In part due to the limited access and capability of sleep centers, the field of sleep neurology is in a suitable position for real-time, interactive, audio-video telecommunications (telemedicine). The American Academy of Sleep Medicine’s (AASM) Taskforce on Sleep Telemedicine supports telemedicine as a means of advancing patient health, by improving access to the expertise of Board-Certified Sleep Medicine Specialists.
From the use of sleep home monitoring devices to PAP therapy data, technology provides an opportunity to reach sleep patients at their home where they feel safe (specially children or vulnerable adults), as opposed to their traveling to a sleep center.
The American Academy of Sleep Medicine (AASM) provides an implementation guide that suggested two models: Center to Home (C2H) or Center to Center (C2C). The C2H model uses the patient’s own technology (laptop, smartphone, etc.) from wherever they choose to access remotely the sleep specialist. In the C2C model, the patient goes to a nearby location, typically a medical office or clinic where the equipment is located, and is then connected with a sleep specialist. Whatever model is available, having a private telecommunications channel that meets the technical requirements is a requisite (see Table 10.1 ).
|Bandwidth: Minimum connection speed @ 384 kbps; videoconferencing software.|
|Resolution: Minimum live video services @ 640 × 480 resolution at 30 frames/second.|
|Software: Software and operating system should be up to date with the latest security updates.|
|Diagnostic equipment: Electronic stethoscope and additional peripheral devices are encouraged to be used if they can aid clinical needs.|
|Safety: Compatible with published regulations for devices used in patient care and infection control procedures followed.|
|Privacy: Use of encryption for both live and stored information, inactivity timeout function, protected health information, and confidential data only stored on secure data storage. Access granted only to authorized users.|
Sleep telemedicine diagnostic approaches
Sleep is affected by circadian rhythms, light, backgrounds, sleep patterns, and other environmental variables. The zeitgeber action of light is influenced by interaction between circadian and homeostatic processes, and the opportunity to assess the home sleep environment is valuable to enhance the sleep interview. Nocturnal Artificial Light exposure (NLE) can be harmful by activating the melanopsin system in the retina, which will result in melatonin suppression. NLE can be assessed by asking the patient to show the amount of luminosity generated by their light bulbs. This can be determined by reading the manufacturer’s package, and also by the use of devices that measure luminous intensity or brightness (luxometers); these are also available as smartphone applications. One hundred lumens is equivalent to about 20 watts, and at higher levels, melatonin alterations can be expected. (It should be noted that most interior designers, unaware of the impact of light on sleep and circadian rhythm, recommend up to 2000 lm for a bedroom.) Measures to decrease NLE further include reducing the light intensity of smartphones, TVs, and computers by activating their nighttime modes, and the use of lenses that filter harmful blue light.
Bedroom temperature verification is simply done by inquiring about thermostat temperature settings at night (see Table 10.2 ).
|1. Nocturnal artificial light exposure.|
|2. Nocturnal utilization of electronic devices|
|3. Bedroom temperature verification.|
|4. Mattress with signs of wear and tear.|
|5. Environmental noises.|
|6. Partner discord|
|7. Potential for injury.|
Tips when taking a sleep history and performing the sleep-oriented exam
Conducting a sleep history via telemedicine should be performed according to the same professional and clinical care standards expected during face-to-face office visits. At the time of this publication, there are no completed trials assessing the noninferiority of the management of neurological sleep disorders (new diagnosis or established diagnosis) such as restless legs syndrome, parasomnia, and narcolepsy via telemedicine compared to usual in-office care.
Most of the sleep exam, including airway inspection and measurement of neck size (using the neck grasp technique, or a measuring tape), can be carried out via telemedicine. An examination assisted by external or intraoral cameras can be conducted to phenotype the upper airway. With optimal light and zoom view, testing of palate elevation and tongue movements can be achieved.
A general setup for airway video examination of the oral airway includes the following:
A well-lit room, avoiding sources of light behind the patient’s head. Ideally, patients should be sitting on a chair. Use an additional light source to enhance visualization of oropharynx subsites (tonsils, etc.).
Have a second person nearby to assist in tasks.
The chin and neck should also be visible, in order to look for bumps or masses.
Examine the back of the patient’s mouth by asking them to use a spoon as a tongue depressor.
In certain situations, the sleep physician may demonstrate the optimal examination technique on themselves first. In this way, patients may learn not to obstruct the physician’s view when doing it themselves.
Obstructive Sleep Apnea (OSA): There are several validated surveys that can be use via telemedicine to identify individuals at risk for sleep apnea. The most commonly used are the STOP-Bang and Berlin questionnaires; administration of these requires approximately 8 min and 2 min to complete, respectively.
Insomnia: The assessment of insomnia severity can be easily achieved by using the insomnia severity index, a 7-item Likert-type scale, which takes about 5 min for completion with total scores ranging from 0 to 28. Cognitive behavioral therapy for insomnia (CBT-I) can also be conducted via telemedicine, by addressing the thoughts and behaviors that promote insomnia.
Narcolepsy: The sleep neurologist should ask about primary symptoms of narcolepsy including excessive daytime sleepiness, sleep-related hallucinations, sleep paralysis, and sudden loss in muscle tone triggered by mostly positive emotions (cataplexy), which is not to be confused with exaggerated startle response. Excessive daytime somnolence can be formally assessed by administering validated tools including the Stanford Sleepiness Scale and/or the Epworth Sleepiness Scale.
Parasomnias: Safety is a major component of parasomnia management. A safety assessment can be done by a video walk-through of the patient’s sleeping environment, and observing the bedroom area for potentially injurious obstacles such as furniture or glass windows.
Additionally, visiting the bedroom facilitates better recall of the nocturnal motor activities, including answers to two important questions: “Does the patient wander outside the bedroom during the event?” and “Does the patient perform complex directed behaviors?”
Before asking the patient to perform certain tasks, it is important to have an assistant or caregiver at home, in order to prevent falls during examination. The use of automatic speech recognition captioning can assist telemedicine evaluations dealing with patients who have clinically significant hearing loss.
A unique benefit of televisits performed in the patient’s home is the ability to examine their sleep environment. The sleep neurologist can request the patient to demonstrate their ability to change positions in bed and the ability to transfer in and out of bed. The presence of orthopnea can also be noted in the supine position, which may suggest neuromuscular weakness. Careful observation may allow optimization of position restriction therapies, by observing the use of mechanical devices to avoid supine sleep.
Bedroom evaluation may be helpful to identify elements that may affect sleep quality. While validation is still needed, the use of a structured exploration of the sleep environment may help identify predisposing and precipitating factors that may contribute to circadian rhythm alterations, sleep disruptions, and insomnia. Table 10.1 shows factors to include in a structured questionnaire for assessment of the sleep environment.
Safety assessment of the sleep home environment related to both the patient and the sleeping partner is particularly revealing via telemedicine. When dealing with cases of potentially injurious parasomnias (such as rapid eye movement (REM) sleep behavior disorder or agitated sleep walking), observation of adequate positioning of barriers on the side of the bed/padding the floor near the bed and removal of sharp items, weapons, sharp edges furniture, glass windows, and clutter from the bed area are crucial to prevent injuries.
Sleep diagnostics and interpretation of sleep studies should be in accordance with the AASM Manual for the Scoring of Sleep and Associated Events. The use of home sleep studies, other than polysomnography (PSG), is now a widespread standard of care. Home-based PSG recordings include electroencephalogram (EEG), electrooculogram (EOG), and electromyogram (EMG), and requires appropriate bandwidth with data transfer to a virtual cloud-based platform for sleep scoring and archiving of raw data (see Table 10.1 ).
Sleep telemedicine treatment approaches
In order to effectively manage sleep apnea patients remotely, wireless positive airway pressure (PAP) transmission of therapy data is essential. Home PAP devices have modems that enable them to send data to the manufacturer’s server (cloud-based platform), which can be accessed by the medical equipment company, patient, and sleep specialist.
Real-time titration of auto PAP has been available for some time, and there is ongoing continued development in technology including long-term home polysomnography, with remote positive airway pressure titration.
Other telemedicine sleep treatment applications include treatment for insomnia. In a randomized noninferiority trial, telemedicine delivery of cognitive behavioral therapy (CBT) for insomnia was not inferior to face-to-face encounters for insomnia, with similar improvements on daytime functioning outcomes.
The AASM taskforce endorses the use of live interactive telemedicine as an alternative for prescription of sedative hypnotics, stimulant medications, wakefulness-promoting medications, or other controlled substances prescribed by the sleep specialist.
Telemedicine follow-up approaches
The cloud-based platform becomes a source of a large amount of data which can help promote engagement of patients by access to education resources, efficacy of treatment (residual apnea-hypopnea index), adherence, assessment of mask leaks, and troubleshooting of common problems. Active patient engagement using technology is beneficial in terms of improving daily PAP use; however, the use of these applications may inadvertently exclude less technically savvy patients. Nevertheless, evidence suggests that adherence to PAP is improved with telemedicine.
Smartphone applications, smartwatches, and even finger rings are widely distributed among consumers Those applications are multiple and use technologies including movement sensor, microphone, video, oximetry, actigraphy, and ballistocardiography to measure sleep stages, although validation data are lacking.
Another aspect that is likely to interact with telemedicine is the ever-changing use of consumer sleep technologies (CSTs). Sleep apps remain among the most popular apps downloaded for smartphone devices, and their utilization continues to increase. The lack of validation data and absence of Food and Drug Administration (FDA) clearance raise concerns about the accuracy of CST data. CST tools are not substitutes for formal sleep evaluation; however, as long as sleep neurologists acknowledge CST-gathered sleep data, CSTs may enhance clinical interaction by improving patient engagement.
Furthermore, the tracking of objective data using CSTs, with the resultant self-correlation with daytime function, may lead to an unrealistic and anxious pursuit for the perfect sleep. This condition has been named orthosomnia.
Additionally, therapies other than PAP, including dental devices, have the potential to be monitored remotely using thermal sensors implanted into the dental device by reading the device at mouth temperature vs. room temperature (device taken out of the mouth).
Sleep telemedicine offers a unique opportunity for the enhancement of clinical data pertaining to the sleep history and the home sleep environment. Widespread application of sleep telemedicine should maintain ethical and clinical care standards expected in face-to-face office visits.
Sleep telemedicine is a fast-moving scenario with potential concerns of limited compensation. Progress of financial regulations and protocols in telemedicine is required to sustain further implementation by patients and sleep specialists.