This is the current release of the guideline.

The levels of evidence (1-4) and levels of recommendation (standard, guideline, option) are defined at the end of the "Major Recommendation" field.

General Recommendations for Evaluation of Circadian Rhythm Sleep Disorders (CRSD)

1. Use of a sleep log or diary is indicated in the assessment of patients with a suspected CRSD. (Guideline)
2. Actigraphy is indicated to assist in evaluation of patients suspected of CRSDs, including irregular sleep-wake disorder (ISWR), free-running disorder (FRD) (with or without blindness) (Option), and in advanced sleep phase disorder (ASPD), delayed sleep phase disorder (DSPD), and shift work disorder (SWD). (Guideline)
3. Actigraphy is useful as an outcome measure in evaluating the response to treatment for CRSDs. (Guideline)
4. There is insufficient evidence to recommend the routine use of the Morningness-Eveningness Questionnaire (MEQ) for the clinical evaluation of CRSDs. (Option)
5. Circadian phase markers are useful to determine circadian phase and confirm the diagnosis of FRD in sighted and unsighted patients but there is insufficient evidence to recommend their routine use in the diagnosis of SWD, jet lag disorder (JLD), ASPD, DSPD, or ISWR. (Option)
6. Polysomnography (PSG) is indicated to rule out another primary sleep disorder in patients with symptoms suggestive of both a CRSD and another primary sleep disorder, but is not routinely indicated for the diagnosis of CRSDs. (Standard)

Recommendations for Evaluation and Treatments of Circadian Rhythm Sleep Disorders

Shift Work Disorder

1. Both the Morningness-Eveningness Questionnaire (MEQ) and measurement of circadian phase markers (e.g., core body temperature nadir or timing of melatonin secretion) are at present of unproved usefulness in evaluation of patients with suspected SWD. (Option)
2. Planned napping before or during the night shift is indicated to improve alertness and performance among night shift workers. (Standard)
3. Timed light exposure in the work environment and light restriction in the morning, when feasible, is indicated to decrease sleepiness and improve alertness during night shift work. (Guideline)
4. Administration of melatonin prior to daytime sleep is indicated to promote daytime sleep among night shift workers. (Guideline)
5. Hypnotic medications may be used to promote daytime sleep among night shift workers. Carryover of sedation to the nighttime shift with potential adverse consequences for nighttime performance and safety must be considered. (Guideline)
6. Modafinil is indicated to enhance alertness during the night shift for SWD. (Guideline)

   Caffeine is indicated to enhance alertness during the night shift for SWD. (Option)

Jet Lag Disorder

1. There is insufficient evidence to recommend the routine use of actigraphy, polysomnography, or measurement of circadian phase markers in the evaluation of jet lag disorder. (Option)
2. When time at destination is expected to be brief (i.e., two days or less), keeping home-based sleep hours, rather than adopting destination sleep hours, may reduce sleepiness and jet lag symptoms. (Option)
3. The combination of morning exposure to bright light and shifting the sleep schedule one hour earlier each day for three days prior to eastward travel may lessen symptoms of jet lag. (Option)
4. Melatonin administered at the appropriate time is indicated to reduce symptoms of jet lag and improve sleep following travel across multiple time zones. (Standard)
5. Short-term use of a benzodiazepine receptor agonist hypnotic is indicated for the treatment of jet lag-induced insomnia, but potential adverse effects must be considered, and effects on daytime symptoms of jet lag disorder have not been adequately addressed. (Option)
6. Caffeine is indicated as a way to counteract jet lag-induced sleepiness, but may also disrupt nighttime sleep. (Option)

Advanced Sleep Phase Disorder

1. There is insufficient evidence to recommend the use of the MEQ for the routine diagnosis of ASPD. (Option)
2. Polysomnography is not routinely indicated for the diagnosis of ASPD. (Standard)
3. There is insufficient evidence to recommend the use of circadian markers for the routine diagnosis of ASPD. (Option)
4. Prescribed sleep/wake scheduling, timed light exposure, or timed melatonin administration are indicated as treatments for patients with ASPD. (Option)

Delayed Sleep Phase Disorder

1. Polysomnography is not indicated in the routine assessment of DSPD. (Standard)
2. Morning light exposure is indicated in the treatment of DSPD. Optimal timing, duration, and dosing of morning light treatment for DSPD remain to be determined. (Guideline)
3. Chronotherapy (i.e., prescribed progressive delay in the schedule of sleep time until the desired sleep schedule is reached) may be useful for DSPD. (Option)
4. Properly timed melatonin administration is indicated as a therapy for DSPD. (Guideline)
5. Vitamin B12 is not indicated in the treatment for DSPD. (Guideline)
6. There is insufficient evidence supporting the use of hypnotic medications to promote sleep or the use of stimulant medications to promote alertness for DSPD. (Option)

Free-Running Circadian Rhythm Sleep Disorder

1. Sleep logs are useful for assessment in FRD patients. (Option)
2. Circadian phase markers are useful to determine circadian phase and confirm the diagnosis of FRD in sighted and unsighted patients. (Option)
3. Prescribed sleep/wake scheduling as a method to improve circadian rhythms may be useful for therapy of FRD in sighted individuals. (Option)
4. Circadian phase shifting by timed light exposure may be used to treat FRD in sighted individuals. (Option)
5. Circadian phase shifting by timed melatonin administration may be used to treat FRD in sighted individuals. (Option)
6. Timed melatonin administration is indicated for the therapy of FRD in blind individuals. (Guideline)
7. There is insufficient evidence to support using vitamin B12 in treating FRD in sighted individuals. (Option)

Irregular Sleep-Wake Rhythm

1. The use of sleep logs and/or actigraphy are indicated to identify and monitor treatment outcomes in ISWR, including in older people with dementia and those living in nursing homes. (Guideline)
2. Daytime bright light exposure may improve circadian rest-activity rhythms and consolidation of sleep and wake in nursing home residents with dementia and ISWR. (Option)
3. Melatonin is not indicated for the treatment of ISWR in older people with dementia, but may be indicated for children with ISWR and severe psychomotor retardation. (Option)
4. Mixed modality approaches combining bright light exposure, physical activity, and other behavioral elements are indicated in treatment of ISWR among older people with dementia (Guideline), including nursing home residents (Guideline), and children with ISWR and moderate to severe mental retardation. (Option)

Definitions:

Level 1

Risk/Assessment: Validating¹ cohort with well-validated reference standards²

Treatment: High quality randomized controlled trial (RCT) on well-characterized subjects or patients

Level 2

Risk/Assessment: Smaller or "exploratory" cohort study or one that has incompletely validated reference standards²

Treatment: Cohort study or flawed clinical trial (e.g., small N, blinding not specified, possible assignment to treatment, incompletely validated reference standards²)

Level 3

Risk/Assessment: Case control or cross sectional study

Treatment: Case control study

Level 4

Risk/Assessment: Case series (and poor quality cohort and case control studies)

Treatment: Case series (and poor quality cohort and case control studies)

Notes

1. Validating studies test the quality of a specific diagnostic test, based on prior evidence.
2. Reference standards: polysomnography (PSG), sleep logs, actigraphy, phase markers, validated self-reports.

Levels of Recommendation

Standard: This is a generally accepted patient-care strategy that reflects a high degree of clinical certainty. The term standard generally implies the use of Level I Evidence, which directly addresses the clinical issue, or overwhelming Level II Evidence.

Guideline: This is a patient-care strategy that reflects a moderate degree of clinical certainty. The term guideline implies the use of Level II Evidence or a consensus of Level III Evidence.

Option: This is a patient-care strategy that reflects uncertain clinical use. The term option implies either inconclusive or conflicting evidence or conflicting expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations" field).

Not applicable: The guideline was not adapted from another source.

2007 Nov

American Academy of Sleep Medicine - Professional Association

American Academy of Sleep Medicine

Standards of Practice Committee

Committee Members: Timothy I. Morgenthaler, MD; Teofilo Lee-Chiong, MD; Cathy Alessi, MD; Leah Friedman, PhD; R. Nisha Aurora, MD; Brian Boehlecke, MD; Terry Brown, DO; Andrew L. Chesson Jr., MD; Vishesh Kapur, MD, MP; Rama Maganti, MD; Judith Owens, MD; Jeffrey Pancer, DDS; Todd J. Swick, MD; Rochelle Zak, MD; Standards of Practice Committee of the AASM

The authors have indicated no financial conflict of interest.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on April 11, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the American Academy of Sleep Medicine (AASM) for information regarding reproduction of AASM guidelines.