Actigraphy In Patients Research Articles

Sleep Fragmentation and Sleep-Wake Cycle Dysregulation Are Associated with Cerebral Tau Burden in Patients with Mild Cognitive Impairment due to Alzheimer's Disease: A Case Series.

Although disturbed sleep is frequent in patients with mild cognitive impairment (MCI) and dementia due to Alzheimer's disease (AD), the association between sleep and tau pathology is unclear. This case series focused on measuring the sleep-wake rhythm over 7 days through actigraphy in patients diagnosed with MCI due to AD. Further, the association between sleep-wake cycle and tau deposition measured through positron emission tomography (PET) was explored. This case series included 6 MCI due to AD patients (2 women and 4 men, mean age 73.17±5.53 years), who completed neuropsychological testing, 7-day actigraphy, and tau PET imaging with radiolabeled compounds aimed to estimate the density and distribution of aggregated tau neurofibrillary tangles in the brain. The case series indicated that patients with MCI due to AD who exhibited greater tau deposition in the frontal, parietal, and limbic regions, as well as in the precuneus and olfactory regions, also showed increased sleep fragmentation, as measured through actigraphy. The findings from this case series suggest a potential link between tau deposition in key brain regions associated with AD and both sleep fragmentation and sleep-wake cycle dysregulation in a small sample of patients with MCI due to AD. These preliminary results warrant further investigation in larger, more comprehensive studies to confirm and expand upon these findings.

Comparison of rTMS of 1hz, 5hz and 10hz on sleep actigraphy in patients with depression

Comparison of rTMS of 1hz, 5hz and 10hz on sleep actigraphy in patients with depression

0803 Extreme upper extremity movements in patient with narcolepsy type 1 and REM sleep behavior disorder affecting actigraphy results

Abstract Introduction Narcolepsy with Cataplexy is a central disorder of hypersomnia that is characterized by excessive daytime sleepiness and Rapid eye movement (REM) dissociation phenomena. A common manifestation of narcolepsy is REM behavioral disorder (RBD), a parasomnia characterized by loss of muscle atonia during REM sleep (RSWA). While RBD is relatively common in patients with narcolepsy, very extreme movements are considered rare. Report of Cases: A 20-year-old male with no significant past medical history presented with 8 months of new onset daytime sleepiness, sleep paralysis, and auditory hallucinations at sleep onset. After initial evaluation at our sleep center, he was scheduled for actigraphy testing and sleep logs, followed by video polysomnogram and mean sleep latency testing (MSLT). Initial PSG results were notable for a total sleep time of 498 minutes, a normal apnea-hypopnea index of 0.7/hr., sleep onset latency of 0 minutes, and REM latency of 0 minutes. Based upon military medical standards, the MSLT scheduled for the following morning was cancelled due to limited sleep during the preceding 2 weeks as measured via actigraphy. However, the patient’s sleep logs reported over 7.5 hours of sleep per night. The patient’s video PSG was reviewed, which showed evidence of frank RSWA, as well as episodes of dream enactment behavior during REM sleep, all including very violent movement in his upper extremities. Repeat trial of MSLT 2 weeks later showed mean sleep latency of 1.7 minutes, with 5 sleep onset REM periods (SOREMPS), and evidence of dream enactment involving the upper extremities during 3 of these SOREMPS. Conclusion We present the case of a patient with narcolepsy and RBD with significant upper extremity movements to the point of affecting the actigraphy sleep/wake detection algorithm. Actigraphy has been validated as a diagnostic tool in assessing sleep and wake patterns in individuals without significant REM sleep dissociation phenomena; however, our case highlights the necessity of further research of the validity of actigraphy in patients with Narcolepsy and/or REM behavioral disorder. Support (If Any)

The impact of pimavanserin on psychotic phenotypes and tau phosphorylation in the P301L/COMT- and rTg(P301L)4510 mouse models of Alzheimer's disease.

IntroductionPsychosis in Alzheimer's disease (AD) is associated with grave clinical consequences including a precipitous cognitive decline and a hastened demise. These outcomes are aggravated by use of existing antipsychotic medications, which are also associated with cognitive decline and increased mortality; preclinical models that would develop new therapeutic approaches are desperately needed. The current report evaluates the ability of the neoteric antipsychotic, pimavanserin, to normalize hyperkinesis and sensorimotor gating in the novel catechol‐O‐methyltransferase (COMT) deleted P301L/COMT– and rTg(P301L)4510 models of psychotic AD, and the impact of pimavanserin on tau pathology.MethodsFemale P301L/COMT– mice were behaviorally characterized for abnormalities of locomotion and sensorimotor gating, and biochemically characterized for patterns of tau phosphorylation relative to relevant controls utilizing high‐sensitivity tau enzyme‐linked immunosorbent assay (ELISA). Female P301L/COMT– and rTg(P301L)4510 mice were randomized to pimavanserin or vehicle treatment to study the ability of pimavanserin to normalize locomotion and rescue sensorimotor gating. Additionally, high‐sensitivity tau ELISA was used to investigate the impact of treatment on tau phosphorylation.ResultsP301L/COMT– mice evidenced a hyperlocomotive phenotype and deficits of sensorimotor gating relative to wild‐type mice on the same background, and increased tau phosphorylation relative to COMT‐competent P301L mice. Pimavanserin normalized the hyperkinetic phenotype in both the P301L/COMT– and rTg(P301L)4510 mice but had no impact on sensorimotor gating in either model. Pimavanserin treatment had little impact on tau phosphorylation patterns.DiscussionThese data suggest that pimavanserin ameliorates tau‐driven excessive locomotion. Given the morbidity associated with aberrant motor behaviors such as pacing in AD and lack of effective treatments, future studies of the impact of pimavanserin on actigraphy in patients with this syndrome may be warranted.

Intravesical Bacillus Calmette-Guerin treatment-induced sleep quality deterioration in patients with non-muscle invasive bladder cancer: functional outcome assessment based on a questionnaire survey and actigraphy.

We investigated sleep parameters and patient-reported outcomes before, during, and after induction Bacillus Calmette-Guerin therapy using questionnaires and actigraphy in patients with non-muscle invasive bladder cancer. We investigated 10 patients who received Bacillus Calmette-Guerin therapy once weekly for 8 weeks. The International Prostate Symptom Score, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, Functional Assessment of Cancer Therapy-Bladder, and multi-item Short Form-8 tools were used to assess patient-reported outcomes. Participants completed all questionnaires before (baseline), at the 4th and 8th doses, and 1 month after the last Bacillus Calmette-Guerin dose. The MotionWatch8 was fastened to patients' waist throughout the study. Composite sleep quality was determined based on sleep duration, efficiency, and fragmentation. We observed a transient increase in frequency/nocturia subscores and the insomnia subscore. The number of patients with poor sleep quality increased from 0 (0%) at baseline to 7 (70%) at the 4th dose and to 6 (60%) patients at the 8th dose. Among 10 patients, 6 (60%) were assigned to the sleep deterioration groupand 4 (40%) to the non-deterioration group. Sleep quality was restored to baseline levels in 5 of 6 patients (83%) within 1 month after the last dose in the sleep deterioration group, and the nocturia subscore of the International Prostate Symptom Score was significantly increased only in this group (P=0.03). This is the first study that confirms intravesical Bacillus Calmette-Guerin-induced sleep quality deterioration based on a questionnaire survey and actigraphy.

Characteristics of Sleep Structure Assessed by Objective Measurements in Patients With Amnestic Mild Cognitive Impairment: A Meta-Analysis

Objectives: This study aims to explore the differences of sleep structure between patients with amnestic mild cognitive impairment (aMCI) and elderly people with normal cognition, which will help to provide evidence for the relationship between sleep disturbances and cognitive impairment.Methods: A systematic review and meta-analysis were conducted on the literature on sleep parameters obtained by polysomnography or actigraphy in patients with aMCI. The PubMed and EMBASE databases were searched up to April 2020. Inclusion and exclusion criteria were established according to evidence-based medicine methods, and data of all eligible studies were meta-analyzed using the Review Manager 5.3 software.Results: Among the 1,171 literature articles on sleep structure of patients with MCI, eight case-control studies met the inclusion criteria and were included in this meta-analysis. A total of 278 subjects were included, of which 103 were patients with aMCI and 175 were elderly people with normal cognition. The results showed that sleep efficiency (SE) and slow wave sleep (SWS) of patients with aMCI were significantly lower than those of healthy elderly people. Compared with the control group, the percentage of stage 1 of non-rapid eye movement (N1%) in the aMCI patients group increased, and the percentage of stage 2 of non-rapid eye movement (N2%) decreased.Conclusions: Patients with aMCI may experience more severe sleep disturbances than normal cognitive elderly people. There were specific changes, especially in SE and SWS, in the sleep structure of patients with aMCI when compared to those with normal cognition.

Characterization and determinants of sleep measured by self-report and wrist actigraphy in patients with interstitial lung disease

PURPOSE The purpose of this study was to determine the association between sleep measurements by wrist actigraphy and patient self-report and assess the impact of physical activity and extrapulmonary symptoms on sleep quality in patients with fibrotic interstitial lung disease (ILD). METHODS Patients were recruited from specialized ILD clinics. Total sleep time, sleep efficiency, sleep latency and number of sleep disturbances were measured using the Pittsburgh Sleep Quality Index (PSQI) and an ActiGraph monitor worn on patients’ non-dominant wrist for seven consecutive days. Step counts were monitored over the same period using a waist monitor. Extrapulmonary symptoms were assessed with the Hospital Anxiety and Depression Scale and Brief Pain Inventory. Multivariable analyses were used to examine whether physical activity and extrapulmonary symptoms were determinants of sleep quality in fibrotic ILD. RESULTS A total of 111 patients were assessed (62% male, mean age 70 ± 9 years). Mean self-reported total sleep time was 494 ± 80mins/night. Median self-reported sleep efficiency and latency were 97% (94–98%) and 15 min (8–30 min), respectively. Poor sleep quality was reported in 61% of patients. Wrist monitors detected a mean total sleep time of 441 ± 72mins/night. Median sleep efficiency and latency measured by wrist monitors were 88% (83–91%) and 2 min (0–7 min), respectively. The PSQI was largely within limits of agreement in reference to the wrist monitor recordings. Higher pain severity was an independent predictor of reduced sleep efficiency, increased sleep latency and greater number of sleep disturbances measured by the PSQI on adjusted analyses. CONCLUSIONS The PSQI is generally in agreement with wrist actigraphy measurements. Pain is a determinant of sleep in fibrotic ILD.

The AWAKE-HF Study: Sacubitril/Valsartan Impact on Daily Physical Activity and Sleep in Heart Failure.

AWAKE-HF evaluated the effect of the initiation of sacubitril/valsartan versus enalapril on activity and sleep using actigraphy in patients who have heart failure with reduced ejection fraction (HFrEF). In this randomized, double-blind study, patients with HFrEF (n = 140) were randomly assigned to sacubitril/valsartan or enalapril for 8weeks, followed by an 8-week open-label phase with sacubitril/valsartan. Primary endpoint was change from baseline in mean activity counts during the most active 30min/day at week 8. The key secondary endpoint was change in mean nightly activity counts/minute from baseline to week 8. Kansas City Cardiomyopathy Questionnaire-23 (KCCQ-23) was an exploratory endpoint. There were no detectable differences between groups in geometric mean ratio of activity counts during the most active 30min/day at week 8 compared with baseline (0.9456 [sacubitril/valsartan:enalapril]; 95% confidence interval [CI] 0.8863-1.0088; P = 0.0895) or in mean change from baseline in activity during sleep (difference: 2.038counts/min; 95% CI - 0.062 to 4.138; P = 0.0570). Change from baseline to week 8 in KCCQ-23 was 2.89 for sacubitril/valsartan and 4.19 for enalapril, both nonsignificant. In AWAKE-HF, no detectable differences in activity and sleep were observed when comparing sacubitril/valsartan with enalapril in patients with HFrEF using a wearable biosensor. ClinicalTrials.gov, NCT02970669.

7-Days actigraphy in patients with Parkinson disease: a 2-years follow-up

The 2nd International Workshop on Science and Technology of Advanced Materials and Devices (STAMD 2017) was held at February 08-10, 2017 in Seoul, South Korea. STAMD 2017 brought together experts from many research areas who presented and discussed the most recent developments and future trends in the field of advanced materials science and engineering.The topics of interest of STAMD 2017 included but were not limited to: optics, nanoelectronics, photonics, advanced materials and devices, fabrication and measurement procedures, nanomedicine and biotechnology, sensors and actuators, energy harvesting and storage, computational science and technology. The STAMD 2017 combined oral and poster presentations by a number of recognized international researchers. This workshop offered an ideal platform to present, share and exchange the ideas, as well as to establish contacts for the academicians, young researchers and students all around the world.This special issue contains selected manuscripts submitted for publication in Materials Today: Proceedings journal. The STAMD 2017 organizers would like to thank the reviewers, scientific committee, delegates and workshop staff for their contributions to make STAMD 2017 a very successful event.

WITHDRAWN: 7-days actigraphy in patients with Parkinson disease: A 2-years follow-up

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Objective analysis of sleep disturbance by using actigraphy in patients with Parkinson’s disease

Background: Sleep disturbance are a common type of non-motor symptoms in Parkinson’s diseases (PD). Actigraphy can correctly measure the severity of sleep disturbance in patients with PD who have involuntary movements associated with a decreased activity threshold.

Feasibility of Continuous Actigraphy in Patients in a Medical Intensive Care Unit.

Poor sleep and immobility are common in patients in the medical intensive care unit (MICU) and are associated with adverse outcomes. Interventions to promote sleep and mobilization in the MICU are gaining popularity, but feasible instruments to measure their effectiveness are lacking. Actigraphy may be useful for large-scale, continuous measurement of sleep and activity, but its feasibility in MICU patients has not been rigorously evaluated. To evaluate the feasibility of continuous actigraphy measurement in consecutive MICU patients. Wrist and ankle actigraphy data were collected for 48 hours in consenting MICU patients. Actigraphy-based measures of estimated sleep and activity were summarized by using descriptive statistics. Agreement between wrist and ankle measurements was evaluated using Cohen κ statistics (for sleep quantity) and intraclass correlation coefficients (for activity). Overall, 35 of 48 (73%) eligible patients were enrolled, including 10 requiring mechanical ventilation. Of these patients, 34 (97%) completed the 48-hour actigraphy period; 20 (57%) found the devices comfortable. Wrist devices logged a mean (SD) of 33.4 (8.8) hours of estimated sleep (72% [19%] of recording period) and 19.6 (17.2) movements per 30-second epoch. Ankle devices recorded 43.2 (4.1) hours of estimated sleep (93% [7%] of recording period) and 5.1 (6.0) movements per 30 seconds. Uninterrupted actigraphy is feasible and generally well tolerated by MICU patients and may be considered for future large-scale studies. Wrist and ankle actigraphy measurements of sleep and activity in this setting agree poorly and cannot be used interchangeably.

Actigraphy in Patients With Major Depressive Disorder Undergoing Repetitive Transcranial Magnetic Stimulation

The effects of repetitive transcranial magnetic stimulation (rTMS) on physical activity and sleep patterns in individuals with major depressive disorder (MDD) remain unclear. We examined the effects of rTMS treatment on the rest-activity cycle and sleep disturbances in MDD. In this open-label pilot study, 14 patients with medication-resistant MDD underwent 10 rTMS sessions over the bilateral dorsolateral prefrontal cortex. In addition to Hamilton Depression Rating Scale and Pittsburgh Sleep Quality Index scores, waist actigraphy was used to evaluate alterations in the rest-activity cycle over the course of rTMS treatments. Actigraphic data were evaluated at baseline and in the first (rTMS sessions 1-3), second (rTMS sessions 4-7), and third (rTMS sessions 8-10) sections. Although Hamilton Depression Rating Scale and Pittsburgh Sleep Quality Index scores were significantly improved by rTMS, sleep variables assessed by actigraphy did not show significant changes. However, post hoc tests indicated a significant increase in mean steps per day between the baseline and first section time points (P = 0.014; t13 = -2.316). Our data indicated that a daytime physical activity response to rTMS occurred in early sessions, whereas subjective symptom improvements were consistent across all sessions. Future double-blind placebo-controlled studies assessing the effects of rTMS on the rest-activity cycle and sleep disturbances in MDD are warranted.

Sleep by actigraphy in patients with remitted bipolar disorders

Sleep by actigraphy in patients with remitted bipolar disorders

Actigraphic Analysis of Patients with Cervical Disc Herniation.

To analyze the relationship between the severity of pain and sleep disorder using wrist actigraphy in patients with cervical disc herniation (CDH). Fifty patients with the diagnosis of CDH underwent subjective tests and actigraphic analysis in preoperative period, and at the end of postoperative first week and postoperative first month. The data of the subjective tests and actigraphic analysis were compared. There was a strong and statistically significant negative correlation between the subjective tests of Visual Analog Scale (VAS) for Pain 0-1-2 and the objective parameters of Sleep Onset Latency (SOL) 0-1-2 (rs= -0.798, p=0.009 - rs= - 0.832, p=0.006 - rs=- 0.710, p=0.004). There was a positive correlation between the subjective tests of VAS for Pain 0-1-2 and the objective parameters of Sleep Efficiency (SEF) 0-1-2 (rs=0.721, p=0.006 - rs= 0.768, p=0.001 - rs= 0.748, p=0.001). Actigraphy may be used for the evaluation of cervical disc surgery, as an alternative and objective test for sleep disorders.

Objective Sleep Quality Assessment Using Wrist Actigraphy in Patients With Ulcerative Colitis

Introduction: Patients with inflammatory bowel disease (IBD) have a higher prevalence of subjective sleep disturbances and this has been associated with subclinical inflammation and risk for active disease at 6 months. Although these associations are of interest, objective sleep assessment has not been performed in ulcerative colitis (UC) patients. Methods: This is a prospective assessment of adult UC patients in clinical remission who underwent surveillance colonoscopy and wore a wrist actigraphy watch for 7 days prior to colonoscopy. Subjective sleep quality and quality of life were assessed using the Pittsburgh sleep quality index (PSQI) and the short inflammatory bowel disease questionnaire (SIBDQ). Objective sleep parameters assessed were: sleep onset latency (SOL), total sleep time (TST), wake after sleep onset (WASO), sleep efficiency (SE). Endoscopy and pathology were reviewed for all patients. Statistical analysis included a Fischer’s exact test, Student’s t-test, and Pearson’s correlation coefficient. Results: Fourteen UC patients participated in the study, 9 (64%) were male, the mean age was 44.7 years (standard deviation [SD] 14.2 years), 9 patients (64.3%) were described as having pancolitis, and the mean duration of disease was 16.3 years (SD 11.4 years). A greater number of patients had abnormal objective vs. subjective sleep measures (8 (57.1%) vs. 4 (38.6%)). The mean total time in bed was 481 minutes (SD 72.4 minutes) and TST of 346 minutes (SD 112 minutes), with a calculated SE of 71.3% (SD 6%), SOL 28.5 minutes (SD 22.1 minutes), WASO 40.7 minutes (SD 17.4 minutes), and number of awakenings 30.8 (SD 12.8). Five (35.7%) patients had inflammation present on endoscopic assessment. Patients with inflammation were older (55 years vs. 39 years; p=0.04), had longer disease duration (25.8 years vs. 11 years; p=0.01), and had higher PSQI scores (7.2 vs. 2.9; p<0.01). There were no differences in objective sleep parameters between patients with inflammation and those without inflammation. There was a trend towards higher quality of life scores in patients without inflammation (p=0.08). There was an excellent correlation in all patients between SIBDQ scores and PSQI scores (r=-0.74), WASO (r=+0.64), and number of awakenings (r=+0.61). Conclusion: This is the first description of patients with UC using wrist actigraphy to assess sleep quality. There were no statistical differences in objective sleep measures between patients with histologic inflammation and those without inflammation. Despite all patients being in clinical remission, a large percentage had disrupted sleep. There was excellent correlation between quality of life and PSQI scores and objective sleep measures; WASO and average number of awakenings.

Actigraphy in patients with treatment-resistant depression undergoing electroconvulsive therapy

Depressive disorder is frequently accompanied by changes in psychomotor activity and disturbances of the sleep–wake cycle. The chronobiological effects of electroconvulsive therapy (ECT) in patients with treatment-resistant depression (TRD) are largely unknown. The objective of the current study was to measure the influence of ECT on patients' activity and sleep. 15 patients with unipolar TRD were treated with ECT. Activity levels were measured with wrist actigraphy before and after ECT. Remission rate (score on the 17-item Hamilton Depression Rating Scale lower than 8 points) was 40.0%. Remitters had increases of 56.0% on light activity, 49.8% on total activity, and 70.2% on circadian amplitude, while there was no significant change of these variables in subjects who did not experience remission. The circadian acrophase and actigraphic sleep-parameters were not significantly affected by treatment.

Clinical Application of Actigraphy in Psychotic Disorders: A Systematic Review

Actigraphy has become increasingly recognized as a useful method to study sleep/wake patterns and activity monitoring. It is a reliable tool for confirming a diagnosis and evaluating the effect of treatments for sleep problems in patients with primary psychiatric diagnoses such as schizophrenia. In addition, actigraphy is an objective measure that circumvents the lack of insight and often unreliable self-reporting of mental health related problems. However, the literature regarding the use of actigraphy in research and clinical applications related to severe psychiatric populations is scarce. Amalgamation of the evidence is needed to advance the use of actigraphy in psychiatry. We summarized the literature to date related to the use of actigraphy in patients with psychotic disorders, specifically schizophrenia. We conducted a systematic review of journal databases. Sixty-six studies emerged from the search of the electronic search engines, 14 were RCTs/case-control studies and 14 were review/guideline papers and others were case studies. Results of the RCT/case-control studies comparing the use of actigraphy with patients versus control were summarized. Actigraphy not only allows for the objective evaluation of sleep habits and circadian rhythm disorders, but also helps to clarify and compare sleep and activity patterns among severe psychiatric disorders such as schizophrenia. Additionally, actigraphy data can be used as an outcome measure for changes in sleep patterns either when primary psychotic disorders are treated and/or when the sleep disturbance associated with the psychotic disorder is treated. Finally, actigraphy serves as a supplementary tool to study neuropathology of movement-related psychiatric disorders including schizophrenia.

Estimation of sleep disturbances using wrist actigraphy in patients with postural tachycardia syndrome

Patients with postural tachycardia syndrome (POTS) commonly complain of fatigue, unrefreshing sleep, daytime sleepiness and diminished quality of life. The study objective was to assess sleep quality in POTS patients using wrist actigraphy. Prospective study with control group. Patients with POTS (n = 36) and healthy subjects (n = 36) completed a detailed sleep log and actigraphy for 7 days. Compared with healthy subjects, POTS patients have more self-reported problems including days with restless sleep (53 ± 30% vs. 21 ± 20%; P<0.001) and tiredness (75 ± 23% vs. 39 ± 27%; P<0.001). Using actigraphy, POTS patients have lower sleep efficiency (73 ± 13% vs. 79 ± 6%; P = 0.01). Actigraphy determined sleep onset latency (SOL) did not vary significantly in the two groups, but subjective SOL was higher in POTS patient (56 ± 66 min vs. 1 3 ± 9 min; P = 0.001). In POTS patients, there was a significant correlation between subjective complaints of tiredness and actigraphic sleep efficiency (Rs = -0.36; R(2) = 0.15; P = 0.01), significant correlations between actigraphic SOL and upright norepinephrine levels (P = 0.040), and between wake after sleep onset and standing heart rate (P = 0.02). POTS patients have more sleep-related symptoms and poor sleep efficiency. The pattern of subjective vs. objective SOL mismatch is suggestive of sleep-state misperception. High norepinephrine correlated with actigraphic SOL, and this activation of the stress system may contribute significantly to a hyperarousal state with consequent insomnia, poor mental and physical health in POTS patients.

Comparison of sleep diary and actigraphy to evaluate total sleep time in hypersomnia patients

A sleep diary is often employed for diagnosing and treating hypersomnia. However, its reliability needs to be evaluated because overlooked chronic sleep insufficiency could be misdiagnosed as narcolepsy. In this study, we compared simultaneous sleep measurements using a sleep diary and by actigraphy in patients visiting our sleep clinic for the first time with complaints of excessive daytime sleepiness. Of the 28 patients enrolled, 24 complied with both these requirements. In this population, the results obtained using a sleep diary tended to estimate a statistically significant earlier sleep onset time and longer total sleep time than those via actigraphy. For total sleep time, this tendency was more prominent in patients with a higher Epworth Sleepiness Scale score. In 5 of the 24 (20.8%) patients, the sleep diary records indicated >6 h of total sleep time while the actigraphy records indicated 1 h. These results suggested that sleep insufficiency in hypersomnia patients may be overlooked when their sleep time is assessed using only a sleep diary in the initial phase of the diagnostic procedure, and the simultaneous use of actigraphy may be preferable in this assessment.