Gregg Marshall, PhD, RRT, RPSGT
Chair/Associate Professor
College of Health Professions
Department of Respiratory Care
Texas State University-San Marcos
San Marcos, TX
TSSP Sleep Conference
The role of
actigraphy in sleep
assessment and
TSSP Sleep Conference
• No conflict of interest with industry or
grant funding agencies that may be
characterized as financial, real, or
perceived as real with regards to the
following information.
Disclosure Statement…..
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• 1) Describe the fundamental basics of
actigraphy devices
• 2) Discuss the value of actigraphy as a
prescreening device for sleep disorders
• 3) Describe current clinical
applications of the use of actigraphy
• 4) Discuss the potential role of
actigraphy within sleep labs/centers
Learning Objectives
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• Small, non-invasive, watch-like device that is
wrist worn and contains an accelerometer to
monitor the number of wrist movements per
epoch (ie: 30 or 60 sec)
• Electronic device consisting of
• Piezoelectric accelerometer (velocity, gforce)….and there’s an APP for that!
• Low-pass filter (filtering out all but 2-3 Hz
band to eliminate external vibrations)
• Start/stop timer to allow accumulating
• Memory to store data
• Interface (USB) to program device and
download data from memory
Q1:How does actigraphy work?
TSSP Sleep Conference
• Continuously measures movement and
ambient light over time
• Light sensor recalls all levels of light
• Various models offer features that may
provide additional movement/light
• Depending on the model, activity is
recorded in various ways according to
each unique algorithm for estimating
sleep/wake measures
Actigraphy basics….
TSSP Sleep Conference
Actigraphy watches
TSSP Sleep Conference
• Scoring algorithms are used to identify
sleep or wake states from activity counts
to identify sleep parameters
• Time In Bed
• Total Sleep Time (TST)
• Wake After Sleep Onset (WASO)
• Sleep Efficiency (TST/Total Time In
• Wake Bouts
• Sleep Onset Latency (SOL)
Q2: What sleep values can
actigraphy provide?
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• Actigraphy cannot address
• Sleep staging
• Snoring
• Apnea/hypopnea
• SpO2 desaturation
• HR, RR, body position
• Thoracic/abdominal effort
What’s missing?
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• nPSG is the gold standard for measuring
sleep, however wrist actigraphy may
provide sleep/wake information that can
supplement PSG testing or be used to prescreen some patients
• Previous studies (Paquet, 2007; Sadeh,
2002; Johnson, 2007) have suggested a
wide range of findings from “less than
useful” to “reasonable good estimate” of
sleep disorders
Q3: What are the clinical
applications for actigraphy?
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• The AASM Update for 2007 concluded
the use of actigraphy in assessing and
managing of sleep disorders has allowed
the development of evidence-based
recommendations for the use of
actigraphy in the clinical setting
• After a review of literature/research
regarding actigraphy, AASM’s SPC and
BOD made ten specific recommendations
for the use of actigraphy in clinical
AASM’s Standards of Practice
Committee findings….
TSSP Sleep Conference
• 1) Valid way to assist in determining
sleep patterns in normal, health adult
populations and in patients suspected
of certain sleep disorders
• 2) Indicated to assist evaluation of
patients with ASPS, DSPS, shift work
sleep disorder, circadian rhythm
disorders, jet lag, & non-24-hour
sleep/wake syndrome (including
associated with blindness)
AASM recommendations
TSSP Sleep Conference
• 3) When nPSG not available, actigraphy is
indicated as method to estimate TST in
patients with OSA and may improve
accuracy of assessing severity of OSA
• 4) Indicated as a method to characterize
circadian rhythm patterns or insomnia
(including association with depression)
• 5) Indicated to determine circadian
pattern and estimate average daily sleep
time in hypersomnia
AASM recommendations
TSSP Sleep Conference
• 6) Useful outcome measure in
evaluating response to treatment for
circadian rhythm disorders
• 7) Useful to evaluate response to
treatment of insomnia
• 8) Useful to characterize/monitor sleep
and circadian rhythm patterns and
document treatment outcomes among
older adults living in community
AASM recommendations
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• 9) Indicated for characterizing and
monitoring sleep/circadian rhythm
patterns and document treatment
outcomes among older nursing home
residents in whom traditional nPSG
assessment is difficult
• 10) Indicated for delineating sleep
patterns/document treatment responses
in normal infants, children and special
pediatric populations in whom traditional
nPSG is difficult to perform or interpret
AASM recommendations
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• Finally, additional research warranted
to further refine and broaden the
clinical value of actigraphy to assess
sleep and sleep disorders
• Six specific recommendations for
future actigraphy-focused research
AASM recommendations
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• Longitudinal look at sleep
characteristics rather than a “snapshot” provided by nPSG study
• Helpful with documenting actual sleep
patterns for some dyssomnias,
parasomnias, and medical/psychiatric
conditions (psychoses, mood disorders,
panic, alcoholism)
• Sleep history “at a glance”
Q4: How can actigraphy be
used in sleep labs/center?
13 days
Tracking 24 hours
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Sleep Cycle
21 days
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14 days
TSSP Sleep Conference
14 days
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2 Blackwell
T, et al. (2011). Factors that May Influence the Classification of Sleep-Wake by Wrist Actigraphy:
The MrOS Sleep Study. Journal of Clinical Sleep Medicine, 7(4), 357-367.
TSSP Sleep Conference
• Recent study2 in Journal of Clinical Sleep
Medicine (Aug 2011) documents strong
correlation between wrist actigraphy & home
Compumedics Safiro Unit (12 channel)
• N = 3135 men
• N = 896 with concurrent PSG/actigraphy
• Number of sleep related characteristics had
a significant impact on the accuracy of
actigraphy & should be considered when
using actigraphy to screen sleep disorders
Actigraphy & home nPSG
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• CPT Code #95803 “Actigraphy testing, recording,
analysis, interpretation, and report (minimum of
72 hours to 14 consecutive days of recording.”
• $162.41 without geographic adjustments
• Related CPT codes: 99203, 99211, 99245, 99070
• Medicare not covering, BCBS views as
experiment/investigational so not covered
• Some providers are covering the CPT
• Kelly A. Carden MD, ([email protected])
Chair of AASM Coding & Compliance Committee
managing reimbursement, asks if actigraphy CPT
submissions are being denied that she be contacted
with the information so she can use it to try and
reverse trend
Actigraphy & CPT codes
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• How can we use actigraphy to assess
patient groups that will not easily be
assessed in sleep labs/center?
• How can we begin to turn the tide of
reimbursable diagnostics to include
more options?
• Research remains our best tool to bring
about change in the profession
Actigraphy Sleep Research
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• 2nd largest cohort of veteran
men/women returning from war
theater in the state
• Over 1700 men/women returning after
• Surveyed in over 20 items of needs
specific to returning veteran college
• Greatest need/complaint?
Texas State University
Veteran vs non-Veteran
Student Pilot Sleep Study
• N = 20 (10 Veteran and 10 non-Veteran
TxState students
• Wore Actiwatch2 for 7 days/nights
• Measured
• 1) Time in Bed
• 2) Total Sleep Time
• 3) Sleep Onset Latency
• 4) Sleep Efficiency
• 5) Time Wake After Sleep Onset (WASO)
• 6) # Wake Bouts
Vet/non-Vet Sleep Pilot
• Although both groups spend about the same
amount of time in bed and woke up about the
same number of times per night, differences with
veteran students experiencing
• 1)  Total Sleep Time
• 2)  Sleep Efficiency
• 3)  Sleep Latency
• 4)  WASO
• Each of these issues impact academic success and
quality of emotions and mental health
TSSP Sleep Conference
• Actigraphy has demonstrated a reasonable
reliability as an sleep diagnostic/assessment
device for some patient demographic groups
• Studies comparing actigraphy outcomes to
nPSG diagnostics seem overall positive
• Although reimbursement issues are a current
barrier preventing more utilization, changes in
coverage may be in the future
• Sleep labs/centers may find actigraphy useful
in tracking longitudinal sleep information that
may be missed by a one-night nPSG study
The future….
Johnson, N., Kirchner, L., Rosen, C., Storfer-Isser, A., Cartar, L., Ancoli-Israel, S.,
Emancipator, J., Kibler, A., Redline, S. (2007). Sleep Estimation Using Wrist
Actigraphy in Adolescents With and Without Sleep Disordered Breathing: A
Comparisoin of Three Data Modes. SLEEP, 30(7), 899-905.
Morgenthaler, T., Alessi, C., Friedman, L., Owens, J., Kapur, V., Boehlecke, B., Brown, T.,
Chesson, A., Coleman, J., Lee-Chiong, T.,Pancer, J., Swick, T. (2007). Practice
Parameters for the Use of Actigraphy in the Assessment of Sleep and Sleep Disorders:
An Update for 2007. Sleep, 30(4), 519-529.
Paquet, J., Kawinska, A., Carrier, J. (2007). Wake Detection Capacity of Actigraphy During
Sleep. SLEEP, 30(10), 1362-1369.
Sadeh, A., Acebo,C. (2002). The role of actigraphy in sleep medicine. Sleep Medicine
Reviews, 6(2), 113-124.
TSSP Sleep Conference
Blackwell, T., Ancoli-Israel, S., Redline, S., Stone, K. (2011). Factors that May Influence the
Classification of Sleep-Wake by Wrist Actigraphy: The MrOS Sleep Study. Journal of
Clinical Sleep Medicine, 7(4), 357-375.

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