Guidelines Issued for Management of Circadian Rhythm Sleep Disorders
November 5, 2007 — The American Academy of Sleep Medicine (AASM) has issued practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders (CRSDs), which are published in the November 1 issue of Sleep.
"The expanding science of circadian rhythm biology and a growing literature in human clinical research on circadian rhythm sleep disorders (CRSDs) prompted the American Academy of Sleep Medicine (AASM) to convene a task force of experts to write a review of this important topic," write Timothy I. Morgenthaler, MD, and colleagues from the Standards of Practice Committee of the AASM. "These practice parameters were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the AASM to present recommendations for the assessment and treatment of CRSDs based on the two accompanying comprehensive reviews. The main diagnostic tools considered include sleep logs, actigraphy, the Morningness-Eveningness Questionnaire (MEQ), biologic phase markers, and polysomnography."
The accompanying review includes 2 sections: the first including a general introduction to circadian biology, as well as "exogenous" CRSDs (shift work disorder and jet lag disorder), and the second highlighting the "endogenous" CRSDs (advanced sleep phase disorder, delayed sleep phase disorder, irregular sleep-wake rhythm, and the non–24-hour sleep-wake syndrome [nonentrained type] or free-running disorder).
Both reviews summarize the peer-reviewed scientific literature published through October 2006, and the authors evaluated the evidence according to the Oxford System for Evidence-Based Medicine. Using this evidence, the Standards of Practice Committee and Board of Directors of the AASM determined levels of treatment recommendation, ranging from standard (highest level of certainty) through guideline (intermediate level) to option (weakest level).
Other recently published updated practice parameters addressed the use of actigraphy and light therapy, so key findings from these were summarized in the present AASM statement.
Specific recommendations are as follows:
Use of a sleep log or diary is indicated to evaluate patients with suspected CRSD (guideline).
Actigraphy is indicated to facilitate the assessment of patients with suspected CRSDs. Depending on which CRSD is suspected, the strength of recommendation varies from "Option" to "Guideline."
Polysomnography is not routinely indicated for the diagnosis of CRSDs. However, polysomnography may be needed to exclude another primary sleep disorder (standard).
For routine clinical evaluation of CRSDs, evidence is insufficient to justify the use of MEQ (option).
Although biologic phase markers are useful to determine circadian phase and confirm the diagnosis of free-running disorder in sighted and unsighted patients, evidence is insufficient to recommend their routine use in the diagnosis of shift work disorder, jet lag disorder, advanced sleep phase disorder, delayed sleep phase disorder, or irregular sleep-wake rhythm (option).
Actigraphy is a useful outcome measure in determining the response to treatment of CRSDs (guideline). Available treatments include planned sleep schedules, timed light exposure, timed melatonin doses, hypnotics, stimulants, and alerting agents.
Planned or prescribed sleep schedules are indicated in jet lag disorder, shift work disorder, delayed sleep phase disorder, advanced sleep phase disorder, irregular sleep-wake rhythm, (except for elderly, nursing home residents with dementia) and free-running disorder (option).
Specifically dosed and timed light exposure is indicated for each of the circadian disorders, although success varies based on the specific diagnosis (option).
Timed melatonin administration is indicated for shift work disorder, advanced sleep phase disorder, and free-running disorder in sighted individuals (option); for jet lag disorder, delayed sleep phase disorder, and free-running disorder in unsighted persons (guideline); and for irregular sleep-wake rhythm in children who have moderate to severe psychomotor retardation (option).
To promote or improve daytime sleep among night shift workers, hypnotic medications may be indicated (guideline).
Hypnotic medications may also be indicated to treat jet lag–induced insomnia (option).
Although stimulants may be indicated to improve alertness in jet lag disorder and shift work disorder (option), they may have associated risks that should be carefully considered before use.
For patients with shift work disorder, modafinil may be indicated to improve alertness during the night shift (guideline).
"We acknowledge that while the disorders are classified as endogenous or exogenous, the physiologic underpinnings of each disorder are not so surgically separated," the authors conclude. "In reality, combinations of endogenous and exogenous factors lead to the manifestations of each disorder."
All members of the AASM Standards of Practice Committee and Board of Directors were found to have disclosed no relevant financial relationships pertinent to this topic.
Sleep. 2007;00:000-000.