Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health.

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.

A rating scale for drug-induced akathisia has been derived that incorporates diagnostic criteria for pseudoakathisia, and mild, moderate, and severe akathisia. It comprises items for rating the observable, restless movements which characterise the condition, the subjective awareness of restlessness, and any distress associated with the akathisia. In addition, there is an item for rating global severity. A standard examination procedure is recommended. The inter-rater reliability for the scale items (Cohen's kappa) ranged from 0.738 to 0.955. Akathisia was found in eight of 42 schizophrenic in-patients, and nine had pseudoakathisia, where the typical sense of inner restlessness was not reported.

A rating scale for drug-induced akathisia

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

Drawing on the mood regulation and job-stress recovery literature, four self-report measures for assessing how individuals unwind and recuperate from work during leisure time were developed (Study 1). Confirmatory factor analyses with a calibration and a cross-validation sample (total N 930) showed that four recovery experiences can be differentiated: psychological detachment from work, relaxation, mastery, and control (Study 2). Examination of the nomological net in a subsample of Study 2 (N 271) revealed moderate relations of the recovery experiences with measures of job stressors and psychological well-being; relations with coping and personality variables were generally low (Study 3). Potential applications for the future use of these short 4-item measures in longitudinal and diary research are discussed.

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The Recovery Experience Questionnaire: Development and validation of a measure for assessing recuperation and unwinding from work.

Study objectives This study investigated the relationship between sleep loss and emotional reactivity in medical residents. We hypothesized that this relationship is shaped by the effect of sleep loss on cog-nitive-energy resources required for coping with goal-disruptive events or for capitalizing on new opportunities offered by goal-enhancing events. Settings 15 medical wards in 4 large hospitals in Israel. Participants 78 medical residents, 67% men, aged 26 to 39 years. Design Actigraphic sleep-wake cycles were measured for 5- to 7-day periods, surrounding nightshifts, every 6 months, covering the first 2 years of residency. During each study period, emotional reactivity was investigated using the experience-sampling methodology by which residents received 3 phone calls at random times during their working day for 3 consecutive days. These calls reminded them to fill out brief questionnaires concerning change of circumstances over the previous 15 minutes and to rate their emotional response to these circumstances using the Positive Affect and Negative Affect Scales. Fatigue at those times was measured by a subscale of the Profile of Mood States. Measurements and results Multilevel regression analysis was used to determine the influence of sleep duration and sleep fragmentation on the emotional reactions to goal-disruptive and goal-enhancing daytime events. We found that sleep loss intensified negative emotions and fatigue following daytime disruptive events, while positive emotion was mitigated following goal-enhancing events. Sleep loss also resulted in an overall elevated baseline for positive emotion. Conclusions Sleep loss amplifies the negative emotive effects of disruptive events while reducing the positive effect of goal-enhancing events. Methodologically, the study highlights the utility and advantages of event-level analysis as opposed to the current practice of random sampling of emotion states during waking hours, disregarding contextual factors associated with purposeful, goal-oriented behavior episodes.

The effects of sleep loss on medical residents' emotional reactions to work events : a cognitive-energy model

Study objectives: This study investigated the relationship between sleep loss and emotional reactivity in medical residents. We hypothesized that this relationship is shaped by the effect of sleep loss on cognitive-energy resources required for coping with goal-disruptive events or for capitalizing on new opportunities offered by goal-enhancing events. Settings: 15 medical wards in 4 large hospitals in Israel. Participants: 78 medical residents, 67% men, aged 26 to 39 years. Design: Actigraphic sleep-wake cycles were measured for 5- to 7-day periods, surrounding nightshifts, every 6 months, covering the first 2 years of residency. During each study period, emotional reactivity was investigated using the experience-sampling methodology by which residents received 3 phone calls at random times during their working day for 3 consecutive days. These calls reminded them to fill out brief questionnaires concerning change of circumstances over the previous 15 minutes and to rate their emotional response to these circumstances using the Positive Affect and Negative Affect Scales. Fatigue at those times was measured by a subscale of the Profile of Mood States. Measurements and Results: Multilevel regression analysis was used to determine the influence of sleep duration and sleep fragmentation on the emotional reactions to goal-disruptive and goal-enhancing daytime events. We found that sleep loss intensified negative emotions and fatigue following daytime disruptive events, while positive emotion was mitigated following goal-enhancing events. Sleep loss also resulted in an overall elevated baseline for positive emotion. Conclusions: Sleep loss amplifies the negative emotive effects of disruptive events while reducing the positive effect of goal-enhancing events. Methodologically, the study highlights the utility and advantages of event-level analysis as opposed to the current practice of random sampling of emotion states during waking hours, disregarding contextual factors associated with purposeful, goal-oriented behavior episodes.

The Effects of Sleep Loss on Medical Residents' Emotional Reactions to Work Events: a Cognitive-Energy Model SLEEP, SLEEP DEPRIVATION AND PERFORMANCE

Two studies were conducted to evaluate actigraphic home-monitoring for the assessment of infants' and children's sleep patterns. In the first study, 11 children (aged 12 to 48 months) were monitored in the laboratory by traditional polysomnography and by actigraphy for one night. Actigraphic automatic sleep-wake scorings were compared with those of the polysomnograph; total agreement rate was 85.3%. In the second study, sleep patterns of 63 sleep-disturbed and 34 control healthy children (aged 9 to 27 months) were compared. These children were home-monitored by actigraph for a mean of 4.45 nights (total 482 nights). Actigraphic data were analyzed by an automated scoring procedure. Sleep quality of the sleep-disturbed children, measured by actigraphically derived sleep percent and number of longer-than-5-minute wakings, was significantly lower than that of the control subjects (P less than .0001). Sleep measures showed significant night-to-night stability in both groups. The stability of specific measures and their age trends were different between the groups. Actigraphic sleep measures alone could discriminate between sleep-disturbed and control children with a highly correct assignment rate of 79.4% and 91.2%, respectively.

Actigraphic home-monitoring sleep-disturbed and control infants and young children: a new method for pediatric assessment of sleep-wake patterns.

In the present study we investigated the effects of school starting time on daytime behavior and sleep. Eight-hundred and eleven 5th grade pupils (10-12 years old) from 28 classes in 18 schools throughout Israel were divided into "early risers" (N = 232) who started school at 07:10 (42%) at least 2 times a week, and "regular risers" (N = 340) who always started school at 08:00 (58%). The remaining 239 pupils started school between 7:20 and 07:55 (and also after 08:00), and were not included in the study. Self-administered questionnaires concerning sleep habits during school days, weekends, and holidays, daytime fatigue, sleepiness, and difficulties concentrating and paying attention in school were completed by all children. Mean sleep time of the "early risers" was significantly shorter than that of the "regular risers." Early risers complained significantly more about daytime fatigue and sleepiness, and about attention and concentration difficulties in school. Their complaints were independent of the reported hours of sleep. We conclude that early starting of school negatively affects total sleep time and, as a consequence, has a negative effect on daytime behavior. The implications of these findings to the ongoing controversy concerning sleep need in contemporary society are discussed.

Starting times of school: effects on daytime functioning of fifth-grade children in Israel.

This study focuses on daily work events as proximal stimuli for discrete emotional reactions and suggests that availability of energy resources required for coping with goal-disruptive events, or for capitalizing on new opportunities offered by goal-enhancing events, influences intensity of emotional reactions. Using experience-sampling methodology with a sample of hospital residents, it is shown that negative emotion and fatigue following disruptive events are intensified when only limited energy resources are available due to current workload. However, positive emotions, promoted by goal-enhancing events, are mitigated due to inability to capitalize on new opportunities or challenges. Aftereffects of work events reveal that the energizing effect of goal-enhancing events mitigates end-of-day fatigue and negative emotion on high-workload days, although the effect of disruptive events is diminished by the end of such days, apparently because of lesser conspicuity against a background of high workload. Theoretical and practical implications are discussed.

Rachel Epstein

Papers

The effects of sleep loss on medical residents' emotional reactions to work events : a cognitive-energy model

The Effects of Sleep Loss on Medical Residents' Emotional Reactions to Work Events: a Cognitive-Energy Model SLEEP, SLEEP DEPRIVATION AND PERFORMANCE

Actigraphic home-monitoring sleep-disturbed and control infants and young children: a new method for pediatric assessment of sleep-wake patterns.

Starting times of school: effects on daytime functioning of fifth-grade children in Israel.

Effects of energy availability on immediate and delayed emotional reactions to work events.