Circadian Rhythm Sleep Disorders Get New Guidelines

ROCHESTER, Minn., Nov. 1 -- The first comprehensive guidelines for circadian rhythm sleep disorders are out, though with few surprises for sleep medicine specialists.
Action Points
Explain to interested patients that the guidelines provide a more comprehensive approach to circadian rhythm sleep disorders than was previously available.
Consider recommendations from the American Academy of Sleep Medicine in diagnosis and treatment of circadian rhythm sleep disorders.
Nonetheless, the American Academy of Sleep Medicine recommendations may be helpful for clinicians in treating and diagnosing shift work disorder and in the use of melatonin, said Timothy I. Morgenthaler, M.D., of the Mayo Clinic here.
He and colleagues developed the practice parameters because research in the relatively new but growing field of sleep medicine has outpaced clinical developments, they wrote in the Nov. 1 issue of SLEEP.
"Many of the [existing] practice parameters had to do with diagnostic procedures, [and] some of them had to do with very specific therapeutic endeavors," Dr. Morgenthaler said, but there were no cohesive evidence-based guidelines.
The guidelines were developed from two review articles to be published in the same journal issue.
One encompassed exogenous circadian rhythm sleep disorders (shift work disorder and jet lag disorder). The other dealt with endogenous circadian rhythm sleep disorders, which included advanced sleep phase disorder, delayed sleep phase disorder, irregular sleep-wake rhythm, and the non-24-hour sleep-wake syndrome (free-running disorder).
The recommendations were divided by level of evidence into standards that were backed by high-quality randomized controlled trials or well-validated cohorts; guidelines that were supported with only cohort studies or flawed clinical trials; and options, defined by inconclusive or conflicting evidence or conflicting expert opinion.
Melatonin was recommended as indicated across the spectrum of circadian rhythm sleep disorders, except for irregular sleep-wake rhythm disorder in elderly patients with dementia or those in nursing homes. These recommendations were considered options for advanced sleep phase, free-running disorder in sighted patients, and for irregular sleep-wake rhythm patients with moderate to severe mental retardation.
For shift work sleep disorder, actigraphy was recommended for diagnosis and monitoring response to therapy, as was use of a sleep log or diary. But polysomnography, Morningness-Eveningness Questionnaires, and circadian phase markers were not recommended for routine use.
Planned sleep schedules were considered a standard therapy for shift work sleep disorder whereas use of timed light exposure and melatonin, hypnotics, and alerting agents had a lower level of evidence. Caffeine, modafinil (Provigil), and methamphetamine were suggested as options for treatment.
Overall, the standard for polysomnography use was to rule out another primary sleep disorder but not for routine diagnosis of circadian rhythm sleep disorders.
Other guidelines included:
Use of a sleep log or diary to assess patients with a suspected CRSD.
Actigraphy for diagnosis of circadian rhythm disorders aside from jet lag and for evaluating response to treatment across the board.
Morning light exposure for treatment of delayed sleep phase disorder.
Other recommendations at the option level of evidence included:
Maintaining home-based rather than destination sleep hours to combat jet lag when the duration of a trip is expected to be brief.
The combination of morning exposure to bright light and shifting the sleep one hour earlier each day for three days prior to eastward travel to lessen jet lag symptoms.
For advanced sleep phase disorder, use of prescribed sleep-wake scheduling, timed light exposure, or timed melatonin administration.
Progressive delay in scheduled sleep time (chronotherapy) for delayed sleep phase disorders.
For free-running disorder, use of sleep logs and circadian phase markers for assessment and prescribed sleep-wake scheduling as treatment for sighted patients and timed light exposure or melatonin for treatment of both blind and sighted patients.
Daytime light exposure for nursing home residents with dementia and irregular sleep-wake rhythm disorder.
All members of the AASM Standards of Practice Committee and Board of Directors completed detailed conflict of interest statements and were found to have no conflicts of interest with regard to this subject.
Primary source: SLEEPSource reference: Morgenthaler TI, et al "Practice Parameters for the Clinical Evaluation and Treatment of Circadian Rhythm Sleep Disorders: An American Academy of Sleep Medicine Report" Sleep 2007.