Actigraphy : A discussion of a non-invasive measurement of Sleep/Wake and Activity.

1. Actigraphy: A discussion of a non-invasive measurement of Sleep/Wake and Activity. Indiana Society of Sleep Professionals 7th Annual Educational Summit August 16, 2012 Melissa Mohr-Loeks, MPH Clinical Trials/Research Liaison Geriatric Sleep Research Specialist

2. What is Actigraphy? • Actigraphy is the recording of movement using a motion sensor called an accelerometer. • An accelerometer can be either a single or multi axis accelerometer. • A non invasive method of determining human activity and sleep cycles.

3. What is Actigraphy (Continued) • An accelerometer creates an electrical voltage with every movement. The bigger the movement, the greater the voltage created. • Actigraphy is a one dimensional method of determining sleep/wake patterns (PSG is an example of a multi dimensional method of determining sleep/wake patterns). • Actigraphy has been validated against PSG for and generally has an accuracy of greater than 90% when worn on the wrist.

4. Why is Actigraphy Useful? • The cost of Actigraphy is very low compared to the cost of PSG • Actigraphy can support the need of further testing by recording sleep disturbances and can justify further testing by PSG • Actigraphy can have an accuracy of greater than 90% as compared to PSG. • An accelerometer can be worn continuously for multiple days and nights at no additional cost.

5. Why is Actigraphy Useful (continued) • Actigraphy can be worn by almost all subject populations. • Actigraphy is an objective supplement to sleep diaries that are known to have subject bias. • Actigraphy is well recognized for the estimation of sleep parameters of all age groups. • Actigraphy does not restrict patient movement.

6. How does Actigraphy assess sleep? Wrist movements have been found to indicate sleep/wake patterns and has been validated using PSG. Actigraphy is a screening tool that can be used to measure sleep at the patient’s home and in their own bed with the least amount of disruption to their normal routine.

7. Actigraphy Uses • Often, actigraphy is used to determine problems related to sleep patterns such as circadian rhythm or other sleep disorders. • Actigraphy can also be used to determine the effect of various treatments on the body. • Cognitive Behavior Therapy for Insomnia is an example of how Actigraphy can be used to determine how successful therapy is for the patient by incorporating Actigraphy with CBTI.

8. Actigraphy Measures: • Normal Sleep • Insomnia • Circadian Disorder: Delayed Sleep Phase • Circadian Disorder: Advanced Sleep Phase • Circadian Disorder: Non 24 hour or non-entrained type • Circadian Disorder: Irregular Sleep/Wake • Shift work sleep disorder • RLS/PLMD (when worn on the ankle)

9. Normal Sleeper Characteristics • Humans typically display a pronounced decrease in activity during rest • Rest periods are characterized by small intermittent movements while active periods show significant, constant movement. • For normal sleepers, rest and activity shown together display a relatively stable pattern over the 24 hour day. • Variations may occur on weekends

10. Normal Sleep Actogram Example

11. Insomniac Sleeper Characteristics • Rest and activity data displays an unstable pattern, easy to see on an actogram • Activity depicts elevated levels at just about any time of day • Rest periods are variable in length and timing

12. Insomniac Actogram Example

13. Circadian Disorder: Advance Sleep Phase Characteristics • Occurs in 1% of population and is more common in older adults. • ASP is typified by a sleep/wake pattern where sleep onset and wake times are more than 3 hours earlier than normal sleep onset. • Sleep is typically initiated by 8 pm and the patient wakes up very early often by 3am. • An actigraphy record of 7 or more days can help identify ASP patients that would be helped by interventions such as light therapy, chronotherapy or melatonin. • Actigraphy can track changes in the patient’s sleep/wake pattern once these treatments have been initiated.

14. Circadian Disorder: Advance Sleep Phase Example

15. Circadian Disorder:Delayed Sleep Disorder Characteristics • Occurs in 7%-16% of adolescent/young adults • Occurs in 10% of patients with chronic insomnia • Typified by sleep/wake pattern where sleep onset and wake times are delayed 3-6 hours relative to normal sleep/wake times and may be due to circadian function or behaviorally induced sources. • An actigraphy record of 7 or more days can help identify DSP patients for treatment such as light therapy, chronotherapy or melatonin. • Actigraphy can track document changes in the patient’s sleep/wake pattern once these treatments have been initiated.

16. Circadian Disorder: Delayed Sleep Disorder Example

17. Non 24 hour or Non-Entrained Free Running Characteristics • This is most commonly found in blind patients • Typified by the lack of a stable relationship between the 24-hour light-dark cycle and the circadian pacemaker. • Actigraphy can easily show where the rest periods recur at a period that is greater than 24 hours resulting in a shifting of the rest periods later each day. • An actigraphy record of 7 or more days can help identify these patients for treatment with melatonin. • Actigraphy can track changes in the patient’s sleep/wake patterns once treatment is initiated.

18. Non-Entrained Free Running Example

19. Shift Worker Sleep Disorder Characteristics • Typified by altered patterns of sleep/wake in order to work at jobs with variable hours. • Actigraphycan track these patterns. • Actigraphy easily shows the fragmentation of consolidated sleep periods surrounding shift changes. • “Weekends” and days off are easily identified by definite changes in sleep/activity patterns.

20. Shift Worker Example

21. Pediatric Sleep Actogram

22. Reimbursement information • General coverage guidelines: • Actigraphy studies may be covered for the diagnosis and treatment of sleep disorders. • Coverage and reimbursement for actigraphy services still vary by payer. • CMS has not yet issued coverage guidelines for Actigraphy.

23. Reimbursement (continued) • Coding guidelines: • Actigraphy services are currently using a Category I CPT code. • As the case with newly established codes, some payers may not recognize this code and provide instructions on alternate or potentially outdated coding guidelines. • It is important to submit claims using the new Category I CPT code 95803 for reporting actigraphy services.

24. CPT Code Additional Information • Actigraphy, testing, recording, analysis, interpretation and report (minimum of 72-hours to 14 consecutive days). • There are additional codes that may be used to report actigraphy-related services (available upon request). • It is recommended that healthcare providers verify recommended coding guidelines with payers prior to submitting claims for these services.

25. Types of currently available actigraphy devices for sleep monitoring

26. Actigraphy Summary • Benefits are: • Screens for sleep disorders • Cost benefit • Ease of use • Objective measure of sleep/wake • Ambulatory, long-term data collection • Reliable • Validated with PSG

27. Conflict of Interest Disclosure __x__Ido not have any potential conflicts of interest to disclose, OR ____I wish to disclose the following potential conflicts of interest: Type of Potential Conflict/Details of Potential Conflict ____Grant/Research Support ____Consultant ____Speakers’ Bureaus ____Financial support ____Other

28. Questions?