title: The visual scoring of sleep in adults.
abstract: The 1968 Rechtschaffen and Kales (R & K) sleep scoring manual was published 15 years after REM sleep was discovered. Advances in the ensuing 28 years warranted a re-look at visual scoring of sleep stages. This paper describes the work of the AASM Visual Scoring Task Force, including methodology, a literature review and the rationale behind the new rules. Reliability studies of R & K scoring were reviewed; reliability was low for stage one and moderate for slow wave sleep. Evidence indicated that K complexes and slow waves are expressed maximal frontally, spindles centrally and alpha rhythm over the occipital region. Three derivations of EEG, two of electro-oculography, and one of chin EMG were recommended. Scoring by 30-second epochs was retained. New terminology for sleep stages was proposed. Attenuation of alpha rhythm was determined to be the most valid electrophysiological marker of sleep onset. Alternative measures were proposed for non-alpha generating subjects. K complexes associated with arousals were determined to be insufficient alone to define the new stage N2. No evidence was found to justify dividing slow wave sleep into two stages. No reasons were found to alter the current slow wave amplitude criteria at any age. The phenomena of REM sleep were defined. The rules for defining onset and termination of REM sleep periods were simplified. Movement time was eliminated and major body movements defined. Studies are needed to test the reliability of the new rules. Future advances in technology may require modification of these rules with time.
authors.affiliation: Mayo Sleep Disorders Center, Mayo Clinic College of Medicine, Rochester, MN 55902, USA. msilber@mayo.edu
authors.forename: Michael H
authors.initials: MH
authors.lastname: Silber
authors.forename: Sonia
authors.initials: S
authors.lastname: Ancoli-Israel
authors.forename: Michael H
authors.initials: MH
authors.lastname: Bonnet
authors.forename: Sudhansu
authors.initials: S
authors.lastname: Chokroverty
authors.forename: Madeleine M
authors.initials: MM
authors.lastname: Grigg-Damberger
authors.forename: Max
authors.initials: M
authors.lastname: Hirshkowitz
authors.forename: Sheldon
authors.initials: S
authors.lastname: Kapen
authors.forename: Sharon A
authors.initials: SA
authors.lastname: Keenan
authors.forename: Meir H
authors.initials: MH
authors.lastname: Kryger
authors.forename: Thomas
authors.initials: T
authors.lastname: Penzel
authors.forename: Mark R
authors.initials: MR
authors.lastname: Pressman
authors.forename: Conrad
authors.initials: C
authors.lastname: Iber
mesh_terms: D000328:Adult; D004569:Electroencephalography; D004585:Electrooculography / Q000295:instrumentation* / Q000706:statistics & numerical data*; D006801:Humans; D017286:Polysomnography / Q000295:instrumentation*; D012106:Research / Q000706:statistics & numerical data; D012107:Research Design; D012890:Sleep / Q000502:physiology; D012894:Sleep Stages / Q000502:physiology; D012893:Sleep Wake Disorders / Q000175:diagnosis*; D012895:Sleep, REM / Q000502:physiology*