Gregg Marshall PhD RRT RPSGT ChairAssociate Professor College of Health Professions Department of Respiratory Care Texas State UniversitySan Marcos San Marcos TX TSSP Sleep Conference 1028292011 ID: 815964
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Slide1
The role of actigraphy in sleep assessment and screening
Gregg Marshall, PhD, RRT, RPSGTChair/Associate ProfessorCollege of Health ProfessionsDepartment of Respiratory CareTexas State University-San MarcosSan Marcos, TX
TSSP Sleep Conference
10.28-29.2011
Slide2Disclosure Statement…..
No conflict of interest with industry or grant funding agencies that may be characterized as financial, real, or perceived as real with regards to the following information.10.28-29.2011TSSP Sleep Conference
Slide3Learning Objectives
1) Describe the fundamental basics of actigraphy devices2) Discuss the value of actigraphy as a prescreening device for sleep disorders3) Describe current clinical applications of the use of actigraphy studies4) Discuss the potential role of actigraphy within sleep labs/centers10.28-29.2011TSSP Sleep Conference
Slide4Q1:How does actigraphy work?
Small, non-invasive, watch-like device that is wrist worn and contains an accelerometer to monitor the number of wrist movements per epoch (ie: 30 or 60 sec)Electronic device consisting ofPiezoelectric accelerometer (velocity, g-force)….and there’s an APP for that!Low-pass filter (filtering out all but 2-3 Hz band to eliminate external vibrations)Start/stop timer to allow accumulating valuesMemory to store dataInterface (USB) to program device and download data from memory
10.28-29.2011
TSSP Sleep Conference
Slide5Actigraphy basics….
Continuously measures movement and ambient light over timeLight sensor recalls all levels of lightVarious models offer features that may provide additional movement/light measurementsDepending on the model, activity is recorded in various ways according to each unique algorithm for estimating sleep/wake measures10.28-29.2011
TSSP Sleep Conference
Slide6Actigraphy watches
10.28-29.2011TSSP Sleep Conference
Slide7Q2: What sleep values can actigraphy provide?
Scoring algorithms are used to identify sleep or wake states from activity counts to identify sleep parametersTime In Bed Total Sleep Time (TST) Wake After Sleep Onset (WASO)Sleep
Efficiency (TST/Total Time In Bed) Wake Bouts Sleep
Onset Latency (SOL)
10.28-29.2011
TSSP Sleep Conference
Slide8What’s missing?
Actigraphy cannot addressSleep stagingSnoringApnea/hypopneaSpO2 desaturationHR, RR, body positionThoracic/abdominal effortECG10.28-29.2011
TSSP Sleep Conference
Slide9Q3: What are the clinical applications for actigraphy?
nPSG is the gold standard for measuring sleep, however wrist actigraphy may provide sleep/wake information that can supplement PSG testing or be used to pre-screen some patientsPrevious studies (Paquet, 2007; Sadeh, 2002; Johnson, 2007) have suggested a wide range of findings from “less than useful” to “reasonable good estimate” of sleep disorders10.28-29.2011TSSP Sleep Conference
Slide10AASM’s Standards of Practice Committee findings….
The AASM Update for 2007 concluded the use of actigraphy in assessing and managing of sleep disorders has allowed the development of evidence-based recommendations for the use of actigraphy in the clinical settingAfter a review of literature/research regarding actigraphy, AASM’s SPC and BOD made ten specific recommendations for the use of actigraphy in clinical practice 10.28-29.2011
TSSP Sleep Conference
Slide11AASM recommendations
1) Valid way to assist in determining sleep patterns in normal, health adult populations and in patients suspected of certain sleep disorders2) Indicated to assist evaluation of patients with ASPS, DSPS, shift work sleep disorder, circadian rhythm disorders, jet lag, & non-24-hour sleep/wake syndrome (including associated with blindness)10.28-29.2011
TSSP Sleep Conference
Slide12AASM recommendations
3) When nPSG not available, actigraphy is indicated as method to estimate TST in patients with OSA and may improve accuracy of assessing severity of OSA4) Indicated as a method to characterize circadian rhythm patterns or insomnia (including association with depression)5) Indicated to determine circadian pattern and estimate average daily sleep time in hypersomnia10.28-29.2011
TSSP Sleep Conference
Slide13AASM recommendations
6) Useful outcome measure in evaluating response to treatment for circadian rhythm disorders7) Useful to evaluate response to treatment of insomnia8) Useful to characterize/monitor sleep and circadian rhythm patterns and document treatment outcomes among older adults living in community10.28-29.2011TSSP Sleep Conference
Slide14AASM recommendations
9) Indicated for characterizing and monitoring sleep/circadian rhythm patterns and document treatment outcomes among older nursing home residents in whom traditional nPSG assessment is difficult10) Indicated for delineating sleep patterns/document treatment responses in normal infants, children and special pediatric populations in whom traditional nPSG is difficult to perform or interpret10.28-29.2011
TSSP Sleep Conference
Slide15AASM recommendations
Finally, additional research warranted to further refine and broaden the clinical value of actigraphy to assess sleep and sleep disordersSix specific recommendations for future actigraphy-focused research10.28-29.2011TSSP Sleep Conference
Slide16Q4: How can actigraphy be used in sleep labs/center?
Longitudinal look at sleep characteristics rather than a “snap-shot” provided by nPSG studyHelpful with documenting actual sleep patterns for some dyssomnias, parasomnias, and medical/psychiatric conditions (psychoses, mood disorders, panic, alcoholism)Sleep history “at a glance”10.28-29.2011
TSSP Sleep Conference
Slide17Normal
Sleep Cycle10.28-29.2011TSSP Sleep Conference
13 days
Tracking 24 hours
Slide18Insomnia
10.28-29.2011TSSP Sleep Conference21 days
Slide19Delayed
Sleep Phase (DSP)10.28-29.2011TSSP Sleep Conference
14 days
Slide20Shift-workers
Syndrome10.28-29.2011TSSP Sleep Conference14 days
Slide21Actigraphy & home nPSG correlation…
Recent study2 in Journal of Clinical Sleep Medicine (Aug 2011) documents strong correlation between wrist actigraphy & home Compumedics Safiro Unit (12 channel)N = 3135 menN = 896 with concurrent PSG/actigraphy studiesNumber of sleep related characteristics had a significant impact on the accuracy of actigraphy & should be considered when using actigraphy to screen sleep disorders
10.28-29.2011
TSSP Sleep Conference
2
Blackwell T, et al. (2011). Factors that May Influence the Classification of Sleep-Wake by Wrist Actigraphy: The
MrOS
Sleep Study.
Journal of Clinical Sleep Medicine
,
7(4), 357-367.
Slide22Actigraphy & CPT codes
CPT Code #95803 “Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording.” $162.41 without geographic adjustmentsRelated CPT codes: 99203, 99211, 99245, 99070Medicare not covering, BCBS views as experiment/investigational so not coveredSome providers are covering the CPTKelly A. Carden MD,
(CWinter-Rosenberg@aasmnet.org) Chair of AASM Coding & Compliance Committee managing reimbursement, asks if actigraphy CPT submissions are being denied that she be contacted with the information so she can use it to try and reverse trend
10.28-29.2011
TSSP Sleep Conference
Slide23Actigraphy Sleep Research
How can we use actigraphy to assess patient groups that will not easily be assessed in sleep labs/center?How can we begin to turn the tide of reimbursable diagnostics to include more options?Research remains our best tool to bring about change in the profession10.28-29.2011TSSP Sleep Conference
Slide24Texas State University
2nd largest cohort of veteran men/women returning from war theater in the stateOver 1700 men/women returning after deploymentSurveyed in over 20 items of needs specific to returning veteran college studentsGreatest need/complaint?10.28-29.2011
TSSP Sleep Conference
Slide25Veteran vs non-Veteran Student Pilot Sleep Study
N = 20 (10 Veteran and 10 non-Veteran TxState studentsWore Actiwatch2 for 7 days/nightsMeasured 1) Time in Bed2) Total Sleep Time 3) Sleep Onset Latency 4) Sleep Efficiency 5) Time Wake After Sleep Onset (WASO) 6) # Wake Bouts
Slide26Vet/non-Vet Sleep Pilot Conclusion
Although both groups spend about the same amount of time in bed and woke up about the same number of times per night, differences with veteran students experiencing1) Total Sleep Time2)
Sleep Efficiency3)
Sleep Latency
4)
WASO
Each of these issues impact academic success and quality of emotions and mental health
Slide27The future….
Actigraphy has demonstrated a reasonable reliability as an sleep diagnostic/assessment device for some patient demographic groupsStudies comparing actigraphy outcomes to nPSG diagnostics seem overall positiveAlthough reimbursement issues are a current barrier preventing more utilization, changes in coverage may be in the futureSleep labs/centers may find actigraphy useful in tracking longitudinal sleep information that may be missed by a one-night nPSG study
10.28-29.2011
TSSP Sleep Conference
Slide28References
Blackwell, T., Ancoli-Israel, S., Redline, S., Stone, K. (2011). Factors that May Influence the Classification of Sleep-Wake by Wrist Actigraphy: The MrOS Sleep Study. Journal of Clinical Sleep Medicine, 7(4), 357-375.Johnson
, N., Kirchner, L., Rosen, C., Storfer-Isser, A., Cartar, L.,
Ancoli
-Israel, S.,
Emancipator, J.,
Kibler
, A., Redline, S. (2007). Sleep Estimation Using Wrist
Actigraphy in Adolescents With and Without Sleep Disordered Breathing: A
Comparisoin
of Three Data Modes.
SLEEP, 30(7),
899-905.
Morgenthaler
, T.,
Alessi
, C., Friedman, L., Owens, J.,
Kapur
, V.,
Boehlecke
, B., Brown, T.,
Chesson
, A., Coleman, J., Lee-
Chiong
, T.,
Pancer
, J., Swick, T. (2007). Practice
Parameters for the Use of Actigraphy in the Assessment of Sleep and Sleep Disorders:
An Update for 2007.
Sleep, 30(4),
519-529.
Paquet
, J.,
Kawinska
, A., Carrier, J. (2007). Wake Detection Capacity of Actigraphy During
Sleep.
SLEEP, 30(10),
1362-1369.
Sadeh
, A.,
Acebo,C
. (2002). The role of actigraphy in sleep medicine.
Sleep Medicine
Reviews, 6(2),
113-124
.
10.28-29.2011
TSSP Sleep Conference