Clinical ReviewThe role and validity of actigraphy in sleep medicine: An update
Introduction
Over the last two decades actigraphy has become a major assessment tool in sleep research and sleep medicine. The rate of relative growth in number of scientific publications that include actigraphy (see Fig. 1) exceeds the rate of growth in publications that include polysomnography (PSG) (from an actigraphy-PSG ratio of about 1:10 in 1991 to a ratio of about 1:4 in 2009). This increase reflects the growing appeal of actigraphy to clinicians and researchers in sleep medicine. Earlier reviews and guidelines introduced by the American Sleep Disorders Association (ASDA) have established the use of actigraphy as a reliable and valid sleep assessment method in specific domains of sleep research and sleep medicine.1, 2, 3, 4, 5, 6 The current review is an update based on the literature published after the previous review published in 2002 in Sleep Medicine Reviews.6 It is based on a literature search that included Pubmed, Social and Science Citation Index databases and covers only articles published in peer-reviewed journals (excluding meeting abstracts or proceedings). Because of the large number of papers published each year, this review covers only papers that address methodological issues related to the use of actigraphy in sleep medicine and those that are directly related to clinical applications in sleep medicine. Thus, dozens of papers, addressing the use of actigraphy in assessing sleep in specific conditions or populations were not included.
Actigraphy is based on small wrist-watch like devices that monitor movements for extended periods of time. The raw activity scores (e.g., in 1-min epochs) are translated to sleep-wake scores based on computerized scoring algorithms. There are different commercial devices in the market and each device has its own measurement characteristics and therefore requires appropriate sleep-wake scoring algorithms and validation studies. To avoid commercial pitfalls, this review will not address specific devices or comparisons, but the readers are strongly advised to consider the presented issues and their relevance to the specific device they are using or planning to use.
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Reliability and validity issues
The strengths and limitations of actigraphy in sleep assessment have been repeatedly outlined.1, 2, 3, 4, 5, 6 In this section, additional information is provided with regard to the main established topics and some new ones.
Assessment of insomnia
The role of actigraphy in the evaluation of insomnia has been documented in earlier reports.1, 2, 3, 41 The main consistent conclusion has been that actigraphy overestimates sleep time (as manifested in shorter SOL and WASO) because of efforts of individuals with insomnia to fall asleep by lying in bed motionless for extended periods. New studies have replicated, challenged and extended these earlier reports.
Lichstein et al.42 conducted a PSG-Actigraphy validation study, based on one laboratory
Assessment of non-pharmacologic interventions for insomnia
Recent studies on insomnia treatment have replicated earlier findings and demonstrated that actigraphy is sensitive to intervention effects as reflected in improvement of actigraphic sleep measures.43, 44, 66, 67 For instance, Sivertsen et al.44 reported that actigraphy detected the changes in total sleep time and WASO, but failed to detect the PSG-identified improvement in SOL and SE. The authors concluded that the clinical utility of actigraphy in older adults with insomnia is still
Conclusions and recommendations
The following conclusions can be derived from this review:
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In comparison to PSG, actigraphy has reasonable validity and reliability in assessing sleep-wake patterns in normal individuals with average or good sleep quality.
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The validity of actigraphy in special populations (e.g., elderly people, individuals with other major health problems or individuals with poor sleep quality) is more questionable.
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The main methodological problem associated with the validity of actigraphic sleep-wake scoring is
Conflict of interests
The author has no conflict of interests to disclose.
Acknowledgement
I thank Liat Tikotzky for her helpful review and comments.
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