The WASM Sleep Medicine Curriculum 1.2 may be viewed below or
downloaded by clicking here. This curriculum was prepared
by Max Hirshkiowitz, chair of the Education Committee, with assistance from the
Governing Council Members and Education Committee of the World Association of
Sleep Medicine (WASM).
Goals:
The WASM Curriculum provides a road map for training
sleep specialists. It serves as a
partner with content-specific educational material that will ultimately be
posted on the WASM website. The
overarching of the WASM Curriculum and its associated content-specific
educational material is to provide training opportunities for individuals to
learn and understand sleep medicine's history, underlying science, assessment
techniques, diagnostic nosology, and standards of practice. Upon completion of
content outline here, the individual should be able to.
1. Relate
how information from basic science underlie sleep mechanisms
2. Conduct
a clinical sleep assessment that integrates sleep history, sleep problems,
related medical problems, and relevant medications.
3. Recognize
and differentiate sleep-related breathing disorders
4. Recognize
and differentiate different types of insomnia
5. Recognize
and differentiate narcolepsy from different types of hypersomnia.
6. Recognize
and differentiate different types of movement events
7. Recognize
and differentiate different parasomnia
8. Recognize
and differentiate pediatric sleep disorders.
9. Realize
the array of sleep procedures and techniques needed for your individual
practice, patient care, and research
10. Conduct
polysomnography and related technical procedures
11. Conduct
and interpret home sleep testing
12. Differentiate
PSG tracings of wakefulness from sleep, REM from NREM sleep, & N2 from N3
13. Recognize
CNS arousals from sleep
14. Recognize
and differentiate different types of respiratory events
15. Determine
optimal positive airway pressure from a titration sleep study
16. Classify
sleep disorders according to standardized nosology
17. Derive
a well-reasoned differential diagnosis.
18. Describe
pharmacological treatment of different sleep disorder, including knowledge
about adverse effects of different treatments
19. Describe
behavioral and cognitive behavioral treatment methods for sleep disorders
20. Prepare
a final report that includes sleep history, diagnosis, polysomnographic (and/or
other technical procedure) interpretation, and treatment recommendations
This updated document was developed using materials
contributed and gathered from a variety of sources. It is designed to be in
general accordance with ACGME guidelines and current standards of practice. As
a practical matter, we constructed this outline to provide the framework for
developing content-specific materials. These content-specific materials will
populate the WASM educational website to provide high-quality information
concerning sleep medicine, worldwide. A
prioritized topic listings and a guidebook for preparing content-specific
material will be forthcoming. This document represents the efforts of many
individuals whose help was greatly appreciated.
WASM Sleep Medicine Curriculum 1.2
October
20, 2012
Prepared by
Max Hirshkowitz with assistance from the
Governing
Council Members and Education Committee
World
Association of Sleep Medicine (WASM)
For general
distribution and posting on WASM Website
Comments & Instructions: This updated document was developed using materials
contributed and gathered from a variety of sources. It is designed to be in
general accordance with ACGME guidelines and current standards of practice. As
a practical matter, we constructed this outline to provide the framework for developing
content-specific materials. These content-specific materials will populate the
WASM educational website to provide high-quality information concerning sleep
medicine, worldwide. A prioritized topic
listings and a guidebook for preparing content-specific material will be
forthcoming. This document represents the efforts of many individuals whose
help was greatly appreciated.
Table of Contents
General Overview ………………………………………………………………….……….. 3
Curriculum Topics ………………………….. Basic Science………………................ 4
…………………………………………….……. Applied Technology…….…..…..…….. 5
………………………………………………….. Sleep Medicine……….………………… 6
………………………………………………….. Clinical and Laboratory Assessment 8
Proposed Presentation Topics……………. Basic Science……………….………….. 10
………………………………………………….. Technology and Technique…………... 10
………………………………………………….. Sleep Disorders………………………… 10
………………………………………………….. Pediatric Sleep Medicine……………... 11
………………………………………………….. Special topics…………………………… 11
Reading Material Listing ……………………………………………………………………… 13
General
Overview
Goals:
The WASM Curriculum provides a road map for training sleep
specialists. It
serves as a partner with content-specific educational material that will
ultimately be posted on the WASM website.
The overarching of the WASM Curriculum and its associated
content-specific educational material is to provide training opportunities for
individuals to learn and understand sleep medicine’s history, underlying science,
assessment techniques, diagnostic nosology, and standards of practice. Upon
completion of content outline here, the individual should be able to…
1. Relate
how information from basic science underlie sleep mechanisms
2. Conduct
a clinical sleep assessment that integrates sleep history, sleep problems,
related medical problems, and relevant medications.
3. Recognize
and differentiate sleep-related breathing disorders
4. Recognize
and differentiate different types of insomnia
5. Recognize
and differentiate narcolepsy from different types of hypersomnia.
6. Recognize
and differentiate different types of movement events
7. Recognize
and differentiate different parasomnia
8. Recognize
and differentiate pediatric sleep disorders.
9. Realize
the array of sleep procedures and techniques needed for your individual
practice, patient care, and research
10. Conduct
polysomnography and related technical procedures
11. Conduct
and interpret home sleep testing
12. Differentiate
PSG tracings of wakefulness from sleep, REM from NREM sleep, & N2 from N3
13. Recognize
CNS arousals from sleep
14. Recognize
and differentiate different types of respiratory events
15. Determine
optimal positive airway pressure from a titration sleep study
16. Classify
sleep disorders according to standardized nosology
17. Derive
a well-reasoned differential diagnosis.
18. Describe
pharmacological treatment of different sleep disorder, including knowledge
about adverse effects of different treatments
19. Describe
behavioral and cognitive behavioral treatment methods for sleep disorders
20. Prepare
a final report that includes sleep history, diagnosis, polysomnographic (and/or
other technical procedure) interpretation, and treatment recommendations
Abbreviations used in this
document
|
AASM – American Academy of Sleep Medicine
ACGME – Accreditation Council for
Graduate Medical Education
CAP- Cyclic Alternating Pattern
EEG- Electroencephalography
EOG- Electrooculography
EMG- Electromyography
ICSD – International
Classification of Sleep Disorders
MSLT- Multiple Sleep Latency Test
MWT- Maintenance of Vigilance
Test
PAP- Positive Airway Pressure
|
PLMD- Periodic Limb Movement
Disorder
PLMS- Periodic Leg Movements
during Sleep
PLMW- Periodic Leg Movements
during Wakefulness
PSG- Polysomnography
REM- Rapid Eye Movement
RWA- REM without atonia
RLS- Restless Legs Syndrome
SIT- Suggested Immobilization
Test
SRBD- Sleep Related Breathing
Disorders
WASM- World Association of Sleep
Medicine
|
Curriculum Topics - Specific Program Content Outline
The WASM curriculum will be
designed to include coverage of the following topics
The
curriculum will cover aspects of basic sciences relevant to sleep and sleep
disorders with emphasis on material from the following disciplines and topics
A. Neuroanatomy and Neurophysiology
B. Circadian neuroanatomy, neurophysiology, neurochemistry,
genetics, behavior
C. Electrophysiology
D. Endocrinology relevant to sleep
E. Motor and muscle control during sleep
F. Respiratory physiology relevant to sleep
G. Physiology of ANS relevant to sleep
H. Cardiovascular physiology relevant to sleep
I. Immunology relevant to sleep
J. Polysomnographic description of normal human sleep
2. The stages of sleep
3. Characteristics of
REM and NREM sleep
4. Normal sleep
pattern in adults
5. Sleep patterns
across the lifespan
K. Dream content and physiology
L. Neuropharmacology of sleep
1. Acetyl Cholinergic
2. Adrenergic
3. Dopaminergic
4. Serotonergic
5. Histaminergic
6. GABAergic
7. Adenosinergic
8. Orexinergic
9. Peptides
10. Neuromodulators
11. Other
M. Effects of sleep deprivation and sleep fragmentation
N. Molecular biology relevant to sleep
O. Neuroimaging studies of sleep
P. Theoretical models in sleep
1. Two factor theory
of sleep regulation
2. Activation synthesis
hypothesis
3. Reciprocal
inhibition theory
II.
Applied Technology
A. Electronics and
instrumentation
B. EEG, EMG, and EOG basics
C. Polysomnographic
recording technique.
D. Polysomnographic
scoring techniques
1. Sleep micro-architecture
2. Sleep macro-architecture (staging)
3. Sleep respiratory event scoring
4. Sleep movement event scoring
5. REM atonia level scoring
6. Abnormal EEG event detection and recognition
7. Sleep cardiac event recognition
8. Polysomnographic artifact recognition
9. Polysomnographic video classification techniques
E. Laboratory Positive
airway pressure and titration
1. Mask types and
fitting
2. Machine
types
3. Patient education
4. Assessing titration adequacy
5. Assessing acceptance and utilization
F. Autotitration techniques
G. Oxygen administration
H. Summarizing the polysomnogram
I. Recording, scoring, and summarizing home sleep testing
J. Conducting and summarizing a multiple sleep latency test
K. Conducting and summarizing a maintenance of wakefulness test
L. Conducting and summarizing a suggested immobilization test
M. Conducting and summarizing a full REM atonia test for REM
Behavior Disorder
N. Recording and summarizing actigraphy
O. Advanced signal processing and analysis techniques
III. Sleep Medicine
A. History
B. Classification systems
for sleep disorders
1. International Classification of Sleep Disorders (ICSD)
2. International Classification of Diseases (ICD9, ICD10)
3. Diagnostic and Statistical Manual of the Mental Disorders (DSM4,
DSM5)
C. Sleep related
breathing disorders
1. Central sleep apnea
syndromes
2. Obstructive sleep
apnea syndromes
3. Sleep related
hypoventilation/hypoxemic syndromes
4. Sleep related
hypoventilation/hypoxemia due to medical conditions
5. Other sleep related
breathing disorders
C. Hypersomnias of
central origin
1. Narcolepsy
2. Recurrent hypersomnia idiopathic
hypersomnia
3. Behaviorally
induced insufficient sleep syndrome
4. Hypersomnia due to
medical condition
5. Hypersomnia due to
drug of substance
6. Other hypersomnias
D. Insomnias
1. Adjustment insomnia
2. Psychophysiological insomnia
3. Paradoxical insomnia
4. Idiopathic insomnia
5. Insomnia
associated with mental disorder
6. Inadequate sleep
hygiene
7. Behavioral insomnia
of childhood
8. Insomnia due to
drug or substance
9. Insomnia due to
medical condition
10. Other insomnia
classifications
E. Sleep-related movement disorders
1. Periodic Limb
Movement Disorder
2. Restless Legs
Syndrome (Willis Ekbom Disease)
3. Sleep related leg
cramps
4. Rhythmic movement
disorders in sleep
5. Sleep bruxism
F. Parasomnias
1. NREM Parasomnias: Confusional awakenings, sleep walking, and
sleep terrors
2. REM Parasomnias: Nightmares, sleep
paralysis, REM behavior disorder
3. Other
Parasomnia: Sleep related dissociative disorders,
sleep enuresis, sleep related groaning, exploding head syndrome, sleep related
hallucinations, sleep related eating disorder, other.
G. Circadian rhythm
disorders
1. Delayed sleep phase disorder
2. Advanced sleep phase disorder
3. Irregular sleep-wake rhythm
4. Nonentrained sleep-wake rhythm
5. Jet lag disorder
6. Shift work disorder
7. Circadian disorder due to medical condition
8. Circadian disorder due to drug or substance
9. Other circadian disorders
H. Sleep and psychiatric
disorders
I. Sleep and neurological
disorders
J. Sleep and medical
disorders
K. Epidemiology of sleep
disorders
L. Sleep disorders and
public safety
M. Current standards of
practice
N. Cognitive behavioral therapy for insomnia
O. Clinical Pharmacology
of sleep
1. Pharmacokinetics, pharmacodynamics, and drug metabolism
2. Pharmacological treatment of insomnia
3. Pharmacological treatment of Sleepiness
4. Pharmacological treatment of movement disorders
5. Pharmacological treatment of parasomnia
6. Pharmacological treatment of circadian disorders
P. Sleep medicine
forensics
Q. Ethical, economic, and
legal aspects of sleep disorders
1. Hours of duty regulation- health care
2. Hours of duty regulation-
transportation industry
IV.
Sleep Disorders- Clinical and Laboratory Assessment
A. Clinical
1. Cardinal
Manifestations of Sleep Disorders
2. Conducting a
clinical sleep interview
a. Sleep schedule: Weekday, weekend,
napping, shift work
b. Sleepiness, tiredness or fatigue,
sleep scale interpretation, sleep attacks, asleep at the wheel
c. Sleep-disordered breathing:
Snoring, choking or gasping, witnessed apnea, morning headaches, morning dry
mouth
d.
Narcolepsy: Cataplexy, sleep paralysis, hypnagogia
e.
Insomnias: Initiating sleep, maintaining sleep, non-refreshing sleep,
early morning awakening, crawling legs, leg kicking, rumination, fearfulness of
not sleeping, pain, mood, mood scale interpretation; sleep diary assessment;
structured interviews and patient reported measures.
f. Movement Disorders: leg kicking,
difficulty sitting/lying still in evening or night, night leg cramps, jerking
at sleep onset.
g. Parasomnia: sleep walking, fearful
awakenings (early, middle, or late in the night, with or without paralysis,
dream recall or not), dream enactment (hitting, punching, injury, associated
with dreaming), leg cramps, sleep talking and other vocalizations (e.g.
shouting, laughing, singing), bedwetting, leaving the bed at night (eyes open
or closed).
h. Circadian rhythm disorders:
sleeping in early evening, sleeping during first part of day, difficulty
sleeping first part of night, difficulty staying asleep in early morning,
difficulty staying awake in morning.
i. Other: GERD, nocturnal coughing,
nocturnal headache
j. Comorbid conditions
k. Medication and substance use
l. Overall effect of sleep problem on
level of distress, activity of daily living, and quality of life
B. Interpreting
Laboratory and Home Testing Results
1. PSG
2. MSLT
3. MWT
4. HST
5. SIT
6. Actigraphy
C. Other Testing
1. Questionnaires used to assess sleep and sleep
disorders
2. Genetic testing for sleep disorders
3. Blood work (e.g., ferritin; thyroid panel)
D. Preparing a clinical sleep interpretation report
1. Background
a. Sleep history, habits, and problems
b. Sleep schedule
c. Sleepiness rating
d. Signs and symptoms
e. Depression rating
f. Comorbid conditions and concurrent
medication
2. Polysomnographic and related results
a. Testing performed
b. Sleep and arousal parameters
c. Sleep-related breathing results
d. Leg movement activity
e. REM atonia results
(differentiating tonic and phasic; specifying which muscles)
f. abnormal cardiac activity,
abnormal EEG activity, and CAP
g. MSLT and MWT results
h. SIT results
i. Positive
airway pressure results
j. Video analysis and comments
3. Actigraphy
4. Diagnosis
5. Treatment
Plan Recommendations
6. Safety warnings
7. Follow-up plan
V. Safety in the clinic and
laboratory
A. Acute and urgent events in sleep medicine
B. Acute and urgent events in the sleep laboratory
C. Safety and infection control in the sleep laboratory
VI. Methodology for Sleep Research
A. Research methods
B. Experimental design
C. Statistical methods
Proposed Presentation Topics
Below is a topic listing from our curriculum on sleep and its disorders.
We should consider developing as PowerPoint © and/or video presentation for
each of these topics.
I. Basic Science
A.
Sleep
neurobiology: Physiology, Neurophysiology, Circadian Rhythms- Role of
the Pons in the generation of REM Sleep (EEG characteristics, REM atonia). Structural anatomy of wakefulness versus
sleep. Physiological rhythms of the
sleeping brain affecting all body systems.
Functional neuroanatomy of sleep. Sleep and cognition.
B.
Somnopharmacology-
REM off neurotransmitters –Serotonin and Norepinephrine. REM on neurotransmitters –
acetylcholine. Role of the reticular
nucleus of the thalamus in the generation of delta sleep and sleep
spindles. Role of acetylcholine,
dopamine, histamine, orexin (hypocretin) in wakefulness. Structural anatomy of wakefulness versus
sleep. Physiological rhythms of the
sleeping brain affecting all body systems.
C.
Sleep and
Endocrine Physiology
D.
Sleep and
Cardiovascular Physiology
II. Technology and Techniques
A.
Recording
PSG & Scoring PSG-
B.
Advanced
Scoring PSG
C.
Video
polysomnography
D.
Assessing
Sleepiness & Alertness (includes MSLT and MWT)
E.
Actigraphy
F.
Psychological and Psychometric testing
G.
Fast-Tracking- Use
of Cardiopulmonary Recorders and AutoPAP
III. Sleep Disorders
A.
Nosology
of Sleep Disorders
B.
Approach
to the patient with sleep problem -adult
C.
Sleep
Related Breathing Disorders- Epidemiology; Relationship to stroke, heart, inflammatory
disease, diagnosis and treatment- What clinical history suggests sleep apnea?
What is an obstructive, mixed, central apnea?
How do we identify them on polysomnography? What are the implications of sleep apnea for
cardiovascular, cerebrovascular disease?
Improvement of excessive daytime drowsiness by treatment of sleep
disordered breathing. What is the role
of continuous positive airway pressure (CPAP), ENT surgery, and dental
appliances in the treatment of sleep apnea?
Cardiac arrhythmias and sleep apnea. Neuroanatomy and neurophysiology of
breathing.
D.
Dyssomnia
associated with psychiatric disorders
E.
Sleep
disorders associated with neurological disorders- Parkinson’s disease,
Huntington’s disease, Dystonia, Alzhiemer’s Disease and “sundowning”, muscular dystrophy,
myotonic dystrophy, myasthenia, amyotrophic lateral sclerosis and sleep
disordered breathing. MSA subforms such as olivo-pontocerebellar atrophy and
sleep disordered breathing and SCA and neuropathies (such as CMT) and sleep
disordered breathing.
F.
Sleep
disorders associated with medical disorders- Asthma, gastroesophageal
reflux, arthritis, congestive heart failure, ulcers etc.
G.
Chronic
respiratory failure and ventilatory support including care of the chronically
ventilated patient
A.
Sleep
related Hypoventilation
B.
Narcolepsy
and hypersomnia- Epi, Genetics, Dx and Management- What are the clinical
features of Narcolepsy? How is the
multiple sleep latency test (MSLT) used?
How can it be used to determine whether Narcolepsy is present or
not? What is Insufficient Sleep Syndrome
and how can it be distinguished from Narcolepsy by history and polysomnography? What is Idiopathic Hypersomnia and how can it
be distinguished from Narcolepsy?
Post-traumatic Hypersomnia. Drugs and Toxins.
C.
Insomnia
Diagnosis- Epidemiology, Clinical features; Etiologies, Comorbidities-
Psychiatric, medical, neurological, medical, and pharmacological causes of
sleep disruption. What is Paradoxical
Insomnia? How does this differ from the
insomnia attributed to anxiety or depression?
Conceptual models for insomnia (Spielman’s 3Ps, neurocognitive,
neurobiological, hyperarousal).
D.
Insomnia-
Cognitive behavioral therapy, including Rules for good sleep hygiene. Cognitive therapy, progressive muscle relaxation. autogenic training, visual guided
Imagery. Hypnosis. Sleep Restriction. Stimulus Control Therapy, Mindfulness-based
Stress Reduction.
E.
Insomnia-
Pharmacotherapy. Benzodiazepine-Receptor Agonists; Melatonin-Receptor
Agonists; Antihistamines; Orexin Antagonists; Sedating Antidepressants;
Atypical Antipsychotics.
F.
Circadian
rhythm disorders- relevant physiology of circadian rhythms. Jet Lag and Shift Work. Delayed Sleep Phase Syndrome. Advanced Sleep Phase Syndrome. Non-24 Hour Syndrome. Irregular Sleep Wake Syndrome. Role of melatonin, bright light, and
chronotherapy in the treatment of circadian rhythm disorders.
G.
RLS (WED):
definition, differential, workup and management- How RLS is identified
clinically and when should a sleep evaluation be conducted. When should a
suggested immobilization test be used? What
are the morbidities and social costs of RLS/WED. What is the relation to
increased risks of cardiovascular disease and increased mortality. What is the
relationship of RLS/WED to iron
deficiency, end stage renal disease,
pregnancy and to multiple medical disorders.
What are the genetic factors for RLS? What is RLS augmentation? What is the role of dopaminergic agents, alpha-2
delta drugs , opioids, oral iron and IV iron in the treatment of RLS/WED
H.
PLMS and
PLMD; definition, differential, workup and management of PLMD- What are the
rules for identifying PLMS on polysomnography?
What is the variation in PLMS
over days? What is the role of leg
activity monitoring for assessment of PLMS?
How do PLMS relate to Perioidic limb movement in sleep? Are PLMS
associated with daytime hypersomnolence?
Are PLMS a marker for renal, cardiovascular, or psychiatric
disease? What is the relationship of PLMS
to the RLS/WED , to narcolepsy, to the REM Sleep Behavior Disorder? How and when is PLMD treated?
I.
Parasomnias,
Movement Disorders and Seizures- Things that go “bump in the night” The REM
Sleep Behavior Disorder. Disorders of
Partial Arousal (sleep walking, sleep terrors, confusional arousals). How do we distinguish these things from sleep
related epilepsy? Benign Neonatal Sleep
Myoclonus and differentiation from epilepsy.
Rhythmic Movement Disorder (head banging and body rocking). Fatal Familial Insomnia (oneiric stupor,
ataxia, myoclonus), Nocturnal Paroxysmal Dystonia. Sleep Related Bruxism. Which
types of epilepsy have a predilection for sleep or the time just before or
after sleep? Benign Rolandic
Epilepsy. Juvenile Myoclonic
Epilepsy. What are the manifestations of
Frontal Lobe Epilepsy? What is Nocturnal
Paroxysmal Dystonia? What other
non-epileptic disorders are in the differential diagnosis of nocturnal
wandering other than frontal lobe epilepsy?
J.
Summarizing
PSG, & Writing a Clinical Report
IV. Pediatric Sleep Medicine
A.
Approach
to the patient with sleep problem -Pediatric
B.
Pediatric
Sleep Medicine- Neonates and Infants including SIDs and related disorders
C.
Pediatric
Sleep Medicine- Toddlers, Young Children, Adolescents including behavioral
insomnia of childhood
D.
Pediatric
Sleep disordered Breathing
E.
Pediatric
Parasomnias- definition, differential, workup and management
V. Special Topics
A.
Standards of Practice
B.
Evidence Based Medicine Approach &
Statistics
A.
Sleep and
metabolic disorders
B.
Dentistry
and Sleep
C.
Case series
presentations and discussions
D.
Sleep
disorders in women
1. Sleep disorders in
pregnancy
2. Menstrual related
sleep disorders
3. Other sleep
disorders in women
E.
Sleep disorders
in mental retardation
F.
The
history of sleep medicine
G.
Sleep at
high altitude
Suggested Reading Material
- ICSD. The International
Classification Sleep Disorders. American Academy of Sleep Medicine, ed.2,
Westchester, Il, 2005.
- All current AASM standards
of practice guidelines- available on AASM website
- The AASM Manual for the
scoring of sleep and associated events: Rules, terminology and technical
specifications Editors: Iber C,
Ancoli-Israel S, Chesson Al Jr, Quan SF. American Academy of Sleep Medicine,
Westchester, Il, 2007.
- SRS Basics of Sleep Guide.
Westchester, IL: Sleep Research Society, 2005.
- Chokroverty S: Sleep
Disorders Medicine, Saunders/Elsevier,
2009 (3rd ed).
- Kryger MH, Roth T, Dement
WC (eds), Principles and Practice of Sleep Medicine, 5th Edition,
Philadelphia: WB Saunders, 2010
- Lee-Chiong TL (ed). Sleep:
A. Comprehensive Handbook, Wiley-Liss, 2006
- Barkoukis TJ, Avidan Ay
(eds). Review of Sleep Medicine, 2nd ed, Butterworth/Elseiver,
2012.
- Chokroverty S, Sahota P
(eds):" Acute And Emergent Events in Sleep
Disorders", Oxford University Press,2011.
- Morin, C. M., & Espie, C. A. (2003). Insomnia:
A clinical guide to assessment and treatment. New York: Kluwer
Academic/Plenum Publishers.
- Butkov N, Lee-Chiong T
(eds). Fundamentals of Sleep Technology, Wolters Kluwer/Lippincott
Williams & Wilkins 2007.
- Tyner FS, Knott Jr, Mayer
WB: Fundamentals of EEG Technology: Basic Concepts and Methods, Raven
Press, New York, 1983.
- Butkov N. Atlas of
Clinical Polysomnography Volume I and II. Ashland, OR: Synapse Media,
1996.