Sleep Medicine Elective Toolkit

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Introduction

This resource is not all-inclusive but is a general guide for the trainee enrolled in a sleep elective. This toolkit represents a living resource undergoing periodic updates.

A trainee’s interest in sleep medicine is often sparked by a stimulating sleep elective experience. This Sleep Medicine Elective Toolkit is designed to encompass common clinical resources related to the sleep medicine field.  It contains a variety of resources that highlight the importance of sleep medicine and findings in the field to inspire a passion for sleep medicine in trainees. At the same time, this is intended to provide trainees who may not plan to focus in career in sleep medicine with a handful of helpful resources to competently manage sleep disorders within their own specialties.

The objective is to improve sleep education by providing a resource that may be used to:

  1. Provide a suggested, overarching guide for education during existing sleep electives and
  2. Incentivize new clinical sites to offer sleep medicine electives by offering an educational resource for such electives.

This resource is intended for medical students, residents/fellows in training programs of traditional “feeder” specialties* for sleep medicine, medical schools, and program directors, with the hopes they will find this to be a valuable resource in their sleep medicine experience.

*Feeder specialties for sleep medicine include, but are not limited to pulmonary/critical care, neurology, internal medicine, family medicine, pediatrics, psychiatry, otorhinolaryngology, and anesthesiology

Getting Started

Learn the fast facts about a sleep medicine rotation, opportunities to get involved as a trainee, and resources to help you as you start your sleep medicine rotation.

    • A sleep medicine rotation is likely to be primarily a clinic-based (outpatient) rotation. Occasionally, there is an opportunity to do inpatient consults as well. In addition, most clinicians also spend a certain amount of time each day interpreting sleep studies.
    • The most common sleep disorders encountered in clinic will be sleep apnea, insomnia and restless leg syndrome; however, exposure to a variety of other sleep related disorders (listed below) is also expected.
    • The attending faculty in the sleep center of your rotation may have diverse training backgrounds (see feeder specialties above) given the inherent multidisciplinary nature of sleep medicine.
    • Also depending on the sleep center, there is a chance you will be exposed to weekly didactic conferences as well as grand rounds.
    • Sleep studies are mostly done at night under the supervision of trained sleep technicians with a sleep physician available remotely on call. Sleep technicians are also responsible for scoring sleep studies (identifying different sleep stages, grading the apnea severity, etc.). They are also the one to send the completed study to the physician for final review.
    • Most sleep clinics have a respiratory therapist incorporated in the practice to address and monitor adherence to positive airway pressure (PAP) devices and troubleshoot barriers to treatment.

    • Join or start a Choose Sleep Interest Group (CSIG) at your institution to cultivate medical student interest in sleep medicine clinical care and research, provide opportunities for community outreach, and motivate aspiring physicians to become sleep medicine specialists.
    • Submit a publication to AASM’s REM: A Publication for Residents and Fellows or American Thoracic Society’s Sleep Fragments.
    • Volunteer to undergo a sleep study
    • Shadow a sleep technologist for more exposure to polysomnography
    • Try positive airway pressure therapy to get a sense of what it feels like.

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    Information on Common Sleep Disorders

    Below are common sleep disorders seen by sleep medicine professionals. Click on the plus signs for a list of fast facts, continued readings related to the disorder, or additional online resources.

    • The major brain areas and neurotransmitters in the regulation of sleep and wakefulness, REM and NREM sleep, are well described.
    • The ventrolateral preoptic nucleus in the anterior hypothalamus is active during sleep (primarily NREM sleep) and contains neurons which release inhibitory neurotransmitters, GABA and galanin.
    • Most American adults and many children do not get the full recommended amount of sleep.
    • Adults are recommended to get 7-9 hours of sleep a night.
    • In children, sleep duration generally decreases with age. Newborns may sleep up to 18 hours per 24-hour period without day-night differentiation, whereas adolescents are recommended to get 8-10 hours of sleep nightly.
    • Acute and chronic sleep deprivation can cause a range of neurobehavioral deficits, including lapses of attention, compromised vigilance and depressed mood.

    • Paruthi S, Brooks LJ, D’Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL, Troester MM, Wise MS. Recommended amount of sleep for pediatric populations: a consensus statement of the American Academy of Sleep Medicine. J Clin Sleep Med 2016;12(6):785–786.
    • Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C, Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. J Clin Sleep Med 2015;11(6):591–592.
    • Banks S; Dinges DF. Behavioral and physiological consequences of sleep restriction. J Clin Sleep Med 2007;3(5):519-528.
    • España RA; Scammell TE. Sleep neurobiology for the clinician. Sleep 2004;27(4):811-20
    • Fundamentals of sleep medicine, 1st edition, Richard B. Berry
    • Sleep Medicine Pearls, 3rd edition, Richard B. Berry & Mary H Wagner
    • Pediatric Sleep Pearls, 1st edition, Lourdes Del Rosso & Richard B. Berry & Suzanne Beck & Mary H Wagner & Carole L. Marcus

    • “Sleep: Neurobiology, Medicine & Society” – This 22-hour on-line course, put together by University of Michigan, is designed to give students up-to-date information on the biological, personal, and societal relevance of sleep.

    • Obstructive Sleep Apnea (OSA) is a common condition characterized by repeated episodes of upper airway narrowing and/or collapse during sleep, resulting in breathing pauses.  These episodes may result in intermittent hypoxia, sympathetic activation, intrathoracic pressure swings, inflammation and sleep disruption.
    • Central Sleep Apnea (CSA) is a less common type of sleep-related breathing disorder in which there is a breathing pause caused by decreased respiratory effort
    • Being overweight or obese is the major risk factor for OSA.  Patients with OSA may complain of snoring, gasping awake, breathing pauses seen by a bedpartner, daytime sleepiness, dry mouth, poor concentration, or nocturia.
    • Untreated OSA has been associated with a higher risk of hypertension, stroke, post-operative complications and all-cause mortality.  Untreated OSA also has significant public health consequences including drowsy driving and decreased workplace productivity.
    • Testing options for OSA include home sleep apnea testing (HSAT) and in-laboratory polysomnography (PSG).  PSG is the gold standard and most accurate modality.  HSAT has benefits of convenience and accessibility.  HSAT is an option for patients in whom there is a moderate or high suspicion of OSA based on clinical presentation, as long as certain comorbidities are not present (significant lung disease or heart failure, neuromuscular disease).
    • First-line treatment for OSA is continuous positive airway pressure (CPAP) for most patients.  This is the most studied and effective treatment.  With sufficient education and clinical support, most patients are able to acclimate to using CPAP.  CPAP has been shown to improve daytime sleepiness, neurocognitive function, and blood pressure. CPAP may also reduce the risk of coronary artery disease and atrial fibrillation.
    • Patients should be counseled to use CPAP every time they sleep (including during naps) for the whole time they sleep.
    • For patients unable to tolerate CPAP, alternative OSA treatments include mandibular advancement devices fitted by a qualified dentist, upper airway surgeries and hypoglossal nerve stimulation therapy.

    Clinical Practice Guidelines

    High-yield articles

    • Sleep-related movement disorders are primarily characterized by movements that disturb sleep or its onset.
    • The ICSD-3 lists 10 types of sleep-related movement disorders: restless legs syndrome, periodic limb movement disorder, sleep related leg cramps, sleep related bruxism, sleep related rhythmic movement disorder, benign sleep myoclonus of infancy, propriospinal myoclonus at sleep onset, sleep related movement disorder due to a medical disorder, sleep related movement disorder due to a medication/substance, and unspecified.
    • Restless Legs Syndrome (RLS) is a disorder that is defined by an urge to move the legs which is usually coupled with an uncomfortable or unpleasant sensation that has a predilection for evening time. This sensation is quiescegenic (engendered by stillness) and often relieved by movement.
    • Among children, RLS may be conflated with “growing pains”. For children who are not developmentally capable of describing RLS symptoms, a combination of family history and elevated periodic limb movement may be suggestive of RLS.
    • Prevalence is 5-10% in North America and the female to male ratio is ~2:1
    • Iron deficiency can precipitate RLS and searching for iron deficiency with an aim toward iron supplementation is a reasonable treatment option targeting levels >75ug/L.
    • Genetic predisposition exists with single nuclear polymorphisms in the BTBD9 gene conferring a 50% risk of developing the affliction
    • Some medications that can potentially worsen RLS:
      • Tricyclic antidepressants, selective serotonin reuptake inhibitors, lithium, sedating anti-histamines, dopamine receptor antagonists
    • Pathophysiology involves increased nigrostriatal dopamine production, which leads to increased extracellular dopamine in the striatum

    • American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed. Darien IL: American Academy of Sleep Medicine, 2014.
    • The Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder in Adults—An Update for 2012: Practice Parameters with an Evidence Based Systematic Review and Meta-Analyses. SLEEP 2012;35(8):1039-1062
    • Co-Morbidities, treatment and pathophysiology in restless legs syndrome. Lancet Neurology 2018; 17 (11) 994
    • Long-Term Treatment of Restless Legs Syndrome with Dopamine Agonists. Arch Neurol 2004; 61(9):1393-1397
    • Silber MH et al. Willis Ekbom Disease Foundation revised consensus statement of the management of restless legs syndrome. Mayo Clin Proc 2013; 88(9):977
    • Sleep and Movement Disorders, 2nd Ed Chokroverty S (Ed.), 2013

    • RLS Foundation – The Restless Legs Syndrome Foundation is the leading organization for science-based education and patient services for people suffering from restless legs syndrome.

    • Insomnia is defined as persistent difficulty with sleep initiation, duration, consolidation or quality that occurs, despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment.
    • The ICSD-3 lists 3 types of insomnia: chronic insomnia disorder, short-term insomnia disorder, and other insomnia disorder.
    • The ICSD-3 eliminated primary and secondary insomnia distinctions and primary insomnia subtypes (such as idiopathic insomnia, physiological insomnia, paradoxical insomnia, inadequate sleep hygiene) as these are difficult to reliably ascertain and are of questionable validity.
    • Population-based estimates indicate that 10-15% of adults report persistent and troublesome insomnia.
    • Among younger children, behavioral insomnia due to sleep associations or inadequate limit setting may be seen.
    • Behavioral treatments for insomnia, such as Cognitive Behavioral Therapy for Insomnia (CBT-I), are recommended as first-line treatments. This can be administered in-person, or via group-based or web-based applications. They include several components:
      • Sleep restriction that leads to sleep consolidation
      • Stimulus control therapy with the goal of re-associating the bed with sleeping
      • Relaxation-based interventions to target mental arousal in the form of worries, intrusive thoughts, or a racing mind
      • Cognitive therapy to alter sleep-disruptive believes and maladaptive cognitive processes
      • Sleep hygiene education, which is required but not sufficient for treatment of insomnia
    • Sedative-hypnotics agents are recommended if CBT-I is not sufficient or if the patient is not able to complete behavioral therapy.

    • American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed. Darien IL: American Academy of Sleep Medicine, 2014.
    • Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–349. PMID: 27998379 PMCID: PMC5263087
    • Morgenthaler T; Kramer M; Alessi C et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. SLEEP 2006;29(11): 1415-1419. PMID: 17162987
    • Schutte-Rodin S; Broch L; Buysse D; Dorsey C; Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008;4(5):487-504. PMID: 18853708, PMCID: PMC2576317
    • Patel D, Steinberg J, Patel P. Insomnia in the elderly: a review. J Clin Sleep Med. 2018;14(6):1017–102. PMID: 29852897 PMCID: PMC5991956
    • Kalmbach DA1, Pillai V2, Arnedt JT1, et al. DSM-5 Insomnia and Short Sleep: Comorbidity Landscape and Racial Disparities. 2016 39(12):2101-2111.  PMID: 27634805 PMCID: PMC5103798
    • Morin, Charles M. Cognitive-behavioral Therapy of Insomnia. Sleep Medicine Clinics. 2006. Volume 1, Issue 3 , 375 – 386.
    • JT Arnedt, DA Conroy, DA Poster, et al. Evaluation of the Insomnia Patient. Sleep Medicine Clinics. 2006. Volume 1, issue 3 2006: 319-332.

    • Central Disorders of Hypersomnia are a group of disorders that cause daytime sleepiness and are not due to a disturbance of nocturnal sleep or a circadian rhythm disorder.
    • Daytime sleepiness is an inability to maintain alertness during the day with an irrepressible need to sleep or lapses into sleep.
    • The ICSD-3 lists 8 types of hypersomnias: Narcolepsy Type 1, Narcolepsy Type 2, Idiopathic Hypersomnia, Kleine-Levin Syndrome, Hypersomnia Due to a Medical Disorder, Hypersomnia Due to a Medication or Substance, Hypersomnia Associated with a Psychiatric Disorder, Insufficient Sleep Syndrome
    • Narcolepsy is described as Type 1, with cataplexy, and Type 2, without cataplexy
      • In both, patients have daytime sleepiness for at least 3 months and an MSLT with a mean sleep latency of ≤ 8 minutes and two or more sleep onset REM.
      • In Type 1 Narcolepsy, patients have cataplexy, and may also have a CSF hypocretin-1 concentration measured that is ≤ 110 pg/mL.
      • Some patients will have associated symptoms due to REM dysregulation, including hypnagogic hallucinations, which are vivid dreamlike experiences at wake-sleep transitions, and sleep paralysis, which is an inability to move voluntary muscles at sleep-wake transitions for up to several minutes.
      • The prevalence of Narcolepsy Type 1 is 1 in 2000.
      • The pathophysiology is thought to be destruction of hypothalamic hypocretin-producing cells.
      • Almost all patients with cataplexy are DQB1*0602 positive.
      • Treatment is symptomatic with alerting agents (modafinil, armodafinil, amphetamine, methamphetamine, dextroamphetamine, and methylphenidate) and anticataplectic agents (sodium oxybate, antidepressants).
    • In Idiopathic Hypersomnia (IH), patients have excessive daytime sleepiness in the absence of cataplexy and no more than one sleep-onset REM period on an MSLT
      • The prevalence and pathophysiology of IH are unknown, although there is a female predominance.
      • Treatment is symptomatic with alerting agents.
    • Kleine-Levin Syndrome is characterized by recurrent episodes of excessive daytime sleepiness that are associated with cognitive, psychiatric, and behavioral disturbances, which resolves in between episodes.
      • This is rare with a prevalence of about 1-2 per million.
      • There is a male predominance.
      • The pathophysiology is unknown.

    • American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed. Darien IL: American Academy of Sleep Medicine, 2014.
    • Wise MS, Arand DL, Auger RR, Brooks SN, Watson NF. Treatment of narcolepsy and other hypersomnias of central origin. SLEEP 2007;30(12):1712-27.
    • Morgenthaler TI; Kapur VK; Brown TM; Swick TJ; Alessi C; Aurora RN; Boehlecke B; Chesson AL; Friedman L; Maganti R; Owens J; Pancer J; Zak R; Standards of Practice Committee of the AASM. Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEP 2007;30(12):1705-1711.
    • Ali M, Auger RR, Slocumb NL, Morgenthaler TI. Idiopathic hypersomnia: clinical features and response to treatment. J Clin Sleep Med 2009;5(6):562-8.
    • Habra O, Heinzer R, Haba-Rubio J, Rossetti AO. Prevalence and mimics of Kleine-Levin syndrome: a survey in French-speaking Switzerland. J Clin Sleep Med 2016;12(8):1083–1087.
    • Ugoccioni G, Lavault S, Chaumereuil C, Golmard JL, Gagnon JF, Arnulf I. Long-term cognitive impairment in Kleine-Levin Syndrome. SLEEP 2016;39(2):429-38.
    • Dauvilliers Y, Barateau L. Narcolepsy and other central hypersomnias. Continuum 2017;23(4, Sleep Neurology):989-1004.
    • Scammell TE. Narcolepsy. NEJM 2015; 373:2654-62.’
    • Kornum BR, Knudsen S, Ollila HM, Pizza F, Jennum PJ, Dauvilliers Y, Overeem S. Narcolepsy. Nat Rev Dis Primers 2017;3:16100.
    • Billiard M, Sonka K. Idiopathic hypersomnia. Sleep Med Rev 2016;29:23-33.
    • Miglis MG, Guilleminault C. Kleine-Levin syndrome: a review. Nat Sci Sleep 2014;6:19-26.

    • The ICSD-3 lists 3 core types of parasomnias: NREM-related parasomnias, REM-related parasomnias, and other parasomnias.
    • NREM-related parasomnias are caused by incomplete awakening from sleep (typically N2 or N3 sleep), are associated with amnesia of the episode, and may be triggered by sleep deprivation and stimuli such as touch, sound and OSA.
      • Confusional arousals occurs when a person stays in bed, has a lack of autonomic activation, and may include sleep related abnormal sexual behaviors. It has a lifetime prevalence of up to 18%.
      • Sleep walking (somnambulism) is associated with ambulation and other complex behaviors outside of the bed. It has a lifetime prevalence of 18-40%.
      • Sleep terrors is when there is significant autonomic arousal during the episode.
      • These are not typically treated with medications; aggravating factors are addressed (such as underlying OSA) and safety measures are paramount
      • These are common in children, with higher prevalence rates among those with a positive family history.
      • Sleep restriction, as well as other co-morbid sleep disorders such as OSA, are common triggers for NREM parasomnias in children.
    • Sleep related eating disorder is dysfunctional eating that occurs after an arousal during the main sleep period. It is involuntary and puts an individual at risk for injurious behavior and consumption of inedible or toxic foods.
      • This is in contrast to Night-Eating Syndrome which is characterized by excessive eating between dinner and bedtime and during full awareness during the sleep period, often associated with mood disorders
    • REM Sleep Behavior Disorder (RBD)
      • This diagnosis requires history of sleep related vocalizations and/or complex motor behaviors AND demonstration of the normal loss of atonia during REM sleep as seen on polysomnography.
      • There is often injury to patient and bed partner.
      • Idiopathic RBD is now widely recognized, typically seen in men over 50 years old, and increases risk for development of alpha-synucleinopathies (Parkinson’s disease, multiple system atrophy and dementia with Lewy bodies).
      • RBD is also linked with narcolepsy, withdrawal from alcohol, and other REM-suppressing medications.
      • Treatment often requires pharmacotherapy with clonazepam or melatonin, in addition to safety measures.
    • Nightmare disorder
      • This disorder may be seen with PTSD and certain medications (including varenicline, anti-histaminergics, anticholinesterase inhibitors).
      • Behavioral treatments are recommended.

    • American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed. Darien IL: American Academy of Sleep Medicine, 2014.
    • Aurora RN; Zak RS; Maganti RK; Auerbach SH; Casey KR; Chowdhuri S; Karippot A; Ramar K; Kristo DA; Morgenthaler TI. Best practice guide for the treatment of rem sleep behavior disorder (rbd). J Clin Sleep Med 2010;6(1):85-95. PMID: 20191945 PMCID: PMC2823283
    • Morgenthaler TI, Auerbach S, Casey KR, Kristo D, Maganti R, Ramar K, Zak R, Kartje R. Position paper for the treatment of nightmare disorder in adults: an American Academy of Sleep Medicine position paper. J Clin Sleep Med. 2018;14(6):1041–1055. PMID: 29852917 PMCID: PMC5991964
    • Budhiraja R. The Man who fought in his sleep. J Clin Sleep Med 2007;3(4):427-428.
    • Fahed GP, Mehra RM. A man with abnormal sleep behavior. J Clin Sleep Med 2007;3(5):533-534. PMID: 17803019 PMCID: PMC1978323
    • Boursoulian LJ; Schenck CH; Mahowald MW; Lagrange AH. Differentiating parasomnias from nocturnal seizures. J Clin Sleep Med 2012;8(1):108-112.  PMID: 22334817 PMCID: PMC3266329
    • Schenck CH, Arnulf I, Mahowald MW. Sleep and Sex: What Can Go Wrong? A Review of the Literature on Sleep Related Disorders and Abnormal Sexual Behaviors and Experiences. Sleep 2007;30(6):683- 702. PMID: 17580590 PMCID: PMC1978350
    • Mason TB, Pack AI. Pediatric Parasomnias. Sleep 2007;3092):141-151. PMID: 17326539
    • Schenck CH, Mahowald WM. REM sleep behavior disorder: clinical, developmental, and neuroscience perspectives 16 years after its formal identification in SLEEP. Sleep. 2002;25(2):120-38. PMID: 11902423
    • Ana Fernández-Arcos, Alex Iranzo, Mónica Serradell, Carles Gaig, Joan Santamaria. The Clinical Phenotype of Idiopathic Rapid Eye Movement Sleep Behavior Disorder at Presentation: A Study in 203 Consecutive Patients. Sleep, Volume 39, Issue 1, 1 January 2016, Pages 121–132. PMID: 26940460 PMCID: PMC4678361
    • Yves Dauvilliers, Carlos H. Schenck, Ronald B. Postuma, Alex Iranzo, Pierre-Herve Luppi, Giuseppe Plazzi, Jacques Montplaisir & Bradley Boeve. REM sleep behaviour disorder. Nature Reviews Disease Primers. 2018;19. PMID: 30166532 DOI: 10.1038/s41572-018-0016-5

    • American Academy of Neurology’s NeuroLearn: REM Sleep Behavior Disorder – This program is designed to provide neurologists in practice the knowledge needed to recognize, diagnose, and treat RBD.

    • The biologic circadian rhythm is governed by the suprachiasmatic nucleus which resides in the hypothalamus. Through the retinohypothalamic tract, this connects to the retinal ganglion cells to sense light, which is the strongest zeitgeber or “time-giver” which helps to entrain our circadian rhythm.
    • The ICSD-3 lists 7 types of circadian rhythm sleep-wake disorders: delayed sleep-wake phase disorder, advanced sleep-wake phase disorder, irregular sleep-wake rhythm disorder, non-24-hour sleep-wake rhythm disorder, shift work disorder, jet lag disorder, circadian sleep-wake disorder not otherwise specified (NOS).
    • Circadian rhythm disorders are characterized by symptoms of insomnia, daytime sleepiness, or both; disruption of the sleep-wake rhythm; and associated features such as distress or impaired functioning.
    • There are two primary types of circadian rhythm disorders – intrinsic and extrinsic.
    • Intrinsic circadian rhythm disorders are characterized by disruption of the internal clock, such as delayed sleep-wake phase disorder or advanced sleep-wake phase disorder.
    • Extrinsic circadian rhythm disorders involve desynchronization of the internal biologic rhythm with external cues such as shift work sleep disorder or jet lag syndrome.
    • Delayed sleep-wake phase disorder is characterized by an inability to fall asleep until very late at night, with the resulting need to sleep late in the morning or into the afternoon; but an ability to sleep reasonably well if sleep and wake times are much later than normal.
    • Delayed sleep-wake phase disorder may commonly present during adolescence and is a driving force behind recommendations for delayed high-school start times.
    • Advanced sleep-wake phase disorder is characterized by a need to sleep and wake up much earlier than normal.
    • Non-24-hour sleep-wake disorder occurs when an individual’s day length is longer than 24 hours.
    • Shift work disorder occurs when the circadian rhythms are disturbed due to working during the body’s natural sleep time resulting in difficulty in adjusting to the required schedule.
    • Jet lag occurs when there is changing time zones, which can disrupt light cues and regular bedtimes.

    • American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed. Darien IL: American Academy of Sleep Medicine, 2014.
    • Smith MT, McCrae CS, Cheung J, Martin JL, Harrod CG, Heald JL, Carden KA. Use of Actigraphy for the Evaluation of Sleep Disorders and Circadian Rhythm Sleep-Wake Disorders: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2018 Jul 15;14(7):1231-1237
    • Morgenthaler TI, Lee-Chiong T, Alessi C, Friedman L, Aurora RN, Boehlecke B, Brown T, Chesson AL Jr, Kapur V, Maganti R, Owens J, Pancer J, Swick TJ, Zak R. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 2007 Nov;30(11):1445-59
    • Zee PC, Attarian H, Videnovic A. Circadian rhythm abnormalities. Continuum (Minneap Minn). 2013 Feb;19(1 Sleep Disorders):132-47.
    • Ko CH, Takahashi JS. Molecular components of the mammalian circadian clock. Hum Mol Genet 2006;15:R271YR277

    • There are a variety of diagnostic and therapeutic procedures that are routinely utilized by sleep medicine physicians, including:
      • Sleep-center based procedures:
        • In-lab diagnostic polysomnography – a technologist-attended overnight study of sleep and related physiological monitoring, including sleep staging, respiratory effort and flow, ECG, and limb movements throughout the night. This procedure is used to diagnose sleep-related breathing disorders, REM-sleep behavior disorder, sleep-related seizure disorders, some parasomnias, and to rule out other causes of excessive daytime sleepiness in the evaluation of disorders of central hypersomnolence such as narcolepsy and idiopathic hypersomnia.
        • In-lab positive airway pressure or mandibular advancement device titration polysomnography – a technologist-attended overnight study where sleep physiology is monitored while a previously diagnosed sleep-related breathing disorder is treated with the titration of either positive airway pressure or a mandibular advancement device.
        • Multiple sleep latency testing – a technologist-attended daytime study consisting of sleep physiology monitored nap opportunities performed across the day which is used in the diagnosis of disorders of central hypersomnolence
        • Maintenance of wakefulness testing – a technologist-attended daytime study consisting of sleep/wake physiological monitoring throughout the day to monitor a patient’s ability to stay awake/effectiveness of treatment.
      • Ambulatory procedures:
        • Home sleep apnea testing – an overnight, unattended screening test which monitors breathing and oxygen saturation. This is used in the screening and diagnosis of obstructive sleep apnea in high-risk adult populations without excluding comorbidities including heart failure, chronic-obstructive pulmonary disease, neuromuscular disorders among others.
        • Actigraphy – fine motor movement and light exposure monitoring across multiple days used to gather information about patterns of sleep/wake behavior that is used to aid in the diagnosis of insomnia and circadian rhythm sleep disorders.

    After Your Rotation

    Considering a career in sleep medicine? Learn about the highlights to this career path, along with resources to further pursue this path.

    • Given that multiple specialties in both the adult and pediatric world can get boarded in sleep medicine, everyone’s pathway is unique and based on one’s primary specialty and interests
    • Given this heterogeneity in our provider base, there is an awesome interdisciplinary collaboration at play, which is unlike most other fields.
    • A full-time clinical sleep physician focuses on seeing patients with sleep disorders listed below in clinic and are responsible for taking calls from the sleep lab (most often non-emergent). Most practice completely in the outpatient setting with limited weekend responsibilities. Additionally, the Director of the sleep lab also has further technical and administrative responsibilities.
    • As part-time clinical sleep physician, in addition to the above, takes on responsibilities based on your primary specialty (Pulmonary, Neurology, IM, etc.).
    • As an academic sleep physician, you are responsible for clinical duties noted above, but a negotiable amount of your time can be designated for research based upon your track record, commitment and available funding.

    • Testimonial: What it’s like to be in Sleep Medicine: Shadowing Dr. Chervin
    • Testimonial: A Day in the Life of Dr. Skiba
    • AASM Choose Sleep – Learn about the rewarding potential of a career in sleep medicine and see how you can get more involved.
      • Choose Sleep Webinars – The AASM Sleep Medicine Fellowship Directors Council (SMFDC) offers a free webinar lecture series for sleep medicine fellows and interested residents. These webinars cover a broad range of topics ranging from pediatric sleep and behavior to devices and modalities.
    • American Academy of Sleep Medicine (AASM)
      • Career Center – Use the career center to search for open positions in the field of sleep medicine or find helpful resources and tools to aid in the application process.
      • AASM Mentor Program – Connect with more experienced professionals in the field of sleep medicine by participating in the AASM mentor program. AASM membership required.
      • AASM Sleep Physician Compensation Survey (Need AASM Membership to view).
    • American Thoracic Society (ATS)
      • Choosing Sleep Medicine – Learn about the nature of the practice, applying for a fellowship, employment opportunities, and more.

    This Sleep Medicine Elective Toolkit was created by members of the 2018-2019 AASM Young Physicians Committee: Reena Mehra, MD; Eric Olson, MD; Mustafa Bseikri, MD; Charles Guardia, MD; Chris Hope, MD, MHA, RPSGT; Jennifer Marsella, MD; Nik Samtani, MD; Virginia Skiba, MD; Lauren Tobias, MD and Jessica Vensel Rundo, MD.