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## Complete Summary

#### GUIDELINE TITLE

Practice parameters for using polysomnography to evaluate insomnia: an
update.

#### BIBLIOGRAPHIC SOURCE(S)

Littner M, Hirshkowitz M, Kramer M, Kapen S, Anderson WM, Bailey D,
Berry RB, Davila D, Johnson S, Kushida C, Loube DI, Wise M, Woodson BT.
Practice parameters for using polysomnography to evaluate insomnia: an
update. Sleep 2003 Sep15;26(6):754-60. \[61 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14572131)

#### GUIDELINE STATUS

This is the current release of this guideline.

This guideline updates a previous version: American Sleep Disorders
Association. Practice parameters for the use of polysomnography in the
evaluation of insomnia. Sleep 1995 Jan;18(1):55-7.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Insomnia

-   Sleep-related breathing disorders

-   Periodic limb movement disorder

-   Persistent circadian rhythm disorders, such as delayed-sleep-phase
    syndrome

-   Psychiatric disorders

-   Drug-related effects

-   Dementia

-   Depression

-   Fibrositis fibromyalgia

-   Chronic fatigue syndrome

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Internal Medicine\
Neurology\
Otolaryngology\
Psychiatry\
Psychology\
Pulmonary Medicine\
Sleep Medicine

#### INTENDED USERS

Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### GUIDELINE OBJECTIVE(S)

-   To provide recommendations for the use of polysomnography in the
    evaluation of insomnia

-   To update the American Academy of Sleep Medicine (formerly, American
    Sleep Disorders Association) 1995 practice parameters

#### TARGET POPULATION

Adults with insomnia

#### INTERVENTIONS AND PRACTICES CONSIDERED

Polysomnography

#### MAJOR OUTCOMES CONSIDERED

Utility of polysomnography for diagnosing insomnia according to level of
evidence to answer the following questions:

-   Does polysomnography help in the evaluation of insomnia?

-   Does polysomnography provide information helpful for understanding
    treatment failure?

-   Does polysomnography differentiate between insomnia of different
    etiologies?

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Literature Search Strategy**

A task force appointed by the Standards of Practice Committee (SPC)
examined the previously published practice parameters and the reviews
upon which they were based. Excluding conference abstracts and letters
to the editor, the references cited in the Reite et al (1995) review
paper were considered in the current literature reassessment. Medline
was searched from 1980 through and including articles published up to
February 2002. The terms *insomnia, sleeplessness*, and *sleep
initiation and maintenance disorders* were crossed with the terms
*polysomnography*, *sleep evaluation*, *monitoring ambulatory*, or
*monitoring physiologic*. Searches were also conducted crossing *Ekbom´s
syndrome*, *restless legs syndrome*, *nocturnal myoclonus*,
*fibromyalgia*, and *depression* with *polysomnography*, *sleep
evaluation*, *monitoring ambulatory*, or *monitoring physiologic*. The
two Medline searches were then combined and limited to human subject and
English language publications.

**Inclusion and Exclusion Criteria**

Two Standards of Practice Committee members reviewed all of the titles,
abstracts, and, if needed, the full publication to determine whether the
citation was appropriate for review. Inclusion criteria were: 1) the
study included laboratory polysomnography, 2) a formal diagnosis was
rendered, and 3) there appeared to be a focus on insomnia. Exclusion
criteria were: 1) reports of treatment outcome studies, 2) reports of
ambulatory polysomnography (PSG) and specialized waveform analysis, 3)
reports that did not present original data (editorials, letters, and
reviews), and 4) single case studies.

#### NUMBER OF SOURCE DOCUMENTS

The Medline search strategy produced 706 citation titles. Of these, 23
articles were selected for data extraction.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Level I (Grade A)**

1-Blind, prospective study\
2-Large sample with a spectrum of patients reviewed\
3-Results are compared according to a reference standard

**Level II (Grade B)**

1-Blind, prospective study\
2-Limited sample or limited spectrum of patients included\
3-Results are compared according to a reference standard

**Level III (Grade C)**

1-Not blind, randomized, or prospective\
2-Methodologically limited\
3-Results are compared according to a reference standard

**Level IV (Grade C)**

1-Not blind, randomized, or prospective\
2-Methodologically limited\
3-Results not compared according to a reference standard

**Level V (Grade D)**

1-Not blind, randomized, or prospective\
2-Methodologically limited\
3-Results not compared to any reference

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Data Extraction**

Three of the 4 Standards of Practice Committee (SPC) members
independently extracted information from each article. Extraction
discrepancies were resolved with extraction or grading by another
Standards of Practice Committee member. Only minimal discrepancies were
encountered. Additionally, each article was graded according to criteria
(modified from Sackett \[1993\]) shown in table 2 of the original
guideline document. The extracted data was then summarized.

Of the 8 articles that address diagnostic utility of polysomnography in
patients with insomnia, 5 were level III, grade C; 2 were level IV,
grade C, and 1 was level V, grade D. Table 3B in the original guideline
document focuses on polysomnography in psychiatric disorders associated
with insomnia. Except for a single paper rated as level III, grade C,
the remaining 7 articles on this topic were graded as level IV, grade C.
Finally, Table 3C in the original guideline document tabulates the 6
other relevant reports. One each was rated as level III, grade C and
level V, grade D; the remaining 4 articles were level IV, grade C.

Articles were evaluated to address the utility of polysomnography for
the diagnosis of insomnia according to whether there was evidence to
answer the key questions. The results are detailed in Tables 3A, B and C
in the original guideline document.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Standard**

A *standard* is a generally accepted patient care strategy reflecting a
high degree of clinical certainty. The term *standard* generally implies
a basis in either Level I evidence directly addressing the clinical
issue or overwhelming Level II evidence.

**Guideline**

A *guideline* is a patent care strategy reflecting a moderate degree of
clinical certainty. The term *guideline* implies a basis in Level II
evidence or a consensus of Level III evidence.

**Option**

An *option* is a patient care strategy reflecting uncertain clinical
use. The term *option* implies either inconclusive or conflicting
evidence, or conflicting expert opinion.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The Board of Directors of the American Academy of Sleep Medicine
approved these recommendations.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The recommendation ratings (i.e., standard, guideline, option) are given
in brackets after each recommendation. Definitions used in the rating
schemes follow the recommendations.

1.  Insomnia is an important public-health problem that requires
    accurate diagnosis and effective treatment. (Standard)

2.  Insomnia is primarily diagnosed by clinical evaluation through a
    careful, detailed medical, psychiatric, and thorough sleep history
    (which includes assessment of sleep patterns and waking processes).
    (Standard)

3.  Polysomnography is indicated when sleep-related breathing disorders
    or periodic limb movement disorder is suspected. (Standard)

4.  Polysomnography is indicated when initial diagnosis is uncertain,
    treatment fails (behavioral or pharmacologic), or precipitous
    arousals occur with violent or injurious behavior. (Guideline)

5.  Polysomnography is not indicated for the routine evaluation of
    transient or chronic insomnia. (Guideline)

6.  Polysomnography is not indicated for the routine evaluation of
    insomnia due to psychiatric disorders. (Guideline)

7.  Polysomnography is not clinically useful in differentiating the
    insomnia associated with dementia from other forms of insomnia,
    including insomnia associated with depression. (Guideline)

8.  Polysomnography is not useful in establishing the diagnosis of
    insomnia associated with fibromyalgia or chronic fatigue syndrome
    because the alpha-delta sleep pattern described in fibromyalgia
    syndrome is a nonspecific finding. (Guideline)

**[Definitions]{.underline}**:

**Standard**

A *standard* is a generally accepted patient care strategy reflecting a
high degree of clinical certainty. The term *standard* generally implies
a basis in either Level I evidence directly addressing the clinical
issue or overwhelming Level II evidence.

**Guideline**

A *guideline* is a patent care strategy reflecting a moderate degree of
clinical certainty. The term *guideline* implies a basis in Level II
evidence or a consensus of Level III evidence.

**Option**

An *option* is a patient care strategy reflecting uncertain clinical
use. The term *option* implies either inconclusive or conflicting
evidence, or conflicting expert opinion.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Recommendations are rated as standards, guidelines, or options based on
evidence from studies published in peer-reviewed journals that were
evaluated and listed in the evidence tables (see Tables 3A, 3B, and 3C
in the original guideline document). However, when scientific evidence
is not available, insufficient, or inconclusive, the recommendations
were based on consensus opinion of the committee.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   The American Academy of Sleep Medicine expects these guidelines to
    have a positive effect on professional behavior, patient outcomes,
    and possibly health care costs.

-   Overnight polysomnography is a standard tool in sleep medicine for
    evaluating sleep-related pathophysiology, sleep architecture, and
    sleep integrity. Some etiologies underlying insomnia have specific
    pathophysiology detectable with polysomnography (e.g., periodic limb
    movements). Other insomnias may manifest abnormal sleep
    architectural patterns (e.g., major depressive disorder) that, while
    recognizable, are diagnostically nonspecific. Finally, sleep
    integrity can be directly measured with polysomnography. Measures
    such as latency to sleep onset, total sleep time, number of arousals
    and awakenings, and sleep efficiency are routinely calculated to
    characterize a night of sleep. Disturbance in such measures
    objectively verify complaints of difficulty initiating and
    maintaining sleep. Furthermore, polysomnographic criteria can
    differentiate physiologically-based sleep disturbances from sleep
    state misperception and help to evaluate whether the subject
    possibly prefers the drug for the wrong reasons (e.g., because of
    euphoriant properties). For this reason, polysomnography is a
    component of the standard procedure used to verify insomnia and
    assess treatment efficacy for research purposes.

-   Monitoring for specific etiology-related pathophysiologies (e.g.,
    obstructive sleep apnea) can be very useful for making a diagnosis
    when insomnia is secondary to another condition.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These practice parameters define principles of practice that should
    meet the needs of most patients in most situations. These guidelines
    are neither inclusive of all proper methods of care nor exclusive of
    other methods of care reasonably directed toward obtaining the same
    result. Judgment regarding the propriety of any care strategy
    ultimately must be made by health care providers with consideration
    given to individual circumstances presented by the patient,
    available diagnostic procedures, and extant treatment resources.

-   These practice parameters reflect the state of knowledge at the time
    of development and will be reviewed, updated, and revised, as new
    information becomes available.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Littner M, Hirshkowitz M, Kramer M, Kapen S, Anderson WM, Bailey D,
Berry RB, Davila D, Johnson S, Kushida C, Loube DI, Wise M, Woodson BT.
Practice parameters for using polysomnography to evaluate insomnia: an
update. Sleep 2003 Sep15;26(6):754-60. \[61 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14572131)

#### ADAPTATION

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

#### DATE RELEASED

1995 (revised 2003 Sep)

#### GUIDELINE DEVELOPER(S)

American Academy of Sleep Medicine - Professional Association

#### SOURCE(S) OF FUNDING

American Academy of Sleep Medicine

#### GUIDELINE COMMITTEE

Standards of Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Michael Littner, MD (VA Greater Los Angeles
Healthcare System and UCLA School of Medicine, Sepulveda, CA); Max
Hirshkowitz, PhD (Baylor College of Medicine and VA Medical Center,
Houston, TX); Milton Kramer, MD (Maimoides Medical Center, Psychiatry
Department, Brooklyn, NY, and New York University School of Medicine,
New York, NY); Sheldon Kapen, MD (VA Medical Center and Wayne State
University, Detroit, MI); W. McDowell Anderson, MD (College of Medicine,
University of South Florida, Tampa, FL); Dennis Bailey, DDS (Englewood,
CO); Richard B. Berry, MD (University of Florida Health Science Center,
Gainesville, FL); David Davila, MD (Baptist Medical Center, Little Rock,
AR); Stephen Johnson, MD (St. Patrick Hospital Sleep Center, Missoula,
MT); Clete Kushida, MD, PhD (Stanford University Center of Excellence
for Sleep Disorders, Stanford, CA); Daniel I. Loube, MD (Sleep Medicine
Institute, Swedish Medical Center, Seattle, WA); Merrill Wise, MD
(Departments of Pediatrics and Neurology, Baylor College of Medicine,
Houston, TX); B. Tucker Woodson, MD (Department of Otolaryngology and
Communication Sciences, Medical College of Wisconsin, Milwaukee, WI)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

All members of the American Academy of Sleep Medicine 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.

#### GUIDELINE STATUS

This is the current release of this guideline.

This guideline updates a previous version: American Sleep Disorders
Association. Practice parameters for the use of polysomnography in the
evaluation of insomnia. Sleep 1995 Jan;18(1):55-7.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Academy of Sleep Medicine (AASM) Web
site](http://www.aasmnet.org/PracticeParameters.aspx).

Print copies: Available from the Standards of Practice Committee,
American Academy of Sleep Medicine, One Westbrook Corporate Center,
Suite 920, Westchester, IL 60154. Web site: [www.aasmnet.org](../=).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on April 25, 1999. The information
was verified by the guideline developer on May 24, 1999. This summary
was updated by ECRI on March 4, 2004. The information was verified by
the guideline developer on March 25, 2004.

#### COPYRIGHT STATEMENT

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.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008