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Characterization of excessive sleepiness is an important task for the sleep clinician, and assessment requires a thorough history and in many cases, objective assessment in the sleep laboratory. These practice parameters were developed to guide the sleep clinician on appropriate clinical use of the Multiple Sleep Latency Test (MSLT), and the Maintenance of Wakefulness Test (MWT). These recommendations replace those published in 1992 in a position paper produced by the American Sleep Disorders Association. A Task Force of content experts was appointed by the American Academy of Sleep Medicine to perform a comprehensive review of the scientific literature and grade the evidence regarding the clinical use of the MSLT and the MWT. Practice parameters were developed based on this review and in most cases evidence based methods were used to support recommendations. When data were insufficient or inconclusive, the collective opinion of experts was used to support recommendations. These recommendations were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. The MSLT is indicated as part of the evaluation of patients with suspected narcolepsy and may be useful in the evaluation of patients with suspected idiopathic hypersomnia. The MSLT is not routinely indicated in the initial evaluation and diagnosis of obstructive sleep apnea syndrome, or in assessment of change following treatment with nasal continuous positive airway pressure (CPAP). The MSLT is not routinely indicated for evaluation of sleepiness in medical and neurological disorders (other than narcolepsy), insomnia, or circadian rhythm disorders. The MWT may be indicated in assessment of individuals in whom the inability to remain awake constitutes a safety issue, or in patients with narcolepsy or idiopathic hypersomnia to assess response to treatment with medications. There is little evidence linking mean sleep latency on the MWT with risk of accidents in real world circumstances. For this reason, the sleep clinician should not rely solely on mean sleep latency as a single indicator of impairment or risk for accidents, but should also rely on clinical judgment. Assessment should involve integration of findings from the clinical history, compliance with treatment, and, in some cases, objective testing using the MWT. These practice parameters also include recommendations for the MSLT and MWT protocols, a discussion of the normative data available for both tests, and a description of issues that need further study.

Study objective This study was designed to determine whether different desaturation indexes (DIs) would be obtained in patients with sleep-disordered breathing by systematically altering two acquisition parameters: the recording setting and the display mode. Design Prospective clinical study. Setting Community sleep-disorders center. Patients The study included 75 patients who were suspected of having sleep-disordered breathing. Interventions Each patient had simultaneous pulse oxyhemoglobin saturation (Sp o 2 ) traces at three recording settings (3 s, 6 s, and 12 s) during the diagnostic phase of split-night polysomnography. On-line and memory displays of those data at each recording setting were obtained. DIs for ≥ 3% desaturation events per hour were calculated for each of the six traces. Results The mean on-line DIs significantly differed from each other, with slower (longer) recording settings resulting in lower values than faster (shorter) settings. The memory DIs all significantly underestimated the on-line DIs. Pearson correlations ranged from 0.82 to 0.90 between the on-line/memory DI pairs, but Bland-Altman analysis detected disagreement at higher levels of disordered breathing. Conclusions These findings confirm that significantly different Sp o 2 data are obtained at various acquisition options. The recording setting and display mode parameters should be disclosed in all reports employing oximetry with the fastest recording setting and on-line display mode preferable for case finding of sleep-disordered breathing.

Continuous positive airway pressure (CPAP) is used to treat patients with the obstructive sleep apnea syndrome (OSAS). The current standard is for an attendant technician to titrate CPAP during full polysomnography to obtain a fixed single pressure. The patient uses CPAP nightly at this fixed single pressure. Recently, devices using new technology that automatically titrate positive airway pressure (APAP) have become available. Such devices continually adjust pressure, as needed, to maintain airway patency (APAP titration). These adjustments can be made with or without attendant technician intervention. Data obtained during APAP titration can be used to provide a fixed single pressure for subsequent treatment. Alternatively, APAP devices can be used in self-adjusting mode for treatment (APAP treatment). A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Standards of Practice Committee developed these practice parameters as a guide to the appropriate use of APAP. Recommendations are as follows: 1) A diagnosis of OSAS must be established by an acceptable method. 2) APAP titration and APAP treatment are not currently recommended for patients with congestive heart failure, significant lung disease (e.g., chronic obstructive pulmonary disease), daytime hypoxemia and respiratory failure from any cause, or prominent nocturnal desaturation other than from OSA (e.g., obesity hypoventilation syndrome). In addition, patients who do not snore (either due to palate surgery or naturally) should not be titrated with an APAP device that relies on vibration or sound in the device's algorithm. 3) APAP devices are not currently recommended for split-night studies since none of the reviewed research studies examined this issue. 4) Certain APAP devices may be used during attended titration to identify by polysomnography a single pressure for use with standard CPAP for treatment of OSA. 5) Once an initial successful attended CPAP or APAP titration has been determined by polysomnography, certain APAP devices may be used in the self-adjusting mode for unattended treatment of patients with OSA. 6) Use of unattended APAP to either initially determine pressures for fixed CPAP or for self-adjusting APAP treatment in CPAP naive patients is not currently established. 7) Patients being treated with fixed CPAP on the basis of APAP titration or being treated with APAP must be followed to determine treatment effectiveness and safety, and 8) a re-evaluation and, if necessary, a standard attended CPAP titration should be performed if symptoms do not resolve or the CPAP or APAP treatment otherwise appears to lack efficacy.

Laser-assisted uvulopalatoplasty (LAUP) is an outpatient surgical procedure which is in use as a treatment for snoring. LAUP also has been used as a treatment for sleep-related breathing disorders, including obstructive sleep apnea. The Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature, and developed these practice parameters as a guide to the appropriate use of this surgery. Adequate controlled studies on the LAUP procedure for sleep-related breathing disorders were not found in peer-reviewed journals. This is consistent with findings in the original practice parameters on LAUP published in 1994. The following recommendations are based on the review of the literature: LAUP is not recommended for treatment of sleep-related breathing disorders. However, it does appear to be comparable to uvulopalatopharyngoplasty (UPPP) for treatment of snoring. Individuals who are candidates for LAUP as a treatment for snoring should undergo a polysomnographic or cardiorespiratory evaluation for sleep-related breathing disorders prior to LAUP and periodic postoperative evaluations for the development of same. Patients should be informed of the best available information of the risks, benefits, and complications of the procedure.

Chronic insomnia is the most common sleep complaint which health care practitioners must confront. Most insomnia patients are not, however, seen by sleep physicians but rather by a variety of primary care physicians. There is little agreement concerning methods for effective assessment and subsequent differential diagnosis of this pervasive problem. The most common basis for diagnosis and subsequent treatment has been the practitioner's clinical impression from an unstructured interview. No systematic, evidence-based guidelines for diagnosis exist for chronic insomnia. This practice parameter paper presents recommendations for the evaluation of chronic insomnia based on the evidence in the accompanying review paper. We recommend use of these parameters by the sleep community, but even more importantly, hope the large number of primary care physicians providing this care can benefit from their use. Conclusions reached in these practice parameters include the following recommendations for the evaluation of chronic insomnia. Since the complaint of insomnia is so widespread and since patients may overlook the impact of poor sleep quality on daily functioning, the health care practitioner should screen for a history of sleep difficulty. This evaluation should include a sleep history focused on common sleep disorders to identify primary and secondary insomnias. Polysomnography, and the Multiple Sleep Latency Test (MSLT) should not be routinely used to screen or diagnose patients with insomnia complaints. However, the complaint of insomnia does not preclude the appropriate use of these tests for diagnosis of specific sleep disorders such as obstructive sleep apnea, periodic limb movement disorder, and narcolepsy that may be present in patients with insomnia. There is insufficient evidence to suggest whether portable sleep studies, actigraphy, or other alternative assessment measures including static charge beds are effective in the evaluation of insomnia complaints. Instruments such as sleep logs, self-administered questionnaires, symptom checklist, or psychological screening tests may be of benefit to discriminate insomnia patients from normals, but these instruments have not been shown to differentiate subtypes of insomnia complaints.

Insomnia is the most common sleep complaint reported to physicians. Treatment has traditionally involved medication. Behavioral approaches have been available for decades, but lack of physician awareness and training, difficulty in obtaining reimbursements, and questions about efficacy have limited their use. These practice parameters review the current evidence with regards to a variety of nonpharmacologic treatments for insomnia. Using a companion paper which provides a background review, the available literature was analyzed. The evidence was graded by previously reported criteria of the American Academy of Sleep Medicine with references to American Psychological Association criteria. Treatments considered include: stimulus control, progressive muscle relaxation, paradoxical intention, biofeedback, sleep restriction, multicomponent cognitive behavioral therapy, sleep hygiene education, imagery training, and cognitive therapy. Improved experimental design has significantly advanced the process of evaluation of nonpharmacologic treatments for insomnia using guidelines outlined by the American Psychological Association (APA). Recommendations for individual therapies using the American Academy of Sleep Medicine recommendation levels for each are: Stimulus Control (Standard); Progressive Muscle Relaxation, Paradoxical Intention, and Biofeedback (Guidelines); Sleep Restriction, and Multicomponent Cognitive Behavioral Therapy (Options); Sleep Hygiene Education, Imagery Training, and Cognitive Therapy had insufficient evidence to be recommended as a single therapy. Optimal duration of therapy, who should perform the treatments, long term outcomes and safety concerns, and the effect of treatment on quality of life are questions in need of future research.

These are the first clinical guidelines published for the treatment of Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD) providing evidence-based practice parameters. They were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. The guidelines provide recommendations for the practice of sleep medicine in North America regarding the treatment of RLS and PLMD. Recommendations are based on the accompanying comprehensive review of the medical literature regarding treatment of RLS and PLMD which was developed by a task force commissioned by the American Academy of Sleep Medicine. Recommendations are identified as standards, guidelines, or options, based on the strength of evidence from published studies that meet criteria for inclusion. Dopaminergic agents are the best studied and most successful agents for treatment of RLS and PLMD. Specific recommendations are also given for the use of opioid, benzodiazepine, anticonvulsant, and adrenergic medications, and for iron supplementation. In general, pharmacological treatment should be limited to individuals who meet diagnostic criteria and especially who experience insomnia and/or excessive sleepiness that is thought to occur secondary to RLS or PLMD. Individuals treated with medication should be followed by a physician and monitored for clinical response and adverse effects. It would be desirable for future investigations to employ multicenter clinical trials, with expanded numbers of subjects using double-blind, placebo-controlled designs, and an assessment of long-term response, side effects, and impact of treatment on quality of life. Evaluation of special groups such as children, pregnant women, and the elderly is warranted.

These clinical guidelines were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. The guidelines provide recommendations for the practice of sleep medicine in North America regarding the use of light therapy for treatment of various sleep disorders. This paper is based on a series of articles in the Journal of Biological Rhythms and also includes evidence tables from an updated Medline review covering the period January 1994 to December 1997. Evidence is presented by grade and level. Recommendations are identified as standards, guidelines, or options. Recommendations are provided for delayed sleep phase syndrome (DSPS), advanced sleep phase syndrome (ASPS), non-24-hour sleep-wake syndrome, jet lag, shift work, dementia, and sleep complaints in the healthy elderly. Light therapy appears generally safe if used within recommended intensity and time limits. Light therapy can be useful in treatment of DSPS and ASPS. Benefits of light therapy are less clear and treatment is an option in jet lag, shift work, and non-24-hour sleep-wake syndrome in some blind patients.

Sleep-wake disturbances are common among patients with cancer (Berger, 2009; Berger et al., 2005; Davidson, Maclean, Brundage, & Schulze, 2002; Sateia & Lang, 2008; Savard, Ivers, Villa, Caplette-Gingras, & Morin, 2011), and are multifactorial in origin (Vena, Parker, Cunningham, Clark, & McMillan, 2004). Among cancer populations, sleep has been studied extensively among patients with breast or lung cancer either subjectively or in combination with actigraphy (ACTG). Although convenient, ACTG assesses only motion or its absence as a proxy of wakefulness or sleep (Tyron, 1991). The sleep of patients with all types of cancer has been studied less extensively using polysomnography (PSG). PSG is considered the gold standard of objective sleep measurement because it assesses and records electroencephalographic sleep changes (Dement, 2011). The current study is the first to describe sleep using PSG in patients with multiple myeloma (MM). MM involves the development of abnormal plasma cells that collect in bone marrow and damage bone. Myeloma cells produce abnormal antibodies called plasma M proteins that accumulate in organs such as the kidneys, resulting in renal damage and failure. An estimated 21,000 new cases of MM, the most common type of plasma cell cancer, were diagnosed in the United States in 2012 (National Cancer Institute [NCI], 2012). MM usually develops in adults older than 65 years and is most common among African Americans and men (NCI, 2012). Disease-related risk factors that may impair sleep in patients with MM include bone pain and peripheral neuropathy, which are among the most common neurologic symptoms of plasma cell cancer (Mangan, 2005). Opiates, often used to manage bone pain, are associated with drowsiness (Rome, 2010), which may contribute to daytime activity and excessive daytime napping, decreasing the homeostatic sleep drive and disrupting circadian rhythms. Treatment-related risk factors that may impair sleep include pain related to oral mucositis and peripheral neuropathy (Palumbo et al., 2008). Oral mucositis is a common side effect of chemotherapy, particularly with intensive treatment (Niscola et al., 2006). Chemotherapy- induced peripheral neuropathy has been well-established in relation to several agents used for MM therapy (such as thalidomide and bortezomib) (Chaudhry, Combiath, Polydefkis, Ferguson, & Borrello, 2008; Delforge et al., 2010; El-Cheikh et al., 2008), and associated sensory symptoms usually are worse at night (Snowden et al., 2011). Other treatment-related side effects include insomnia associated with adjunct corticosteroids (Faiman, Bilotti, Mangan, & Rogers, 2008) and daytime sleepiness and fatigue associated with thalidomide (Celgene Corporation, 2006). Those factors place patients with MM at higher risk for insomnia, noted as a common problem for patients with cancer (Savard et al., 2011). Common complications with MM and its treatment may indirectly contribute to sleep disturbance. Anemia, renal failure, and peripheral neuropathy (Berenson, 2005) are related to iron deficiency, renal disease, and neuropathy, which are major risk factors for restless legs syndrome (RLS) and periodic limb movements (PLMs) (Allen & Earley, 2007; National Center on Sleep Disorders Research, n.d.). Anemia in MM is associated with inadequate erythropoietin production and responsiveness, decreased red blood cell lifespan, and incorrect release of iron from macrophages (normal to high iron stores with low serum iron) (Ludwig & Osterborg, 2010). Renal disease in MM is associated with the immunoglobulin products (M proteins) of monoclonal plasma cells in the bone marrow, which form kidney deposits typically progressing to renal tubular, glomerular, and vascular pathology and failure (Soloman, Weiss, & Herrera, 2010). Those disease-related factors may predispose patients with MM to develop secondary sleep disorders such as RLS and PLMs. Psychosocial factors, such as anxiety, are theorized to be experienced by patients with cancer from the time of diagnosis through completion of induction therapy (Sherman, Simonton, Latif, Plante, & Anaissie, 2009) and may impact sleep. Depression highly correlates with sleep disturbance even before chemotherapy (Phillips, Jim, Donovan, Pinder-Schenck, & Jacobsen, 2012). In addition, depression and anxiety have been associated strongly with sleep problems in older patients with cancer during and following treatment (Sharma et al., 2011). Coleman et al. (2010) reported disturbed sleep and mood in patients with MM. Unpublished findings from that study suggested that total mood disturbance negatively correlated with sleep efficiency, a measure of how long patients slept while in bed attempting to sleep. Sleep efficiency also is considered an objective reflection of subjective sleep quality, the perception of sleep as restorative for function (Van Cauter & Allostatic Working Group, 1997). Therefore, mood disturbance may contribute to the risk of sleep disturbance in patients with MM. Sleep disturbance in patients with MM may result in alteration of normal sleep types, stages, and variables in the daily sleep-wake pattern. Non–rapid eye movement (NREM) sleep is characterized by progression to deep sleep with decreased responsiveness to stimuli and retained muscle tone. Stages 1 and 2 of NREM sleep often are referred to as light sleep, and stages 3 and 4 as deep or slow-wave sleep. Rapid eye movement (REM) sleep is characterized by dreaming, varied responsiveness to stimuli, paralysis of voluntary muscles, increased vital signs and cerebral blood flow, and decreased temperature regulation. A typical night of sleep is composed of four to six 90–110 minute cycles of NREM and REM sleep. Total sleep time is predominantly composed of 75%–80% NREM sleep and 20%–25% REM sleep (Carskadon & Dement, 2005). The inability to attain adequate amounts of deep NREM or REM sleep may change the quality or restorative potential of sleep. Those changes also may be reflected through alterations in sleep variables such as sleep onset latency (time taken to fall asleep), wake time after sleep onset (time spent awake after initial onset of sleep), and sleep efficiency (amount of time spent asleep while attempting to sleep) in addition to the duration of total sleep time. Despite the many risks for sleep disturbance, limited knowledge of sleep problems experienced by patients with MM exists. Coleman et al. (2010) found that sleep for patients with MM was characterized by decreased nocturnal sleep time for age, frequent wake episodes, and a low percentage of time asleep while in bed. However, the objective sleep of patients with MM assessed with PSG has not been described. Therefore, the primary purpose of the current study was to describe the sleep of patients with MM using PSG, before and after a second cycle of high-dose chemotherapy patients received prior to stem cell transplantation.

Study Objectives: Pulse oximetry (SpO 2 ) is a key parameter monitored during polysomnographic studies, and different acquisition settings can be employed to obtain this data. The purpose of this study was to determine if the use of different settings would significantly influence scoring of respiratory disturbance events (RDE). Design: Prospective study Setting: Sleep Disorders Center - community Patients: 30 patients had three identical oximeters simultaneously attached to the digits during polysomnography, each placed in a different recording setting: 3, 6 and 12 seconds. Interventions: None Measurements: RDEs were identified by changes in snoring and flow then sub-categorized as RDE0, RDE1-2 and/or RDE3 if less than 1%, greater than 1 but less than 3%, and 3% or greater oxyhemoglobin desaturation occurred. Each event was given three labels according to the level of desaturation seen on each oximetry tracing. Results: Significant differences in the mean frequency of RDE types at each recording setting were noted (p

Successful treatment of narcolepsy requires an accurate diagnosis to exclude patients with other sleep disorders, which have different treatments, and to avoid unnecessary complications of drug treatment. Treatment objectives should be tailored to individual circumstances. Modafinil, amphetamine, methamphetamine, dextroamphetamine, methylphenidate, selegiline, pemoline, tricyclic antidepressants, and fluoxetine are effective treatments for narcolepsy, but the quality of published clinical evidence supporting them varies. Scheduled naps can be beneficial to combat sleepiness, but naps seldom suffice as primary therapy. Regular follow up of patients with narcolepsy is necessary to educate patients and their families, monitor for complications of therapy and emergent of other sleep disorders, and help the patient adapt to the disease.