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Table 2— AASM Levels of RecommendationsStrength of RecommendationStandardGuidelineOptionDefinitionThis is a generally accepted patient-care strategy that reflects a high degree of clinical certainty.The term standard generally implies the use of Level 1 Evidence, which directly addresses theclinical issue, or overwhelming Level 2 Evidence.This is a patient-care strategy that reflects a moderate degree of clinical certainty. The term guidelineimplies the use of Level 2 Evidence or a consensus of Level 3 Evidence.This is a patient-care strategy that which reflects uncertain clinical use. The term option implieseither inconclusive or conflicting evidence or conflicting expert opinion.as new information becomes available. Each article entered in theevidence tables of the companion review paper was evaluated usingthe Standards of Practice Committee’s levels of evidence (Table1). This evidence is used to support the strength of the recommendations(Table 2) in this paper. Square-bracketed numbers in thispaper refer to sections, tables, or references in the accompanyingreview papers. Other citations, noted by superscripted numbers, referto the reference list at the end of this paper.3.0 RESULTS AND RECOMMENDATIONSThe following recommendations reflect the evidence regardingthe diagnosis and treatment of CRSDs in clinical practice obtainedfrom the two accompanying reviews. For brevity, the findings andrecommendations are summarized in Table 3. Specific details arereviewed in the practice parameters below.3.1 General Recommendations for Evaluation of Circadian RhythmSleep DisordersThis recommendation is unchanged from the recently updatedpractice parameter paper on the use of actigraphy. 6 This priorpractice parameter paper and accompanying review provided evidencethat changes in actigraphy measures are in agreement withother outcome measures in the assessment of response to interventionin patients with CRSDs.3.1.4 There is insufficient evidence to recommend the routine useof the Morningness-Eveningness Questionnaire (MEQ) for theclinical evaluation of CRSDs. (Option)Information regarding evidence for utility of MEQ in specificCRSDs is discussed under the disorder headings in the sectionbelow.3.1.5 Circadian phase markers are useful to determine circadianphase and confirm the diagnosis of FRD in sighted and unsightedpatients but there is insufficient evidence to recommend their routineuse in the diagnosis of SWD, JLD, ASPD, DSPD, or ISWR. (Option)Information regarding evidence for specific CRSDs is discussedunder the disorder headings in the section below.3.1.1 Use of a sleep log or diary is indicated in the assessment ofpatients with a suspected CRSD. (Guideline)This recommendation was determined by inclusion of the useof sleep logs in the International Classification of Sleep Disorders,2 nd Edition (ICSD-2) 5 diagnostic criteria for all CRSDs exceptjet lag. This recommendation was additionally supported byconsensus opinion of the AASM SPC committee.3.1.2 Actigraphy is indicated to assist in evaluation of patientssuspected of CRSDs, including irregular sleep-wake disorder(ISWR), free-running disorder (FRD) (with or without blindness)(Option), and in advanced sleep phase disorder (ASPD), delayedsleep phase disorder (DSPD), and shift work disorder (SWD).(Guideline)This recommendation reiterates the recently updated practice parameterpaper on the use of actigraphy. 6 Here, we indicate specificdisorders. There is generally good agreement among studies showingthat actigraphy data correlate with polysomnography (whenused), sleep logs, and markers of circadian phase in patients withcircadian rhythm sleep disorders, with the conditions indicated.3.1.3 Actigraphy is useful as an outcome measure in evaluatingthe response to treatment for CRSDs. (Guideline)SLEEP, Vol. 30, No. 11, 2007 14473.1.6 Polysomnography is indicated to rule out another primarysleep disorder in patients with symptoms suggestive of both aCRSD and another primary sleep disorder, but is not routinelyindicated for the diagnosis of CRSDs. (Standard)This recommendation reiterates the recently updated practiceparameter paper on the indications for polysomnography andrelated procedures. 10 Polysomnography may be indicated whenconsidering a diagnosis of a CRSD to exclude other potentialcauses for sleep related complaints. For example, shift workerswith hypersomnia may have both suspected obstructive sleepapnea and clinical characteristics consistent with shift work disorder.In this event, PSG is indicated to evaluate and establishappropriate therapy for OSA.3.2 Recommendations for Evaluation and Treatments of CircadianRhythm Sleep Disorders3.2.1 Shift Work DisorderShift work refers to non-standard work schedules, includingpermanent or intermittent night work, early morning work, androtating schedules. An estimated 20% of U.S. workers are involvedin some form of shift work. The percentage of workerswho meet criteria for the diagnosis of shift work disorder (SWD)(i.e., development of sleep disturbances and impairment of wakingalertness and performance) is unclear, and there appear tobe individual differences in susceptibility to SWD (phase tolerance).Practice Parameters for the Clinical Evaluation of CRSD—Morgenthaler et al
Table 3— Summary of RecommendationsEvaluation ToolsShift WorkDisorderJet LagDisorderAdvanced SleepPhase DisorderDelayed SleepPhase DisorderFree RunningDisorderIrregular Sleep-Wake RhythmPolysomnographyNot RoutinelyIndicated(Standard)Not RoutinelyIndicated(Standard)Not RoutinelyIndicated(Standard)Not RoutinelyIndicated(Standard)Not RoutinelyIndicated(Standard)Not RoutinelyIndicated(Standard)Morningness-EveningnessQuestionnaire(MEQ)Insufficientevidence torecommend(Option)Insufficientevidence torecommend(Option)Insufficientevidence torecommend(Option)Insufficientevidence torecommend(Option)Insufficientevidence torecommend(Option)Insufficientevidence torecommend(Option)Circadian phasemarkersInsufficientevidence torecommend(Option)Insufficientevidence torecommend(Option)Insufficientevidence torecommend(Option)Insufficientevidence torecommend(Option)Indicated(Option)Insufficientevidence torecommend(Option)Actigraphy fordiagnosisIndicated(Option)Not routinelyindicated(Option)Indicated(Guideline)Indicated(Guideline)Indicated(Option)Indicated(Option)Actigraphy forresponse totherapyIndicated(Guideline)Indicated(Guideline)Indicated(Guideline)Indicated(Guideline)Indicated(Guideline)Indicated(Guideline)Sleep log ordiaryIndicated(Guideline)Indicated(Guideline)Indicated(Guideline)Indicated(Guideline)Indicated(Guideline)Indicated(Guideline)TherapyPlanned SleepSchedulesIndicated(Standard)Indicated(Option)Indicated(Option)Indicated(Option)Indicated(Option)Mixed modalityindicated (Option/Guideline)*Timed LightExposureIndicated(Guideline)Indicated(Option)Indicated(Option)Indicated(Guideline)Indicated(Option)Indicated(Option)Timed MelatoninAdministrationIndicated(Guideline)Indicated(Standard)Indicated(Option)Indicated(Guideline)Indicated Sighted(Option)Indicated Unsighted(Guideline)Indicatedfor certainpopulation #(Option)HypnoticsIndicated(Guideline)Indicated(Option)- Not Recommended(Option)- -StimulantsIndicated Caff(Option)Indicated(Option)- - - -Alerting Agents 9Indicated(Guideline)- - - - -* Mixed modality therapy may be effective in elderly-demented/Nursing Home ISWR patients (Guideline) or those with moderate to severe mentalretardation (Option)#Timed melatonin may be effective in those with moderate to severe mental retardation, but is not recommended at present for elderly-demented/Nursing Home patients (Option)Caff = caffeine; Sighted=sighted persons; Unsighted=unsighted persons; - = no recommendation formulated due to lack of evidence.SLEEP, Vol. 30, No. 11, 2007 1448Practice Parameters for the Clinical Evaluation of CRSD—Morgenthaler et al
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