adult sleep stage scoring rules

Adult Sleep Stage Scoring RulesAdult Sleep Stage Scoring Rules

Identification and Staging of Adult Human SleepIdentification and Staging of Adult Human Sleep

• All recordings in this course have the following All recordings in this course have the following montage:montage:– EOG (LOC)EOG (LOC)– EOG (ROC)EOG (ROC)– EEG (C3-A2)EEG (C3-A2)– EEG (O1-A2)EEG (O1-A2)– EMG (submental)EMG (submental)

• All recordings in this course have the following All recordings in this course have the following montage:montage:– EOG (LOC)EOG (LOC)– EOG (ROC)EOG (ROC)– EEG (C3-A2)EEG (C3-A2)– EEG (O1-A2)EEG (O1-A2)– EMG (submental)EMG (submental)

Parameters for Staging Human SleepParameters for Staging Human Sleep

• EOG leads - left eye and right eyeEOG leads - left eye and right eye• EEG leads - one central EEG lead and one EEG leads - one central EEG lead and one

occipital EEG lead (minimum) occipital EEG lead (minimum)• EMG - one submental EMG channelEMG - one submental EMG channel

• EOG leads - left eye and right eyeEOG leads - left eye and right eye• EEG leads - one central EEG lead and one EEG leads - one central EEG lead and one

occipital EEG lead (minimum) occipital EEG lead (minimum)• EMG - one submental EMG channelEMG - one submental EMG channel

LOCLOC

ROCROC

Left and Right ElectrooculogramLeft and Right Electrooculogram

Eye BlinksEye Blinks

Electrooculography picks up the inherent voltage of the eye. During eyes-open

wakefulness, sharp deflections in the EOG tracing may indicate the presence of eye blinks.

Electrooculography picks up the inherent voltage of the eye. During eyes-open

wakefulness, sharp deflections in the EOG tracing may indicate the presence of eye blinks.

LOCLOC

ROCROC


During drowsiness and stage one sleep, the eyes begin to slowly roll (SEM’s). Brain wave activity (theta) starts to enter into the EOG tracing as an artifact.

During drowsiness and stage one sleep, the eyes begin to slowly roll (SEM’s). Brain wave activity (theta) starts to enter into the EOG tracing as an artifact.

LOCLOC

ROCROC


During REM sleep, the eyes move rapidly under closed eyelids while dreaming. This produces rapid conjugate eye movements which appear as out-of-phase EOG channel deflections.

During REM sleep, the eyes move rapidly under closed eyelids while dreaming. This produces rapid conjugate eye movements which appear as out-of-phase EOG channel deflections.

Submental EMGSubmental EMG

• Mental, submental, masseter placements are Mental, submental, masseter placements are acceptableacceptable

• Used to detect muscle tone changes for REM vs. Used to detect muscle tone changes for REM vs. NREM sleep NREM sleep

• Muscle tone high during wakefulness and Muscle tone high during wakefulness and NREM sleep NREM sleep

• Muscle tone low during stage REM Muscle tone low during stage REM

• Mental, submental, masseter placements are Mental, submental, masseter placements are acceptableacceptable

• Used to detect muscle tone changes for REM vs. Used to detect muscle tone changes for REM vs. NREM sleep NREM sleep

• Muscle tone high during wakefulness and Muscle tone high during wakefulness and NREM sleep NREM sleep

• Muscle tone low during stage REM Muscle tone low during stage REM

Low EMG during wakefulness and NREM sleep

ROCROC

Mental/Submental EMGMental/Submental EMG

Total duration of yawn causing increased EMG

Submental EMG records muscle Tone. This is a mandatory

recording parameter parameter for staging sleep (REM vs. NREM).

Yawns, swallows, and tooth grinding may also increase

muscle tone.

Submental EMG records muscle Tone. This is a mandatory

recording parameter parameter for staging sleep (REM vs. NREM).

Yawns, swallows, and tooth grinding may also increase

muscle tone.

EEG RecordingEEG Recording

• Minimum paper speed of 10 mm/secMinimum paper speed of 10 mm/sec

• TC of .3 (LFF .3 Hz.) minimumTC of .3 (LFF .3 Hz.) minimum

• Pen deflections of 7.5 - 10 mm for 50µv is Pen deflections of 7.5 - 10 mm for 50µv is recommendedrecommended

• Electrode impedances should not exceed 10KElectrode impedances should not exceed 10K

• Minimum paper speed of 10 mm/secMinimum paper speed of 10 mm/sec

• TC of .3 (LFF .3 Hz.) minimumTC of .3 (LFF .3 Hz.) minimum

• Pen deflections of 7.5 - 10 mm for 50µv is Pen deflections of 7.5 - 10 mm for 50µv is recommendedrecommended

• Electrode impedances should not exceed 10KElectrode impedances should not exceed 10K

Electroencephalography (EEG)Electroencephalography (EEG)

Differential Amplifier

G1G1 G2G2

Alpha ActivityAlpha Activity

• Alpha EEG: 8-13 cps.Alpha EEG: 8-13 cps.

• Alpha: occipital regionAlpha: occipital region

• Alpha: crescendo-decrescendo Alpha: crescendo-decrescendo appearanceappearance

• Decrease in frequency occurs with Decrease in frequency occurs with agingaging

Stage WakeStage Wake

• EOG - Eye blinks OR SEM’s EOG - Eye blinks OR SEM’s

• EEG - >EEG - >½½ epoch has scorable Alpha epoch has scorable Alpha EEG activity. EEG activity.

• Submental EMG - relatively high tone.Submental EMG - relatively high tone.

• EOG - Eye blinks OR SEM’s EOG - Eye blinks OR SEM’s

• EEG - >EEG - >½½ epoch has scorable Alpha epoch has scorable Alpha EEG activity. EEG activity.

• Submental EMG - relatively high tone.Submental EMG - relatively high tone.

Stage WakeEyes Closed vs. Eyes Open

Stage WakeEyes Closed vs. Eyes Open

Eyes open

– >50% of each epoch contains alpha activity.>50% of each epoch contains alpha activity.

– Slow rolling eye movements or eye blinks will be seen in the Slow rolling eye movements or eye blinks will be seen in the EOG channelsEOG channels

– Relatively high submental EMG muscle toneRelatively high submental EMG muscle tone

– >50% of each epoch contains alpha activity.>50% of each epoch contains alpha activity.

– Slow rolling eye movements or eye blinks will be seen in the Slow rolling eye movements or eye blinks will be seen in the EOG channelsEOG channels

– Relatively high submental EMG muscle toneRelatively high submental EMG muscle tone


Theta ActivityTheta Activity

• A frequency of 3-7 cps.A frequency of 3-7 cps.• Produced in the central vertex regionProduced in the central vertex region• No amplitude criteria for ThetaNo amplitude criteria for Theta• The most common sleep frequency The most common sleep frequency

Stage One SleepStage One Sleep

• Scored when >15 seconds of theta is seen, Scored when >15 seconds of theta is seen, replacing an Alpha.replacing an Alpha.

• Considered a transitional sleep stageConsidered a transitional sleep stage

• Very short durationVery short duration

• ““Church Sleep”, or “Car Driving Sleep”.Church Sleep”, or “Car Driving Sleep”.

• Scored when >15 seconds of theta is seen, Scored when >15 seconds of theta is seen, replacing an Alpha.replacing an Alpha.

• Considered a transitional sleep stageConsidered a transitional sleep stage

• Very short durationVery short duration

• ““Church Sleep”, or “Car Driving Sleep”.Church Sleep”, or “Car Driving Sleep”.

• >> 50% of the epoch contains theta activity (3-7 cps.) There may 50% of the epoch contains theta activity (3-7 cps.) There may be alpha activity within <50% of the epoch.be alpha activity within <50% of the epoch.

• Slow rolling eye movements in the EOG channelsSlow rolling eye movements in the EOG channels

• Relatively high submental EMG tone.Relatively high submental EMG tone.

• >> 50% of the epoch contains theta activity (3-7 cps.) There may 50% of the epoch contains theta activity (3-7 cps.) There may be alpha activity within <50% of the epoch.be alpha activity within <50% of the epoch.

• Slow rolling eye movements in the EOG channelsSlow rolling eye movements in the EOG channels

• Relatively high submental EMG tone.Relatively high submental EMG tone.

Stage One SleepStage One Sleep

Sleep SpindlesSleep Spindles

• Sleep Spindle - 12-14 cps. Sleep Spindle - 12-14 cps. • Central - vertex regionCentral - vertex region• >>.5 to 2-3 seconds in duration .5 to 2-3 seconds in duration • .5 second spindles - 6-7 cycles.5 second spindles - 6-7 cycles• Indicative of stage 2 sleep Indicative of stage 2 sleep

• Sleep Spindle - 12-14 cps. Sleep Spindle - 12-14 cps. • Central - vertex regionCentral - vertex region• >>.5 to 2-3 seconds in duration .5 to 2-3 seconds in duration • .5 second spindles - 6-7 cycles.5 second spindles - 6-7 cycles• Indicative of stage 2 sleep Indicative of stage 2 sleep

K ComplexesK Complexes– Sharp, slow waves, with a negative then positive Sharp, slow waves, with a negative then positive

deflectiondeflection– No amplitude criteria No amplitude criteria – Duration must be at least .5 secondsDuration must be at least .5 seconds– Predominantly central-vertex in originPredominantly central-vertex in origin– Indicative of stage 2 sleepIndicative of stage 2 sleep– They may occur with stimuli or without stimuli.They may occur with stimuli or without stimuli.

– Sharp, slow waves, with a negative then positive Sharp, slow waves, with a negative then positive deflectiondeflection

– No amplitude criteria No amplitude criteria – Duration must be at least .5 secondsDuration must be at least .5 seconds– Predominantly central-vertex in originPredominantly central-vertex in origin– Indicative of stage 2 sleepIndicative of stage 2 sleep– They may occur with stimuli or without stimuli.They may occur with stimuli or without stimuli.

– Background EEG is Theta (3-7 cps.)Background EEG is Theta (3-7 cps.)

– K-Complexes and Spindles occur episodicallyK-Complexes and Spindles occur episodically

– Mirrored EEG in the EOG leadsMirrored EEG in the EOG leads

– Low tonic submental EMGLow tonic submental EMG

– Background EEG is Theta (3-7 cps.)Background EEG is Theta (3-7 cps.)

– K-Complexes and Spindles occur episodicallyK-Complexes and Spindles occur episodically

– Mirrored EEG in the EOG leadsMirrored EEG in the EOG leads

– Low tonic submental EMGLow tonic submental EMG

Stage Two SleepStage Two SleepStage Two SleepStage Two Sleep

Stage Two SleepStage Two Sleep

– Excessive spindles may indicate the presence of Excessive spindles may indicate the presence of some medications (benzodiazepines) some medications (benzodiazepines)

– Normal variant for scoring human sleepNormal variant for scoring human sleep

– Excessive spindles may indicate the presence of Excessive spindles may indicate the presence of some medications (benzodiazepines) some medications (benzodiazepines)

– Normal variant for scoring human sleepNormal variant for scoring human sleep

– Stage 2 sleep with low K complex quantity and high Stage 2 sleep with low K complex quantity and high amplitude spindles. amplitude spindles.

– Normal variant Normal variant

– Stage 2 sleep with low K complex quantity and high Stage 2 sleep with low K complex quantity and high amplitude spindles. amplitude spindles.

– Normal variant Normal variant

Stage Two (Typical look)Stage Two (Typical look)

Stage Two Sleep Three Minute Rule

Stage Two Sleep Three Minute Rule

• If a K complex or spindle is not seen within If a K complex or spindle is not seen within three minutes of the previous K or spindle, three minutes of the previous K or spindle, the scoring will default to stage one (1) sleep. the scoring will default to stage one (1) sleep.

• If a K complex or spindle is not seen within If a K complex or spindle is not seen within three minutes of the previous K or spindle, three minutes of the previous K or spindle, the scoring will default to stage one (1) sleep. the scoring will default to stage one (1) sleep.

Delta ActivityDelta Activity

– Sleep Delta Activity - Sleep Delta Activity - frequency of .5-2 cps. frequency of .5-2 cps.

– Clinical EEG - frequency of Clinical EEG - frequency of >> .5-4 cps. .5-4 cps.

– Seen predominantly in the Seen predominantly in the frontal regionfrontal region

– Delta Activity - amplitude of Delta Activity - amplitude of >> 7575

Stage Three SleepStage Three Sleep

– 20% to 50% Delta Activity is seen. 20% to 50% Delta Activity is seen. – EOG leads will only pick up the EEG activity.EOG leads will only pick up the EEG activity.– EMG may be slightly lower than that of Stage two.EMG may be slightly lower than that of Stage two.

– 20% to 50% Delta Activity is seen. 20% to 50% Delta Activity is seen. – EOG leads will only pick up the EEG activity.EOG leads will only pick up the EEG activity.– EMG may be slightly lower than that of Stage two.EMG may be slightly lower than that of Stage two.

• Stage three or four?Stage three or four?• Stage three or four?Stage three or four?• Frequencies >2cps. Must be eliminated from Frequencies >2cps. Must be eliminated from

consideration.consideration.• Frequencies >2cps. Must be eliminated from Frequencies >2cps. Must be eliminated from

consideration.consideration.• K Complexes must be eliminated from delta counts.K Complexes must be eliminated from delta counts.• K Complexes must be eliminated from delta counts.K Complexes must be eliminated from delta counts.

Stage Three vs. Stage FourStage Three vs. Stage FourStage Three vs. Stage FourStage Three vs. Stage Four

• >50% Delta Activity in the EEG Leads. >50% Delta Activity in the EEG Leads.

• EOG is only recording frontal EEG activity.EOG is only recording frontal EEG activity.

• EMG is at the same level as Stage Three sleep.EMG is at the same level as Stage Three sleep.

• >50% Delta Activity in the EEG Leads. >50% Delta Activity in the EEG Leads.

• EOG is only recording frontal EEG activity.EOG is only recording frontal EEG activity.

• EMG is at the same level as Stage Three sleep.EMG is at the same level as Stage Three sleep.

Stage Four SleepStage Four Sleep

– Mixed frequency EEG. Alpha may be seen; usually 1-2 cps. slower than waking

– REM’s are seen in the EOG leads.

– Low submental EMG

– Any two of the previous three criteria must be present to score REM Sleep.

– Mixed frequency EEG. Alpha may be seen; usually 1-2 cps. slower than waking

– REM’s are seen in the EOG leads.

– Low submental EMG

– Any two of the previous three criteria must be present to score REM Sleep.

Stage REM SleepStage REM SleepStage REM SleepStage REM Sleep

Tonic REMTonic REM

Phasic REMPhasic REM

REM With K Complexes or SpindlesREM With K Complexes or Spindles

• K Complexes and/or spindles may occur while in K Complexes and/or spindles may occur while in stage REM.stage REM.

• Each K or Spindle must be separated by phasic REM Each K or Spindle must be separated by phasic REM activity. activity.

• While in stage REM, > 3 minute separation periods While in stage REM, > 3 minute separation periods between K complexes or spindles without REM’s is between K complexes or spindles without REM’s is scored as stage 2.scored as stage 2.

• To maintain REM sleep, K’s or spindles must be To maintain REM sleep, K’s or spindles must be separated by phasic REMseparated by phasic REM

• K Complexes and/or spindles may occur while in K Complexes and/or spindles may occur while in stage REM.stage REM.

• Each K or Spindle must be separated by phasic REM Each K or Spindle must be separated by phasic REM activity. activity.

• While in stage REM, > 3 minute separation periods While in stage REM, > 3 minute separation periods between K complexes or spindles without REM’s is between K complexes or spindles without REM’s is scored as stage 2.scored as stage 2.

• To maintain REM sleep, K’s or spindles must be To maintain REM sleep, K’s or spindles must be separated by phasic REMseparated by phasic REM

Movement TimeMovement Time

• Amplifier blocking or excessive EMGAmplifier blocking or excessive EMG

• Obscured tracingObscured tracing

• Sleep must occur before and afterSleep must occur before and after

• >> 15 seconds 15 seconds < < than one minute than one minute

• Scorable stage of sleepScorable stage of sleep

• Amplifier blocking or excessive EMGAmplifier blocking or excessive EMG

• Obscured tracingObscured tracing

• Sleep must occur before and afterSleep must occur before and after

• >> 15 seconds 15 seconds < < than one minute than one minute

• Scorable stage of sleepScorable stage of sleep

• Amplifier blocking, excessive muscle activity, and obscurity of the EEG make up Amplifier blocking, excessive muscle activity, and obscurity of the EEG make up the scoring criteria for REM sleep. the scoring criteria for REM sleep.

• Amplifier blocking, excessive muscle activity, and obscurity of the EEG make up Amplifier blocking, excessive muscle activity, and obscurity of the EEG make up the scoring criteria for REM sleep. the scoring criteria for REM sleep.

Movement TimeMovement Time

– < 15 seconds in total duration < 15 seconds in total duration

– >> 3 seconds but < 15 seconds of EEG shift to faster frequency 3 seconds but < 15 seconds of EEG shift to faster frequency

– Sleep is maintained Sleep is maintained

– < 15 seconds in total duration < 15 seconds in total duration

– >> 3 seconds but < 15 seconds of EEG shift to faster frequency 3 seconds but < 15 seconds of EEG shift to faster frequency

– Sleep is maintained Sleep is maintained

Random Body Movements and/or EEG ArousalsRandom Body Movements and/or EEG Arousals

Over 15 Over 15 seconds of seconds of amplifier amplifier blocking, etc., blocking, etc., that obscures that obscures recordrecord

Very short Very short duration duration (< 15 seconds) (< 15 seconds) activity with no activity with no EEG obscuringEEG obscuring

Very short Very short duration duration (< 15 seconds) (< 15 seconds) activity with no activity with no EEG obscuringEEG obscuring

EEG ArousalEEG Arousal

MVT TimeMVT Time

Stage REM: Phasic TwitchingStage REM: Phasic Twitching

The arrows are pointing to Phasic TwitchingThe arrows are pointing to Phasic Twitching

– Very short muscle Very short muscle twitches that normally twitches that normally occur in REM Sleep.occur in REM Sleep.

– May occur in the inner May occur in the inner ear, genioglossal, limb, ear, genioglossal, limb, and facial musclesand facial muscles

– Another form of phasic Another form of phasic activity is Penile activity is Penile Tumescence. Tumescence.

– Very short muscle Very short muscle twitches that normally twitches that normally occur in REM Sleep.occur in REM Sleep.

– May occur in the inner May occur in the inner ear, genioglossal, limb, ear, genioglossal, limb, and facial musclesand facial muscles

– Another form of phasic Another form of phasic activity is Penile activity is Penile Tumescence. Tumescence.

Sawtooth PatternSawtooth Pattern

– Jagged evenly formed Jagged evenly formed EEG pattern seen usually EEG pattern seen usually in the vertex regionin the vertex region

– Seen predominantly in Seen predominantly in REMREM

– Jagged evenly formed Jagged evenly formed EEG pattern seen usually EEG pattern seen usually in the vertex regionin the vertex region

– Seen predominantly in Seen predominantly in REMREM

• Alpha frequencies intrude into Delta Sleep. Alpha frequencies intrude into Delta Sleep.

• Usually 2-3 cps. slower than waking alpha Usually 2-3 cps. slower than waking alpha

• Fibromyalgia or other muscular / joint pain disorders.Fibromyalgia or other muscular / joint pain disorders.

• Alpha frequencies intrude into Delta Sleep. Alpha frequencies intrude into Delta Sleep.

• Usually 2-3 cps. slower than waking alpha Usually 2-3 cps. slower than waking alpha

• Fibromyalgia or other muscular / joint pain disorders.Fibromyalgia or other muscular / joint pain disorders.

Alpha Delta Sleep (non-restorative sleep)Alpha Delta Sleep (non-restorative sleep)

Non-Restorative SleepNon-Restorative Sleep

• Significant alpha intrusion

• Alpha frequencies within 2-3 cps. of waking alpha range

• Significant alpha intrusion

• Alpha frequencies within 2-3 cps. of waking alpha range

Self Test SectionSelf Test Section

• Guess the correct answer to the following Guess the correct answer to the following questions. Press the space bar to see the questions. Press the space bar to see the answer.answer.

• HAVE FUNHAVE FUN

• Guess the correct answer to the following Guess the correct answer to the following questions. Press the space bar to see the questions. Press the space bar to see the answer.answer.

• HAVE FUNHAVE FUN

What stage is this? What stage is this? A. Stage 2A. Stage 2

B. Stage 1B. Stage 1

C. Stage WakeC. Stage Wake

D. Stage REMD. Stage REM




C. Stage 4C. Stage 4


Stage 4Stage 4





Stage 2Stage 2


B. Stage MVTB. Stage MVT



Stage MVTStage MVT





Stage REMStage REM

What stage is this? What stage is this? A. Stage 2A. Stage 2B. Stage 1B. Stage 1C. Stage WakeC. Stage WakeD. Stage 3D. Stage 3

Stage 2Stage 2

What stage is this? What stage is this? A. Stage 2A. Stage 2B. Stage 3B. Stage 3C. Stage 4C. Stage 4D. Stage REMD. Stage REM

Stage 3Stage 3

What stage is this? Why?What stage is this? Why?

A. Stage 1A. Stage 1




Stage 2Stage 2


A. Stage REMA. Stage REMB. Stage 4B. Stage 4C. Stage 2C. Stage 2D. Stage WakeD. Stage Wake

Stage REMStage REM


A. Stage 4A. Stage 4B. Stage 3B. Stage 3C. Stage 2C. Stage 2D. Stage REMD. Stage REM

Stage 3The frequencyis too fast for

Delta (in most

of this epoch).

Stage 3The frequencyis too fast for

Delta (in most

of this epoch).





Stage 1

No K complex or spindles are seen.

Stage 1

No K complex or spindles are seen.





Stage REMStage REM



C. Stage MVTC. Stage MVT


Stage 2

The activity in the center of the tracing isn’t long enough for MVT

Stage 2

The activity in the center of the tracing isn’t long enough for MVT

adult sleep stage scoring rules

Documents

adult sleep stage

staging sleep rem

nrem sleep muscle tone

nrem sleep muscle tone

common sleep frequency

car driving sleep

sleep spindlessleep

stage rem low emg