiness is very likely to lead to falling asleep and a high accident risk.
PREVENTING SLEEPINESS
SHORT TERM STRATEGY: PREVENTING SLEEPINESS
 Objective: The objective of this study was to investigate if a verbal task can improve alertness and if
performance changes are associated with changes in alertness as measured by EEG. Background: Previous
research has shown that a secondary task can improve performance on a short, monotonous drive. The current
work extends this by examining longer, fatiguing drives. The study also uses EEG to confirm that improved driving
performance is concurrent with improved driver alertness. Method: A 90-min, monotonous simulator drive was
used to place drivers in a fatigued state. Four secondary tasks were used: no verbal task, continuous verbal task,
late verbal task, and a passive radio task. Results: When engaged in a secondary verbal task at the end of the
drive, drivers showed improved lane-keeping performance and had improvements in neurophysiological measures
of alertness. Conclusion: A strategically timed concurrent task can improve performance even for fatiguing
drives.
SHORT TERM STRATEGY: PREVENTING SLEEPINESS
 The aim of this study is to determine whether continuous exposure to monochromatic light in the short wavelengths
(blue light), placed on the dashboard, improves night-time driving performance. In this randomized, double-blind, placebocontrolled, cross-over study, 48 healthy male participants (aged 20–50 years) drove 400 km (250 miles) on motorway
during night-time. They randomly and consecutively received either continuous blue light exposure (GOLite, Philips, 468
nm) during driving or 2*200 mg of caffeine or placebo of caffeine before and during the break. Treatments were
separated by at least 1 week. The outcomes were number of inappropriate line crossings (ILC) and mean standard
deviation of the lateral position (SDLP). Eight participants (17%) complained about dazzle during blue light exposure and
were removed from the analysis. Results from the 40 remaining participants (mean age ± SD: 32.9±11.1) showed that
countermeasures reduced the number of inappropriate line crossings (ILC) (F(2,91.11) = 6.64; p<0.05). Indeed, ILC were
lower with coffee (12.51 [95% CI, 5.86 to 19.66], p = 0.001) and blue light (14.58 [CI, 8.75 to 22.58], p = 0.003) than
with placebo (26.42 [CI, 19.90 to 33.71]). Similar results were found for SDLP. Treatments did not modify the quality,
quantity and timing of 3 subsequent nocturnal sleep episodes. Despite a lesser tolerance, a non-inferior efficacy of
continuous nocturnal blue light exposure compared with caffeine suggests that this in-car countermeasure, used
occasionally, could be used to fight nocturnal sleepiness at the wheel in blue light-tolerant drivers, whatever their age.
SHORT TERM STRATEGY: PREVENTING SLEEPINESS
 Research on public security, especially the safe manipulation and control of vehicles, has gained increasing
attention in recent years. This study proposes a closed-loop drowsiness monitoring and management system that
can estimate subjects’ driving performance. The system observes electroencephalographic (EEG) dynamics and
behavioral changes, delivers arousing feedback to individuals experiencing momentary cognitive lapses, and
assesses the efficacy of the feedback. Results of this study showed that the arousing feedback immediately
improved subject performance, which was accompanied by concurrent theta- and alpha-power suppression in the
bilateral occipital areas. This study further demonstrated the feasibility of accurately assessing the efficacy of
arousing feedback presented to drowsy participants by monitoring the changes in their EEG power spectra.
ALTERING CIRCADIAN RHYTHMS
LONG TERM STRATEGY: ALTERING CIRCADIAN RHYTHMS
 delayed weekend sleep pattern caused a 31.6 min delay of the endogenous melatonin rhythm. Melatonin
administration counteracted the phase delay of endogenous melatonin onset. On Sunday, melatonin administration
increased the sleepiness throughout the evening and reduced sleep onset latency at bedtime. On Monday
morning, subjective sleepiness was decreased in the melatonin condition. Conclusion: A delayed weekend sleep
pattern did show a mild phase delay effect on the endogenous circadian rhythm. A single dose of melatonin can
acutely reverse the weekend drift.
 The human circadian system is maximally sensitive to short-wavelength (blue) light. In a previous study we found
no difference between the magnitude of phase advances produced by bright white versus bright blue-enriched
light using light boxes in a practical protocol that could be used in the real world. Since the spectral sensitivity of
the circadian system may vary with a circadian rhythm, we tested whether the results of our recent phaseadvancing study hold true for phase delays. These results indicate that at light levels commonly used for circadian
phase shifting, blue-enriched polychromatic light is no more effective than the white polychromatic lamps of a
lower correlated color temperature (CCT) for phase delaying the circadian clock.
LONG TERM STRATEGY: ALTERING CIRCADIAN RHYTHMS
 Czeisler et al. first showed that modification of the light-dark cycle could influence the timing of human circadian
rhythms 0), but it was initially unclear whether light and dark were acting only indirectly via their effects on
sleeping and waking or directly on the circadian pacemaker. Lewy et al. showed that bright light but not ordinary
room light is capable of suppressing nocturnal melatonin secretion in humans (2). Similar bright light has
subsequently been shown to have antidepressant effects in patients with seasonal affective disorder (winter
depression) (3-5) and direct phase-shifting effects in humans (4,6-8). Such phase-shifting properties have been
postulated by some researchers to underlie the therapeutic effects of light in seasonal affective disorder (4) and
have been suggested to be of potential value in correcting disordered sleep and biological rhythms, such as occur
in jet lag, shift work, and delayed sleep phase syndrome
LONG TERM STRATEGY: ALTERING CIRCADIAN RHYTHMS
 Various strategies have been proposed for preventing or reducing the impact of fatigue on motor vehicle
accidents. These have included: Educational programs emphasizing the importance of restorative sleep and the
need for drivers to recognize the presence of fatigue symptoms, and to determine when to stop to sleep; The use
of exercise to increase alertness and to promote restorative sleep; The use of substances or drugs to promote
sleep or alertness (i.e. caffeine, modafinil, melatonin and others), as well as specific sleep disorders treatment; The
use of CPAP therapy for reducing excessive sleepiness among drivers who have been diagnosed with obstructive
sleep apnea.
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