This evidence review has been updated regularly with searches of the MEDLINE database. The most recent literature review was performed through May 07, 2024.
HYPERSOMNIAS, PARASOMNIAS, AND SLEEP-RELATED MOVEMENT
Hypersomnias
Evidence reviewed by AASM included a data review of 1602 patients, of which 176 patients had narcolepsy and 1426 had other sleep disorders (Chesson, 1997). In patients with clinical narcolepsy, 2 or more sleep-onset rapid eye movement (REM) periods (SOREMS) had a sensitivity of 41% and predictive value of 57%. The presence of 3 or more SOREMS had a sensitivity of 41% and specificity of 98.8%. However, 7% of obstructive sleep apnea patients and 5% of other sleep disorders patients had 2 SOREMs on MSLT, leading to a low predictive value for narcolepsy. No body of data was found that validated the maintenance of wakefulness test (which measures the patient’s ability to stay awake in a quiet sleep-inducing environment), limited or partial PSG, portable recording, isolated multiple sleep latency test (MSLT), or separately performed polysomnography (PSG) and MSLT as an alternative to the “gold standard” of nocturnal PSG with an MSLT on the following day for the diagnosis of narcolepsy. The 2005 evidence review found that the presence of 2 or more early sleep onset latency episodes was associated with a sensitivity of 0.78 and specificity of 0.93 for the diagnosis of narcolepsy.1 Based on the evidence reviewed, the updated 2005 AASM guidelines indicated that PSG is used to rule out other potential causes of sleepiness followed by an MSLT to confirm the clinical impression of narcolepsy. These tests assume greater significance if cataplexy is lacking. In the absence of cataplexy and when there is 1 or more of the other symptoms, the laboratory criteria are required to establish the diagnosis of narcolepsy.
Parasomnias
Typical or Benign Parasomnia
Evidence reviewed by AASM in 1997 indicated that typical sleepwalking or sleep terrors, with onset in childhood, a positive family history, occurrence during the first third of the night, amnesia for the events, prompt return to sleep following the events, and relatively benign automatistic behaviors, may be diagnosed on the basis of their historic clinical features (Chesson, 1997). This conclusion was based on very consistent descriptive literature (case series and cohort studies).
Violent or Potentially Injurious Parasomnia
When events are not typical of benign partial arousals and where other diagnoses, prognoses, and interventions should be considered, PSG was recommended by Chesson et al (1997), and supported by AASM. The evidence reviewed in 1997 included only 3 articles on disorders of arousal and 2 for REM sleep behavior disorder (RBD) that included comparison data for normal controls. Most articles supporting the utility of PSG were limited by biases inherent in uncontrolled clinical reports. The need for PSG was also indicated in a 2011 review of parasomnias that concluded that although RBD is the only parasomnia that requires PSG for diagnosis, PSG may be needed to rule out another sleep pathology, such as sleep-disordered breathing or periodic limb movements (PLMs) of sleep, that might cause a parasomnia (Goldstein, 2011). Evidence reviewed in a 2010 AASM Best Practice Guide indicates that sleep-related injuries are a significant portion of the morbidity in RBD, with a prevalence in diagnosed RBD patients ranging from 30% to 81% (Aurora, 2010). Types of injuries ranged from ecchymoses and lacerations to fractures and subdural hematomas, with ecchymoses and lacerations being significantly more common than fractures.
In a series of 92 patients, 64% of the bed partners sustained punches, kicks, attempted strangulation, and assault with objects. Minimal diagnostic criteria for RBD requires the presence of REM sleep without atonia, defined as sustained or intermittent elevation of submental electromyogram (EMG) tone or excessive phasic muscle activity in the limb EMG (Aurora, 2010). Two clinical series with over 100 patients each with various parasomnias found that PSG had an overall diagnostic yield in 65% and 91% of cases. Results from a more recent retrospective observational study of video PSG (vPSG) were similar, finding that among a cohort of 516 patients with suspected non-REM parasomnias, 65% had vPSG findings consistent with a clinical diagnosis of parasomnia (Drakatos et al, 2019). A systematic review on the diagnosis of RBD found that diagnostic accuracy is increased with the combined use of clinical history and video PSG to document the intermittent or sustained loss of muscle atonia or actual observation of RBD occurrences (Neikrug,2012).
In a series of 92 patients, 64% of the bed partners sustained punches, kicks, attempted strangulation, and assault with objects. Minimal diagnostic criteria for RBD requires the presence of REM sleep without atonia, defined as sustained or intermittent elevation of submental electromyogram (EMG) tone or excessive phasic muscle activity in the limb EMG (Aurora, 2010). Two clinical series with over 100 patients each with various parasomnias found that PSG had an overall diagnostic yield in 65% and 91% of cases. Results from a more recent retrospective observational study of video PSG (vPSG) were similar, finding that among a cohort of 516 patients with suspected non-REM parasomnias, 65% had vPSG findings consistent with a clinical diagnosis of parasomnia (Drakatos et al, 2019). A systematic review on the diagnosis of RBD found that diagnostic accuracy is increased with the combined use of clinical history and video PSG to document the intermittent or sustained loss of muscle atonia or actual observation of RBD
Sleep-Related Movement Disorder
Restless Legs Syndrome
The 4 cardinal diagnostic features of restless legs syndrome (RLS) include (1) an urge to move the limbs that is usually associated with paresthesias or dysesthesias, (2) symptoms that start or become worse with rest, (3) at least partial relief of symptoms with physical activity, and (4) worsening of symptoms in the evening or at night (Aurora, 2012). Evidence reviewed by AASM included a case control study which found that compared with controls, RLS patients had reduced total sleep time, reduced sleep efficiency, prolonged sleep latencies, decreased slow-wave sleep, and increased nocturnal awakening. However, because the principal symptoms of RLS occur during wake, RLS does not require PSG for diagnosis, except where uncertainty exists in the diagnosis (Kushida, 2005; Chesson, 1997). RLS frequently also has a primary motor symptom that is characterized by the occurrence of PLMs in sleep. The literature indicates that PLMs are best recorded with PSG from the anterior tibialis muscles (Chesson, 1997). PLMs occur in approximately 80% to 90% of patients who have RLS and support the diagnosis of RLS. In cases where there are frequent PLMs during PSG and a subjective perception of poor sleep in the absence of RLS or sleep-related breathing disorder, periodic limb movement disorder (PLMD) can be diagnosed (Aurora, 2012).
Periodic Limb Movement Disorder (PLMD)
PLMD can be diagnosed in the following cases: during PSG; during a subjective perception of poor sleep in the absence of RLS; or during a sleep-related breathing disorder (Aurora, 2010).
Evidence reviewed by AASM showed difficulty in diagnosing PLMD without PSG (Chesson, 1997). In a series of 123 patients evaluated for chronic insomnia, a PLMD diagnosis was confirmed in 5 patients and discovered with PSG in another 10 patients. The PLMD scale from a sleep questionnaire had low sensitivity and specificity. Actigraphy, evoked potentials, and blink reflexes have been found to have little diagnostic specificity or utility. PSG-based diagnosis of PLMD correlated best with frequent awakening at night. In a series of 1171 patients who had PSG at 1 sleep disorders center, 67 patients (6%) had PLMD as the primary and sole sleep diagnosis. The mean sleep efficiency was 53% and daytime sleepiness was reported by 60% of the cohort. The PLMD patients reported disturbed sleep during a mean of 4 nights per week for a mean of 7 years.
SUMMARY OF EVIDENCE
Hypersomnia
For individuals who have suspected hypersomnia who receive PSG, the evidence includes a systematic review on diagnostic accuracy. Relevant outcomes are test accuracy, symptoms, functional outcomes, and quality of life. The evidence has suggested that PSG followed by the multiple sleep latency test is associated with moderate sensitivity and high specificity in support of the diagnosis of narcolepsy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
Parasomnias
For individuals who have typical or benign parasomnia who receive PSG, the evidence includes systematic reviews of studies on diagnostic accuracy and controlled cohort studies. Relevant outcomes are test accuracy, symptoms, functional outcomes, and quality of life. The evidence has suggested that typical and benign parasomnias (eg, sleepwalking, sleep terrors) may be diagnosed on the basis of their clinical features and do not require PSG. The evidence is sufficient to determine that the technology is unlikely to improve the net health outcome.
For individuals who have violent or potentially injurious parasomnia who receive PSG, the evidence includes systematic reviews of studies on diagnostic accuracy and controlled cohort studies. Relevant outcomes are test accuracy, symptoms, functional outcomes, and quality of life. For the diagnosis of REM sleep behavior disorder, the combined use of clinical history and PSG to document the loss of muscle atonia during REM sleep increases diagnostic accuracy and is considered the criterion standard for diagnosis. Diagnostic accuracy is increased with videorecording during PSG to assess parasomnias such as REM sleep behavior disorder. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
Sleep-Related Movement Disorders
For individuals who have restless legs syndrome who receive PSG, the evidence includes systematic reviews of studies on diagnostic accuracy and controlled cohort studies. Relevant outcomes are test accuracy, symptoms, functional outcomes, and quality of life. Restless legs syndrome does not require PSG because the syndrome is a sensorimotor disorder, the symptoms of which occur predominantly when awake; therefore, PSG results are generally not useful. The evidence is sufficient to determine that the technology is unlikely to improve the net health outcome.
For individuals who have periodic limb movement disorder who receive PSG, the evidence includes a systematic review. Relevant outcomes are test accuracy, symptoms, functional outcomes, and quality of life. PSG with electromyography of the anterior tibialis is the only method available to diagnose periodic limb movement disorder, but this sleep-related movement disorder is rare and should only be evaluated using PSG in the absence of symptoms of other disorders. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov did not identify any ongoing or unpublished trials that would likely influence
this review.
PRACTICE GUIDELINES AND POSITION STATEMENTS
American Academy of Sleep Medicine (AASM)
In 2005, the American Academy of Sleep Medicine (AASM) published practice parameters for the indications for polysomnography and related procedures (Kushida, 2005). AASM made the following recommendations on the use of PSG for nonrespiratory indications:
- PSG and a MSLT performed on the day after the PSG are routinely indicated in the evaluation of suspected narcolepsy. (STANDARD)
- Common, uncomplicated, noninjurious parasomnias, such as typical disorders of arousal, nightmares, enuresis, sleeptalking, and bruxism, can usually be diagnosed by clinical evaluation alone. (STANDARD)
- PSG is not routinely indicated in cases of typical, uncomplicated, and non-injurious parasomnias when the diagnosis is clearly delineated. (OPTION)
- A clinical history, neurologic examination, and a routine EEG obtained while the patients is awake and asleep are often sufficient to establish the diagnosis and permit the appropriate treatment of a sleep related seizure disorder. The need for a routine EEG should be based on clinical judgment and the likelihood that the patient has a sleep relate seizure disorder. (OPTION)
- PSG is not routinely indicated for patients with a seizure disorder who have no specific complaints consistent with a sleep disorder. (OPTION)
- PSG is indicated when evaluating patients with sleep behaviors suggestive of parasomnias that are unusual or atypical because of the patient’s age at onset; the time, duration or frequency of occurrence of the behavior; or the specifics of the particular motor patterns in question. (GUIDELINE)
PSG is indicated as an OPTION in the following situations:
- Evaluating sleep related behaviors that are violent or otherwise potentially injurious to the patient or others.
- In situations with forensic considerations (e.g., if onset follows trauma or if the events themselves have been associated with personal injury).
- When the presumed parasomnia or sleep related seizure disorder does not respond to conventional therapy.
- PSG is indicated when a diagnosis of PLMD is considered because of complaints by the patient or an observer of repetitive limb movement during sleep and frequent awakenings, fragmented sleep, difficulty maintaining sleep, or excessive daytime sleepiness. (STANDARD)
- Intra-individual night-to-night variability exists in patients with periodic limb movement sleep disorder, and a single study might not be adequate to establish this diagnosis. (OPTION)
- PSG is not routinely indicated to diagnose or treat restless legs syndrome, except where uncertainty exists in the diagnosis. (STANDARD)
PSG is not routinely indicated for the diagnosis of circadian rhythm sleep disorders. (STANDARD)
In 2017, AASM updated its practice parameters on PSG (Kapur, 2017). The update made few recommendation changes to this review. For narcolepsy, the guidelines note that a clinical history, sleep diaries, PSG, and a MSLT are key items in the evaluation of the disorder.
In 2012, AASM published practice parameters for the nonrespiratory indications for PSG and multiple sleep latency testing in children (Aurora, 2012).
The following recommendations for PSG and MSLT were made:
- PSG is indicated for children suspected of having periodic limb movement disorder (PLMD) for diagnosing PLMD. (STANDARD)
- The MSLT, preceded by nocturnal PSG, is indicated in children as part of the evaluation for suspected narcolepsy. (STANDARD)
- Children with frequent NREM [non•rapid eye movement] parasomnias, epilepsy, or nocturna enuresis should be clinically screened for the presence of comorbid sleep disorders and polysomnography should be performed if there is a suspicion for sleep-disordered breathing or periodic limb movement disorder. (GUIDELINE)
- The MSLT, preceded by nocturnal PSG, is indicated in children suspected of having hypersomnia from causes other than narcolepsy to assess excessive sleepiness and to aid in differentiation from narcolepsy. (OPTION)
- The polysomnogram using an expanded EEG montage is indicated in children to confirm the diagnosis of an atypical or potentially injurious parasomnia or differentiate a parasomnia from sleep-related epilepsy (OPTION)
- Polysomnography is indicated in children suspected of having restless legs syndrome (RLS) who require supportive data for diagnosing RLS. (OPTION)
Recommendations against PSG use:
- Polysomnography is not routinely indicated for evaluation of children with sleep-related bruxism. (STANDARD)
AASM issued a 2012 practice parameter on the treatment of RLS and PLMD in adults (Aurora, 2012). The practice parameter states many different treatment efficacy measures are used to assess RLS due to the multifaceted nature of RLS. Measures include both subjective and objective assessments including a number of various subjective scales. The only objective measurements are sleep-related parameters by PSG or actigraphy.
AASM issued a 2010 Best Practice Guide on the treatment of nightmare disorders in adults (classified as a parasomnia) (Aurora, 2010). AASM states the overnight PSG is not routinely used to assess nightmare disorder but may be used to exclude other parasomnias or sleep-disordered breathing. PSG may underestimate the incidence and frequency of posttraumatic stress disorder-associated nightmares. In 2018, the AASM updated its position paper, however there was no mention of PSG (Morgenthaler et al, 2018).
AASM (2023) issued best practice guide on the treatment of rapid eye movement (REM) sleep behavior disorder (RBD) (Howell et al, 2023). All forms of RBD (primary, secondary, and drug-induced) are defined in the guideline as emergence of dream enactment with a documented elevation in REM sleep motor tone on PSG. In patients with secondary RBG, these findings occur in the context of an underlying disorder, and in patients with drug-induced RBD, they occur after starting or increasing the dose of a serotonergic medication. PSG was mentioned in the context of treatment selection, since pramipexole was noted to be most effective among patients with periodic limb movements seen on PSG.
International RBD Study Group
The Neurophysiology Working Group of the International RBD Study Group (IRBDSG) (Cesari et al, 2022) issued guidelines on video PSG procedures for the diagnosis of RBD. The working group states that video PSG "is mandatory to diagnose RBD, following technical requirements for sleep recording described in Technical Requirements for v-PSG Recording section and scoring REM sleep as described in REM Sleep Scoring section and in the AASM manual". The group also states that video PSG is mandatory to identify prodromal RBD.
U.S. Preventive Services Task Force Recommendations
Not applicable.
Regulatory Status
A large number of polysomnography devices have been approved since 1986. U.S. Food and Drug Administration product code: OLV.