The role of actigraphy in sleep assessment and screening

1. The role of actigraphy in sleep assessment and screening TSSP Sleep Conference Gregg Marshall, PhD, RRT, RPSGT Chair/Associate Professor College of Health Professions Department of Respiratory Care Texas State University-San Marcos San Marcos, TX

2. Disclosure 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. TSSP Sleep Conference

3. Learning Objectives • 1) Describe the fundamental basics of actigraphy devices • 2) Discuss the value of actigraphy as a prescreening device for sleep disorders • 3) Describe current clinical applications of the use of actigraphy studies • 4) Discuss the potential role of actigraphy within sleep labs/centers TSSP Sleep Conference

4. Q1: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 of • Piezoelectric 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 values • Memory to store data • Interface (USB) to program device and download data from memory TSSP Sleep Conference

5. Actigraphy basics…. • Continuously measures movement and ambient light over time • Light sensor recalls all levels of light • Various models offer features that may provide additional movement/light measurements • Depending on the model, activity is recorded in various ways according to each unique algorithm for estimating sleep/wake measures TSSP Sleep Conference

6. Actigraphy watches TSSP Sleep Conference

7. Q2: What sleep values can actigraphy provide? • Scoring algorithms are used to identify sleep or wake states from activity counts to identify sleep parameters • Time In Bed • Total Sleep Time (TST) • Wake After Sleep Onset (WASO) • Sleep Efficiency (TST/Total Time In Bed) • Wake Bouts • Sleep Onset Latency (SOL) TSSP Sleep Conference

8. What’s missing? • Actigraphy cannot address • Sleep staging • Snoring • Apnea/hypopnea • SpO2 desaturation • HR, RR, body position • Thoracic/abdominal effort • ECG TSSP Sleep Conference

9. Q3: 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 patients • Previous studies (Paquet, 2007; Sadeh, 2002; Johnson, 2007) have suggested a wide range of findings from “less than useful” to “reasonable good estimate” of sleep disorders TSSP Sleep Conference

10. AASM’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 setting • After a review of literature/research regarding actigraphy, AASM’s SPC and BOD made ten specific recommendations for the use of actigraphy in clinical practice TSSP Sleep Conference

11. AASM recommendations • 1) Valid way to assist in determining sleep patterns in normal, health adult populations and in patients suspected of certain sleep disorders • 2) 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) TSSP Sleep Conference

12. AASM 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 OSA • 4) 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 hypersomnia TSSP Sleep Conference

13. AASM recommendations • 6) Useful outcome measure in evaluating response to treatment for circadian rhythm disorders • 7) Useful to evaluate response to treatment of insomnia • 8) Useful to characterize/monitor sleep and circadian rhythm patterns and document treatment outcomes among older adults living in community TSSP Sleep Conference

14. AASM 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 difficult • 10) 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 interpret TSSP Sleep Conference

15. AASM recommendations • Finally, additional research warranted to further refine and broaden the clinical value of actigraphy to assess sleep and sleep disorders • Six specific recommendations for future actigraphy-focused research TSSP Sleep Conference

16. Q4: How can actigraphy be used in sleep labs/center? • Longitudinal look at sleep characteristics rather than a “snap-shot” provided by nPSG study • Helpful with documenting actual sleep patterns for some dyssomnias, parasomnias, and medical/psychiatric conditions (psychoses, mood disorders, panic, alcoholism) • Sleep history “at a glance” TSSP Sleep Conference

17. Normal Sleep Cycle TSSP Sleep Conference 13 days Tracking 24 hours

18. Insomnia 21 days TSSP Sleep Conference

19. Delayed Sleep Phase (DSP) TSSP Sleep Conference 14 days

20. Shift-workers Syndrome TSSP Sleep Conference 14 days

21. Actigraphy & 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 men • N = 896 with concurrent PSG/actigraphy studies • Number of sleep related characteristics had a significant impact on the accuracy of actigraphy & should be considered when using actigraphy to screen sleep disorders 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.

22. Actigraphy & 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 adjustments • Related CPT codes: 99203, 99211, 99245, 99070 • Medicare not covering, BCBS views as experiment/investigational so not covered • Some providers are covering the CPT • Kelly 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 TSSP Sleep Conference

23. Actigraphy 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 profession TSSP Sleep Conference

24. Texas State University • 2nd largest cohort of veteran men/women returning from war theater in the state • Over 1700 men/women returning after deployment • Surveyed in over 20 items of needs specific to returning veteran college students • Greatest need/complaint? TSSP Sleep Conference

25. Veteran vs non-Veteran Student Pilot Sleep Study • N = 20 (10 Veteran and 10 non-Veteran TxState students • Wore Actiwatch2 for 7 days/nights • Measured • 1) Time in Bed • 2) Total Sleep Time • 3) Sleep Onset Latency • 4) Sleep Efficiency • 5) Time Wake After Sleep Onset (WASO) • 6) # Wake Bouts

26. Vet/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 experiencing • 1)  Total Sleep Time • 2) Sleep Efficiency • 3)  Sleep Latency • 4)  WASO • Each of these issues impact academic success and quality of emotions and mental health

27. The future…. • Actigraphy has demonstrated a reasonable reliability as an sleep diagnostic/assessment device for some patient demographic groups • Studies comparing actigraphy outcomes to nPSG diagnostics seem overall positive • Although reimbursement issues are a current barrier preventing more utilization, changes in coverage may be in the future • Sleep labs/centers may find actigraphy useful in tracking longitudinal sleep information that may be missed by a one-night nPSG study TSSP Sleep Conference

28. References 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. TSSP Sleep Conference