Issue Navigator

Volume 12 No. 12
Earn CME
Accepted Papers

Sleep Medicine Pearls

A Night of No Sleep?

Bhanu Prakash Kolla, MD, MRCPsych1,2; Meghna P. Mansukhani, MD, FAASM1; Steven I. Altchuler, PhD, MD1,2
1Center for Sleep Medicine, Mayo Clinic, Rochester, MN; 2Department of Psychiatry and Psychology Mayo Clinic, Rochester, MN

Ms. C, a 20-year-old female was referred for a sleep evaluation for hypersomnia. She reported increasing sleepiness over a period of one year. She described a pattern of retiring to bed at 20:00 with an initial sleep latency of 10 minutes. She would sleep uninterrupted until 06:30 and wake to an alarm clock. She avoided napping during the day. Her history was otherwise not suggestive of narcolepsy or sleep apnea. She was not on any medications and had a medical history significant only for celiac sprue.

To evaluate her hypersomnolence, two-week wrist actigraphy, followed by polysomnography and a multiple sleep latency test (MSLT) were ordered. She was instructed to spend at least seven, preferably eight hours in bed every night for two weeks prior to polysomnography and to maintain a sleep log.

Two-week actigraphy revealed a mean sleep time (hours:minutes) of 07:40 (range: 06:15 to 09:53) and sleep efficiency of 86.8% (range: 78.2% to 92.1%). Overall, going to bed and wake up times were fairly consistent. On one night, Sunday the 7th of August, no sleep appeared to have occurred, whereas the patient's sleep log reported a bedtime of 22:00 and a wake time of 09:00 the following morning. The actigraph registered an absence of light that night, which was similar to other nights during the recording timeframe. The actogram is presented in Figure 1.

Actogram depicting the results of two-week wrist actigraphy.

The yellow shading indicates presence of white light as detected by the optic sensor, while absence of shading indicates no light detected by the optical sensor.


Figure 1

Actogram depicting the results of two-week wrist actigraphy.

(more ...)

QUESTION: What is the possible reason for the actigraph determining complete lack of sleep on the night of Sunday, 7th of August, 2016?

ANSWER: Upon inquiring with the patient about the night in question, she informed the clinician that she was in fact asleep but was traveling overnight in a Greyhound bus to get to her sleep appointment. The period of time determined to be wakefulness by the actigraph was thus considered to be artifactual secondary to movement associated with being in the bus.


The International Classification of Sleep Disorders, Third Edition (ICSD-3) does not require, but recommends actigraphy prior to conducting a MSLT. Actigraphy has been demonstrated to more reliably capture complete information regarding sleep/wake patterns compared to sleep logs.1 Actigraphy has also been shown to influence a clinician's decision about whether a patient has obtained enough sleep in order to proceed with MSLT.1 Additionally, the mean sleep latency on MSLT negatively correlates with sleep duration measured by actigraphy and not sleep duration that is self-reported or derived from sleep logs.2

Actigraphy relies on an accelerometer device which records movement data.3 This movement data is converted to activity counts which are then fed as input into classification algorithms. The algorithms, based on the level of activity, determine whether a given time period is either sleep or wake.4 In our patient, the actigraph recorded movement all through the night of the 7th of August, 2016, which was labeled wakefulness. The optic sensor revealed an absence of ambient light between 20:00 to 06:00 the following morning.

The patient's actogram must always be reviewed in conjunction with their sleep logs. Clinical correlation with regard to the patient's sleep environment and careful evaluation to exclude potential movement artefact, which could occur in situations where there is increased baseline movement, is required while evaluating actigraphy results. Information from optic sensors can add value by helping the provider determine whether the patient was in a well-lit environment during the time that sleep is recorded.


  1. Actigraphy relies on movement data to determine sleep/wake

  2. Environments associated with increased movement can result in artifactual findings on actigraphy

  3. The optic sensor can be useful to help determine sleep/ wake times

  4. Clinical correlation is always necessary when interpreting data obtained on actigraphy


This was not an industry supported study. Dr. Mansukahni has received research support from ResMed. The other authors have indicated no financial conflicts of interest. This work was performed at the Mayo Clinic, Rochester, MN.


Kolla BP, Mansukhani MP, Altchuler SI. A night of no sleep? J Clin Sleep Med 2016;12(12):1698–1700.



Auger RR, Varghese R, Silber MH, Slocumb NL. Total sleep time obtained from actigraphy versus sleep logs in an academic sleep center and impact on further sleep testing. Nat Sci Sleep. 2013;5:125–31. [PubMed Central][PubMed]


Bradshaw DA, Yanagi MA, Pak ES, Peery TS, Ruff GA. Nightly sleep duration in the 2-week period preceding multiple sleep latency testing. J Clin Sleep Med. 2007;3:613–9. [PubMed Central][PubMed]


Sadeh A. The role and validity of actigraphy in sleep medicine: an update. Sleep Med Rev. 2011;15:259–67. [PubMed]


Kripke DF, Hahn EK, Grizas AP, et al. Wrist actigraphic scoring for sleep laboratory patients: algorithm development. J Sleep Res. 2010;19:612–9. [PubMed]