Curriculum

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

  1. Conduct a clinical sleep assessment that integrates sleep history, sleep problems, related medical problems, and relevant medications.
  2. Recognize and differentiate sleep-related breathing disorders
  3. Recognize and differentiate different types of insomnia
  4. Recognize and differentiate narcolepsy from different types of hypersomnia.
  5. Recognize and differentiate different types of movement events
  6. Recognize and differentiate different parasomnia
  7. Recognize and differentiate pediatric sleep disorders.
  8. Realize the array of sleep procedures and techniques needed for your individual practice, patient care, and research
  9. Conduct polysomnography and related technical procedures
  10. Conduct and interpret home sleep testing
  11. Differentiate PSG tracings of wakefulness from sleep, REM from NREM sleep, & N2 from N3
  12. Recognize CNS arousals from sleep
  13. Recognize and differentiate different types of respiratory events
  14. Determine optimal positive airway pressure from a titration sleep study
  15. Classify sleep disorders according to standardized nosology
  16. Derive a well-reasoned differential diagnosis.
  17. Describe pharmacological treatment of different sleep disorder, including knowledge about adverse effects of different treatments
  18. Describe behavioral and cognitive behavioral treatment methods for sleep disorders
  19. 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.[1] 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

I. Basic Science

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

  1. 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

  1. Sleep history, habits, and problems
  2. Sleep schedule
  3. Sleepiness rating
  4. Signs and symptoms
  5. Depression rating
  6. Comorbid conditions and concurrent medication

    2. Polysomnographic and related results

  1. Testing performed
  2. Sleep and arousal parameters
  3. Sleep-related breathing results
  4. Leg movement activity
  5. REM atonia results (differentiating tonic and phasic; specifying which muscles)
  6. abnormal cardiac activity, abnormal EEG activity, and CAP
  7. MSLT and MWT results
  8. SIT results
  9. Positive airway pressure results
  10. 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

  1. 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.
  2. 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.
  3. Sleep and Endocrine Physiology
  4. Sleep and Cardiovascular Physiology

II. Technology and Techniques

  1. Recording PSG & Scoring PSG-
  2. Advanced Scoring PSG
  3. Video polysomnography
  4. Assessing Sleepiness & Alertness (includes MSLT and MWT)
  5. Actigraphy
  6. Psychological and Psychometric testing
  7. Fast-Tracking- Use of Cardiopulmonary Recorders and AutoPAP

III. Sleep Disorders

  1. Nosology of Sleep Disorders
  2. Approach to the patient with sleep problem -adult
  3. 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.
  4. Dyssomnia associated with psychiatric disorders
  5. 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.
  6. Sleep disorders associated with medical disorders– Asthma, gastroesophageal reflux, arthritis, congestive heart failure, ulcers etc.
  7. Chronic respiratory failure and ventilatory support including care of the chronically ventilated patient
  8. Sleep related Hypoventilation
  9. 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.
  10. 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).
  11. 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.
  12. Insomnia- Pharmacotherapy. Benzodiazepine-Receptor Agonists; Melatonin-Receptor Agonists; Antihistamines; Orexin Antagonists; Sedating Antidepressants; Atypical Antipsychotics.
  13. 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.
  14. 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
  15. 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?
  16. 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?
  17. Summarizing PSG, & Writing a Clinical Report

IV. Pediatric Sleep Medicine

  1. Approach to the patient with sleep problem -Pediatric
  2. Pediatric Sleep Medicine- Neonates and Infants including SIDs and related disorders
  3. Pediatric Sleep Medicine- Toddlers, Young Children, Adolescents including behavioral insomnia of childhood
  4. Pediatric Sleep disordered Breathing
  5. Pediatric Parasomnias- definition, differential, workup and management

V. Special Topics

  1. Standards of Practice
  2. Evidence Based Medicine Approach & Statistics
  3. Sleep and metabolic disorders
  4. Dentistry and Sleep
  5. Case series presentations and discussions
  6. Sleep disorders in women

              1. Sleep disorders in pregnancy

              2. Menstrual related sleep disorders

              3. Other sleep disorders in women

  1. Sleep disorders in mental retardation
  2. The history of sleep medicine
  3. Sleep at high altitude

Suggested Reading Material [2]

  1. ICSD. The International Classification Sleep Disorders. American Academy of Sleep Medicine, ed.2, Westchester, Il, 2005.
  2. All current AASM standards of practice guidelines- available on AASM website
  3. 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.
  4. SRS Basics of Sleep Guide. Westchester, IL: Sleep Research Society, 2005.
  5. Chokroverty S: Sleep Disorders Medicine, Saunders/Elsevier,       2009 (3rd ed).
  6. Kryger MH, Roth T, Dement WC (eds), Principles and Practice of Sleep Medicine, 5th Edition, Philadelphia: WB Saunders, 2010
  7. Lee-Chiong TL (ed). Sleep: A. Comprehensive Handbook, Wiley-Liss, 2006
  8. Barkoukis TJ, Avidan Ay (eds). Review of Sleep Medicine, 2nd ed, Butterworth/Elseiver, 2012.
  9. Chokroverty S, Sahota P (eds):” Acute And Emergent Events in Sleep Disorders”, Oxford University Press,2011.
  10. Morin, C. M., & Espie, C. A. (2003). Insomnia: A clinical guide to assessment and treatment. New York: Kluwer Academic/Plenum Publishers.
  1. Butkov N, Lee-Chiong T (eds). Fundamentals of Sleep Technology, Wolters Kluwer/Lippincott Williams & Wilkins 2007.
  2. Tyner FS, Knott Jr, Mayer WB: Fundamentals of EEG Technology: Basic Concepts and Methods, Raven Press, New York, 1983.
  3. Butkov N. Atlas of Clinical Polysomnography Volume I and II. Ashland, OR: Synapse Media, 1996.

[1] Sleep Specialist – As used in this document, the label “sleep specialist” designates an individual with advanced training in sleep medicine that has recognized certification by a recognized local authority.

[2] This list includes Currently includes English language materials. This list does not preclude textbooks written in other languages.