In summary, although actigraphy is not as accurate as PSG for determining some sleep measurements, studies are in general agreement that actigraphy, with its ability to record continuously for long time periods, is more reliable than sleep logs which rely on the patients' recall of how many times they woke up or how long they slept during the night and is more reliable than observations which only capture short time periods Actigraphy can provide information obtainable in no other practical way It can also have a role in the medical care of patients with sleep disorders However, it should not be held to the same expectations as polysomnography Actigraphy is one-dimensional, whereas polysomnography comprises at least 3 distinct types of data (EEG, EOG, EMG), which jointly determine whether a person is asleep or awake It is therefore doubtful whether actigraphic data will ever be informationally equivalent to the PSG, although progress on hardware and data processing software is continuously being made Although the 1995 practice parameters paper determined that actigraphy was not appropriate for the diagnosis of sleep disorders, more recent studies suggest that for some disorders, actigraphy may be more practical than PSG While actigraphy is still not appropriate for the diagnosis of sleep disordered breathing or of periodic limb movements in sleep, it is highly appropriate for examining the sleep variability (ie, night-to-night variability) in patients with insomnia Actigraphy is also appropriate for the assessment of and stability of treatment effects of anything from hypnotic drugs to light treatment to CPAP, particularly if assessments are done before and after the start of treatment A recent independent review of the actigraphy literature by Sadeh and Acebo reached many of these same conclusions Some of the research studies failed to find relationships between sleep measures and health-related symptoms The interpretation of these data is also not clear-cut Is it that the actigraph is not reliable enough to the access the relationship between sleep changes and quality of life measures, or, is it that, in fact, there is no relationship between sleep in that population and quality of life measures? Other studies of sleep disordered breathing, where actigraphy was not used and was not an outcome measure also failed to find any relationship with quality of life Is it then the actigraph that is not reliable or that the associations just do not exist? The one area where actigraphy can be used for clinical diagnosis is in the evaluation of circadian rhythm disorders Actigraphy has been shown to be very good for identifying rhythms Results of actigraphic recordings correlate well with measurements of melatonin and of core body temperature rhythms Activity records also show sleep disturbance when sleep is attempted at an unfavorable phase of the circadian cycle Actigraphy therefore would be particularly good for aiding in the diagnosis of delayed or advanced sleep phase syndrome, non-24-hour-sleep syndrome and in the evaluation of sleep disturbances in shift workers It must be remembered, however, that overt rest-activity rhythms are susceptible to various masking effects, so they may not always show the underlying rhythm of the endogenous circadian pacemaker In conclusion, the latest set of research articles suggest that in the clinical setting, actigraphy is reliable for evaluating sleep patterns in patients with insomnia, for studying the effect of treatments designed to improve sleep, in the diagnosis of circadian rhythm disorders (including shift work), and in evaluating sleep in individuals who are less likely to tolerate PSG, such as infants and demented elderly While actigraphy has been used in research studies for many years, up to now, methodological issues had not been systematically addressed in clinical research and practice Those issues have now been addressed and actigraphy may now be reaching the maturity needed for application in the clinical arena

The role of actigraphy in the study of sleep and circadian rhythms.

1.0 BACKGROUND ACTIGRAPHY HAS BEEN USED TO STUDY SLEEP/WAKE PATTERNS FOR OVER 20 YEARS. The advantage of actigraphy over traditional polysomnography (PSG) is that actigraphy can conveniently record continuously for 24-hours a day for days, weeks or even longer. In 1995, Sadeh et al.,1 under the auspices of the American Sleep Disorders Association (now called the American Academy of Sleep Medicine, AASM), reviewed the current knowledge about the role of actigraphy in the evaluation of sleep disorders. They concluded that actigraphy does provide useful information and that it may be a “cost-effective method for assessing specific sleep disorders...[but that] methodological issues have not been systematically addressed in clinical research and practice.” Based on that task force’s report, the AASM Standards of Practice Committee concluded that actigraphy was not indicated for routine diagnosis or for assessment of severity or management of sleep disorders, but might be a useful adjunct for diagnosing insomnia, circadian rhythm disorders or excessive sleepiness.2 Since that time, actigraph technology has improved, and many more studies have been conducted. Several review papers have concluded that wrist actigraphy can usefully approximate sleep versus wake state during 24 hours and have noted that actigraphy has been used for monitoring insomnia, circadian sleep/wake disturbances, and periodic limb movement disorder.3,4 This paper begins where the 1995 paper left off. Under the auspices of the AASM, a new task force was established to review the current state of the art of this technology.

The Role of Actigraphy in the Study of Sleep and Circadian Rhythms AMERICAN ACADEMY OF SLEEP MEDICINE REVIEW PAPER

Auditory and non-auditory effects of noise on health

Noise is pervasive in everyday life and can cause both auditory and non-auditory health eff ects. Noise-induced hearing loss remains highly prevalent in occupational settings, and is increasingly caused by social noise exposure (eg, through personal music players). Our understanding of molecular mechanisms involved in noise-induced haircell and nerve damage has substantially increased, and preventive and therapeutic drugs will probably become available within 10 years. Evidence of the non-auditory eff ects of environmental noise exposure on public health is growing. Observational and experimental studies have shown that noise exposure leads to annoyance, disturbs sleep and causes daytime sleepiness, aff ects patient outcomes and staff performance in hospitals, increases the occurrence of hypertension and cardiovascular disease, and impairs cognitive performance in schoolchildren. In this Review, we stress the importance of adequate noise prevention and mitigation strategies for public health.

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Auditory and non-auditory eff ects of noise on health

Sleep and circadian rhythm disruption are frequently observed in patients with psychiatric disorders and neurodegenerative disease. The abnormal sleep that is experienced by these patients is largely assumed to be the product of medication or some other influence that is not well defined. However, normal brain function and the generation of sleep are linked by common neurotransmitter systems and regulatory pathways. Disruption of sleep alters sleep-wake timing, destabilizes physiology and promotes a range of pathologies (from cognitive to metabolic defects) that are rarely considered to be associated with abnormal sleep. We propose that brain disorders and abnormal sleep have a common mechanistic origin and that many co-morbid pathologies that are found in brain disease arise from a destabilization of sleep mechanisms. The stabilization of sleep may be a means by which to reduce the symptoms of--and permit early intervention of--psychiatric and neurodegenerative disease.

Sleep and circadian rhythm disruption in psychiatric and neurodegenerative disease

Noise protection associated with the construction and extension of airports in the Federal Republic of Germany has been regulated by the law for protection against aircraft noise since 1971. This legislation is due for revision because of different aspects. One aspect is the growth of air traffic which has led many airports to the limits of their capacity and in search of new ways of adaptation to the increasing demand for flight services. Another aspect is the increasing concern of the population about noise effects which has to be addressed by better protection against the effects of aircraft noise. The framework conditions of policy in terms of society as a whole, its health and economic environment need to be put into effect by political action. Science can contribute to this goal by performing noise effects research and by providing recommendations to the political body. However, it remains controversial, what measures are necessary or adequate to assure effective protection of the population against aircraft noise. This is particularly true for the protection of rest and sleep at night. The problem of finding a common basis for adequate recommendations is associated with (1) the low number of primary studies, which also exhibited highly variable results and assessments, (2) the handling of acoustic or psycho-acoustic dimensions for quantifying psychological or physiological reactions, and (3) the conception of how far preventive measures have to go to prove effective. With this in mind, the DLR Institute for Aerospace Medicine is conducting a large-scale, multi-stage study for investigating the acute effects of nocturnal aircraft noise on human sleep. This enterprise is implemented in the framework of the HGF/DLR project "Quiet Air Traffic" for developing sustainable assessment criteria for human-specific effects of aircraft noise at night.

Nocturnal aircraft noise effects.

The influence of simulated microgravity and reduced zeitgebers on the circadian system was examined in eight subjects. The 12-d study included a 3-d period for baseline measurements, 7 d of 6 degrees head-down bed rest, and 2 d for recovery. The sleep-wake cycle was kept constant during the study. The state of the circadian system was assessed from continuous measurements of temperature and ECG, and collections of urine at 3-h intervals for the determination of hormone and electrolyte excretions. Results indicate that only minor changes occurred in rhythm acrophases, whereas daily means for several physiological functions and their circadian amplitudes were significantly altered during the bed-rest phase. These studies using head-down tilt confirm previous findings with horizontal bed rest and indicate that rhythm disturbances can occur without change in the sleep-wake cycle. To the degree that bed-rest studies simulate manned spaceflights, results indicate that variations in circadian cycles can occur even during short-term missions and must be taken into account when interpreting subsequently obtained physiological data.

Response of the circadian system to 6 degrees head-down tilt bed rest.

The study was performed as the second part of an investigation to assess sleep behavior and circadian rhythmicity in aircrew operating regular passenger flights between Germany and East Asia via Anchorage (ANC). Continuous records of sleep and ratings of sleep quality were obtained by sleep logs from 101 B747-cockpit crewmembers, starting at least 3 d before commencing flight duty, continuing during days on duty (the duration depending on the flight schedule) and finishing 4 d after return, at the earliest. Regardless of the specific duty roster, sleep deficit occurred mainly after the first flight leg to ANC, presumably due to the 10-h time zone difference and the short layover time. During the layover in the Far East, the sleep deficit diminished partly because of additional naps. Sleep was often disturbed and scattered over days and nights. Another pronounced sleep deficit occurred after the first return flight from South Korea or Japan to ANC. Compared to the outgoing layover period in ANC, the number and duration of naps increased during this layover and, additionally, on the first 2 d after returning home. Poorer sleep quality ratings were associated with accumulated sleep deficit and increased napping, but significant decrements in sleep quality were seen only during two out of the six different duty rosters. All six of the polar route duty rosters may lead to significant sleep disturbances. During some flight schedules the sleep deficit is large enough to raise operational implications.

Sleep patterns in aircrew operating on the polar route between Germany and east Asia.

Background: During manned space missions, the actual concentration of carbon dioxide (CO 2 ) is frequently elevated to a degree that may affect human functioning and productivity. Therefore, a ground-based international study was performed that tested various psychological and physiological functions under the condition of two different levels of CO 2 . Thus, a specific experiment aimed at the influence of enhanced CO 2 -concentrations on the sleep-wake cycle and the circadian system. Methods: Four volunteers were subjected to a CO 2 concentration of 0.7% and 1.2%, respectively, for 24 consecutive days under each condition. Before they were exposed to these elevated levels, baseline measurements were conducted during 5 d under ambient CO2 concentrations (<o.1%). Circadian parameters were assessed by continuous recording of body temperature and by the determination of excretion rates of cortisol, 6-hydroximelatoninsulfate and catecholamines at 3-h intervals during wake. These measurements were conducted on 3 consecutive days 4 times during the two campaigns. Nondominant wrist activity and subjective fatigue was monitored throughout both study phases. Results: Daily means of activity showed significant differences between the two study conditions (with lower values during the 1.2% condition), but these differences only occurred during day-time, whereas during sleep activity levels remained the same. Diurnal mean and circadian amplitude of the temperature rhythm was also significantly lower during the 1.2% condition. Conclusions: The lower daily mean and circadian amplitudes of temperature during the higher CO2 level can be explained by lower physical activity that was monitored under this level, i.e., a masking effect. We hesitate to explain the lower activity (and hence temperature) as a response to the changed C02 concentration. More probably, subjects became so acquainted with the procedures of the study protocol during the second study phase (1.2% CO 2 ) that they did not need similar effort to conduct the tasks as during the first phase. The activity level during sleep which was the same during the two phases may support this conclusions. Thus, we conclude that CO 2 levels up to 1.2% do not impair the circadian rhythm of healthy men.

Joint NASA-ESA-DARA Study. Part three: circadian rhythms and activity-rest cycle under different CO2 concentrations.

Die physische und psychische Beanspruchung durfte bei keiner Berufsgruppe so extrem hoch sein wie bei Flugpiloten. Somit eignet sich dieser Personenkreis auch vorzuglich zur Ermittlung diesbezuglicher Daten. Unter der Vielzahl belastender Faktoren sind die durch standige Uberwindung von Zeitzonen gestorte zirkadiane Rhythmik und die sehr langen, oft irregularen Arbeitszeiten bei sonstiger korperlicher Immobilitat am wichtigsten. Eine breit gefacherte Fulle von psychologischen, physiologischen und physiologisch-chemischen Mesmethoden dient dazu, diese Belastungen mittels entsprechender Daten zu objektivieren. Die Synopsis aller Mesergebnisse hat das Ziel, die Belastbarkeitsgrenzen rechtzeitig zu erkennen und die Flugsicherheit zu erhalten und zu verbessern.

Alexander Samel

Papers

Nocturnal aircraft noise effects.

Response of the circadian system to 6 degrees head-down tilt bed rest.

Sleep patterns in aircrew operating on the polar route between Germany and east Asia.

Joint NASA-ESA-DARA Study. Part three: circadian rhythms and activity-rest cycle under different CO2 concentrations.

[Long-term monitoring of psychophysiologic values in flight physiology].