SHIFT WORK DISORDER - myCME.com

Table 1—Levels of Evidence:Level Risk/ Assessment Treatment1 Validating 1 cohort with well-validated reference standards 2 High quality randomized controlled trial (RCT) on well-characterizedsubjects or patients2 Smaller or “exploratory” cohort study or one that has Cohort study or flawed clinical trial (e.g., small N, blinding notincompletely validated reference standards 2specified, possible non-random assignment to treatment, incompletelyvalidated reference standards 2 )3 Case control study or cross-sectional survey Case control study4 Case series (and poor quality cohort and case control studies) Case series (and poor quality cohort and case control studies)1. Validating studies test the quality of a specific diagnostic test, based on prior evidence.2. Reference standards: PSG, sleep logs, actigraphy, phase markers, validated self-reports.Oxford levels adapted from Sackett 8mation and a system described by Eddy 4 (i.e., Standard, Guideline,or Option), the Standards of Practice Committee (SPC) andBoard of Directors of the AASM determined levels of treatmentrecommendation presented in the practice parameters below. Thepurpose of the present document is to provide evidence-based recommendationsfor the assessment and treatment of CRSDs.Due to the large volume of relevant literature, the review wasdivided into two papers. One discussed shift work disorder (SWD)and jet lag disorder (JLD), both of which are thought to be relatedto exogenously determined alterations in the timing of sleep andwakefulness rather than disturbances of the endogenous circadiansystem itself. A second paper discussed circadian rhythm sleepdisorders that are considered to result from a primary endogenouscause, including advanced sleep phase disorder (ASPD), delayedsleep phase disorder (DSPD), free-running disorder (FRD), andirregular sleep-wake rhythm disorder (ISWR). The categorizationof CRSDs in the two review papers and this practice parameter paperfollows the classification provided by the International Classificationof Sleep Disorders, 2 nd edition (ICSD-2), 5 with somesimplification of terminology. We acknowledge that while the disordersare classified as endogenous or exogenous, the physiologicunderpinnings of each disorder are not so surgically separated. Inreality, combinations of endogenous and exogenous factors leadto the manifestations of each disorder.Based upon the accompanying review papers and systematicgrading of this evidence, members of the SPC developed thesepractice parameters as a guide to the appropriate assessment andtreatment of CRSDs. The task force did not intensively reviewthe role of actigraphy in the diagnosis of CRSDs since a recentlypublished updated practice parameter paper addresses the use ofactigraphy. 6 To provide a succinct yet comprehensive parameterpaper, key recommendations from the recently published actigraphyparameter paper regarding the use of actigraphy in CRSDsare repeated here. In addition, where appropriate, recommendationsregarding the use of light therapy in the treatment of CRSDsare presented here as an update of the prior practice parameterpaper on the use of light therapy. 72.0 METHODSThe SPC of the AASM commissioned content experts in circadianrhythm sleep disorders in 2005 to review and grade evidence inthe peer-reviewed scientific literature regarding the assessment andtreatment of circadian rhythm disorders. An extensive review designedto find relevant published evidence retrieved 2084 articles,SLEEP, Vol. 30, No. 11, 2007 1446and is described in detail in the review paper. 1 Abstracts of thesearticles were reviewed by task force members to determine if theymet inclusion criteria. Initial data extraction, preliminary evidencegrading in accordance with the standards in Table 1, and initial dataentry into evidence tables were performed by professionals contractedby the SPC to expedite the review process. All evidencetable entries were reviewed by at least one other task force member.Thus, all evidence grading was performed by independent reviewof the article by a minimum of two experts–one, a professional experiencedin the evidence review process, and the other a contentexpert. Areas of disagreement were addressed, and if needed, thechair of the task force arbitrated the final decision on evidence level.Final summaries of information from included articles are listedin an evidence table available at http://www.aasmnet.org/.On the basis of these reviews and noted references, the Standardsof Practice Committee of the American Academy of SleepMedicine (AASM), in conjunction with specialists and other interestedparties, developed the recommendations included in thispractice parameters paper related to the evaluation and therapyof CRSDs.In most cases, the strength of the recommendation is based onevidence from studies published in peer-reviewed journals thatwere evaluated as noted in the evidence table of the companionreview papers. However, when scientific data were absent, insufficient,or inconclusive, the recommendations are based uponconsensus after review and discussion by the SPC. Those recommendationsfor which consensus formed the main basis for therecommendation are specifically indicated.The Board of Directors of the AASM approved these recommendations.All authors of the accompanying review paper, membersof Standards of Practice Committee, and the AASM Board ofDirectors completed detailed conflict-of-interest statements.These practice parameters define principles of practice thatshould meet the needs of most patients in most situations. Theseguidelines should not, however, be considered inclusive of all propermethods of care or exclusive of other methods of care reasonablyexpected to obtain the same results. The ultimate judgment regardingappropriateness of any specific therapy must be made by theclinician and patient, in light of the individual circumstances presentedby the patient, available diagnostic tools, accessible treatmentoptions, resources available, and other relevant factors.The AASM expects these guidelines to have a positive impact onprofessional behavior, patient outcomes, and possibly, health carecosts. These practice parameters reflect the state of knowledge atthe time of development and will be reviewed, updated, and revisedPractice Parameters for the Clinical Evaluation of CRSD—Morgenthaler et al