clinical applications of actigraphy in pediatric populations · clinical applications of actigraphy...

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Clinical Applications of Actigraphy in Pediatric Populations

Lisa J. Meltzer, Ph.D., CBSM

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Conflict of Interest Disclosures for Speakers1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, OR

2. I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support NIH

Consultant Johnson and Johnson

Speakers’ Bureaus

Financial support Sleep Education Fellow, National Sleep Foundation

Other Co-author, Pediatric Sleep Problems: A Clinician’s Guide to Behavioral Interventions

3. The material presented in this lecture has no relationship with any of these potential conflicts, OR

4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:

1.

2.

3.

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A Tale of Two “Terrible” Sleepers

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Similar Clinical Complaints• Patient #1

• 5 year old girl with frequent night wakings• Falls asleep independently in 10 minutes• 4/7 nights wakes and is up for 2-3 hours• Will go tell parents she’s awake, but then goes

back to room to read

• Patient #2• 2 year old girl with disrupted sleep pattern• Falls asleep independently in 10-30 min• Minimum of 1 waking/night, lasting 3-4 hours• Does not cry for parents, but they hear her

laughing and playing

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Validity of Actigraphy in Pediatrics

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Reference Population (n) Device Compared Placement

Sadeh et al. (1991) 12-48 months (11) AMA-32 PSG Left leg

Sadeh et al. (1994) Adults (20), adolescents (16) AMA-32 PSG Both wrists

Sadeh et al. (1995) Infants (41) AMA-32 PSG Left ankle

Gnidovec et al. (2002) Infants (10) Gaehwhiler Direct observation Left ankle

So et al. (2005) Infants (22) AW-64 PSG Between ankle/knee

Hyde et al. (2007) Children (1-12 yrs, 45)* AW-64 PSG Non-dominant wrist

Sitnick et al. (2008) Preschoolers (58)* AW-64 Video Non-dominant ankle

Sung et al. (2009) Preterm infants AW-64 Video Right leg between ankle/knee

Tilmanne et al. (2009) Infants (354) Healthdyne PSG Ankle

Insana et al. (2010) Infants (22) AW-64 PSG Ankle

Weiss et al. (2010) Adolescents (30)Sleepwatch, Actiwatch,

ActicalPSG Non-dominant wrist

(Actical on trunk)

Meltzer et al. (2012) 3-18 years (115) Sleepwatch, Actiwatch PSG Non-dominant wrist

Meltzer et al., (2012), Use of Actigraphy in Pediatric Sleep Research, Sleep Med Rev.

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Reference Population (n) Device Compared Placement

Sadeh et al. (1991) 12-48 months (11) AMA-32 PSG Left leg

Sadeh et al. (1994) Adults (20), adolescents (16) AMA-32 PSG Both wrists

Sadeh et al. (1995) Infants (41) AMA-32 PSG Left ankle

Gnidovec et al. (2002) Infants (10) Gaehwhiler Direct observation Left ankle

So et al. (2005) Infants (22) AW-64 PSG Between ankle/knee

Hyde et al. (2007) Children (1-12 yrs, 45)* AW-64 PSG Non-dominant wrist

Sitnick et al. (2008) Preschoolers (58)* AW-64 Video Non-dominant ankle

Sung et al. (2009) Preterm infants AW-64 Video Right leg between ankle/knee

Tilmanne et al. (2009) Infants (354) Healthdyne PSG Ankle

Insana et al. (2010) Infants (22) AW-64 PSG Ankle

Weiss et al. (2010) Adolescents (30)Sleepwatch, Actiwatch,

ActicalPSG Non-dominant wrist

(Actical on trunk)

Meltzer et al. (2012) 3-18 years (115) Sleepwatch, Actiwatch PSG Non-dominant wrist

Meltzer et al., (2012), Use of Actigraphy in Pediatric Sleep Research, Sleep Med Rev.

71% of comparisons show good sensitivity to detect sleep (>85%)

59% of comparisons show poor specificity to detect wake (<60%)

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Actigraphy in My Clinic

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Detailed Teaching/Instructions

• Care and maintenance

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Detailed Teaching/Instructions

• Care and maintenance • Importance of sleep diary

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Detailed Teaching/Instructions

• Care and maintenance • Importance of sleep diary• Show an example of an actigram

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Detailed Teaching/Instructions

• Care and maintenance • Importance of sleep diary• Show an example of an actigram• Sign receipt

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Follow-Up Visit• 60 minute appointment

• Download actigraph• Review sleep diary for anomalies • Set sleep intervals on scoring program• Create summary variables• Review data with patient/family• Print actigram for patient to take home

• Generate report with summary variables and interpretation

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Billing for Actigraphy• Bill CPT code 95803 for actigraphy in

addition to clinic visit• Category I CPT code (95803)

• Actigraphy, testing, recording, analysis, interpretation and report (minimum of 72-hours to 14 consecutive days of recording, requires the patient to wear a home monitor for 24-hours a day for 3 to 14 days)

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Actigraphy Billing - NJH• Standard charges: tech fee $155, pro fee

$95• Medicare allowable: tech fee $54.12, pro

fee $44.05• Medicaid allowable global fee of $49.96• All commercial payers consider actigraphy

experimental• Patients can self-pay global fee of $98• Patients can sign Advance Beneficiary Notice

(ABN) where if insurance denies, patient is responsible for standard charges

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Clinical Indications and Pediatric Scoring Considerations

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Strongly recommended:• MSLT preceded by >7 days of

actigraphy with sleep log to establish if results biased by insufficient sleep, shift work, or circadian rhythm sleep disorder

Narcolepsy and Actigraphy

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8:30p 7:30a

TIB 10.4 hrs, TST 9.3 hrsSE 90%, 24-hr TST 9.9

11 Year Old Male

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Diagnostic Criteria D:The presence of > 1 of the following:1. MSLT shows mean SOL < 8 minutes2. Total 24-hour sleep time is ≥ 660

minutes (11 hrs) by 24-hour PSG or by wrist actigraphy in association with a sleep log (averaged over at least seven days with unrestricted sleep)

Idiopathic Hypersomnia and Actigraphy

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EDS Episode

Episode Resolved

High Activity

Low Activity

13 Year Old Male

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12p-6p 6p-10p 10p-6a 6a-12p

13 Year Old Male

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Time Block Mean Sleep Minutes

Mean Activity

Count (SD)

Mean Sleep Minutes

Mean Activity

Count (SD)

6pm to 10pm 94.3 111.1 (116.7) 0 225.0 (65.5)

10pm to 6am 299.3 19.8 (36.7) 314.5 77.4 (99.7)

6am to 12pm 111.5 100.5 (108.2) 88.5 184.7 (102.6)

12pm to 6am 74.8 156.5 (118.9) 0 245.1 (58.8)

During Episode After Episode

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Individual Day Analysis

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Diagnostic Criteria B:The patient’s sleep time, established by personal or collateral history, sleep logs, or actigraphy is usually shorter than expected for age

Notes: If there is doubt about the accuracy of personal history or sleep logs, then actigraphy should be performed,

Insufficient Sleep Syndromeand Actigraphy

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Sleep Onset 12:10 a.m.

Sleep Offset 7:49 a.m.

TIB 6.6 hrs, TST 6.4 hrs, SE 97%

Sleep Onset 11:48 a.m.

Sleep Offset 6:15 a.m.

15 Year Old Female

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Diagnostic Criteria D:Sleep log and, whenever possible, actigraphy monitoring for at least 7 days (preferably 14 days) demonstrate a delay in the timing of the habitual sleep period. Both work/school days and free days must be included within this monitoring

Circadian Rhythm Sleep Disorders and Actigraphy

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Sleep Onset 5:35 a.m.

Sleep Offset 1:13 p.m.

TIB 8.4 hrs, TST 7.2 hrs, SE 86%

24 Year Old Female

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Sleep Onset 1:24 a.m.

Sleep Offset 8:21 a.m.

TIB 7.4 hrs, TST 7.0 hrs, SE 94%

24 Year Old Female

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Leg actigraphy has been validated against PSG for the measurement of PLMS and provides a methodology to assess PLMS in large populations, as well as night to night variability

Periodic Limb Movement and Actigraphy

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Restless Sleepers

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Similar Clinical Complaints• Patient #1

• 10 year old male who is difficult to wake• Restless sleeper, kicks in sleep, no one

wants to share a bed

• Patient #2• 17 year old female who feels unrefreshed

upon waking• Restless sleeper, kicks in sleep, no one

wants to share a bed

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Pre-Post Treatment

• 7 year old boy• Difficulties falling asleep and

multiple night wakings• Daytime fatigue and behavior

problems• Restless sleeper• Low serum ferritin (20 ng/mL)

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VARIABLE FIRST STUDY CURRENT STUDY

Reported Bedtime 7:48 p.m. 7:51 p.m.Actigraphy Sleep Onset 8:30 p.m. 8:22 p.m.Reported Wake Time 6:43 a.m. 6:30 a.m.Actigraphy Sleep Offset 6:35 a.m. 6:14 a.m.Sleep Onset Latency 41.4 minutes 31.4 minutesSleep Opportunity 10.7 hours 10.7 hoursActual Sleep Time 8.6 hours 9.3 hoursSleep Efficiency 79% 87%Night Wakings > 20 minutes 1.6 wakings 0.8 wakings% No Activity 54.4% 63.5%% Low Activity 23.8% 22.1%% Moderate to High Activity 21.7% 14.3%

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Challenges/Considerations

• How much activity is normal?

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Which is Normal?

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High Activity

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Medium Activity

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Low Activity

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Challenges/Considerations

• How much activity is normal?• What if bedtime and wake time are not

clear or consistent?

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Parent reported bedtime

and wake time

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Frequent naps

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12p-6p 6p-10p 10p-6a 6a-12p

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Time Block Mean Sleep Minutes Mean Activity Count (SD)

6pm to 10pm 98.6 88.6 (97.5)

10pm to 6am 411.8 17.9 (42.9)

6am to 12pm 54.7 136.9 (91.5)

12pm to 6pm 71.0 136.2 (96.7)

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Challenges/Considerations

• How much activity is normal?• What if bedtime and wake time are not

clear or consistent?• What if there isn’t a diary?

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• In peds, parent often reports on child’s sleep patterns

• Patients not always good historians/ diary keepers

• Sleep patterns can significantly differ on weekdays, weekends, and holidays

• Watches can get lost/damaged• Placement of device/will child tolerate

Challenges/Considerations

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Your Turn

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Why Are These Wakings Circled?

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What Was the Referral Question?

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What Was the Referral Question?

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What Was the Referral Question?

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Summary• Actigraphy useful clinical tool in pediatrics

• Provides additional information about sleep-wake patterns

• Should be used prior to MSLT to ensure adequate sleep duration

• Can monitor treatment adherence/outcomes

• Important to have sleep diary/event markers and to get the watch back!

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Lisa J. Meltzer, Ph.D., CBSMmeltzerL@njhealth.org

Clinical Applications of Actigraphy in Pediatric Populations