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Practice Parameters for Clinical Use of the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test

Michael R. Littner MD1; Clete Kushida MD, PhD2; Merrill Wise MD3; David G. Davila, MD4; Timothy Morgenthaler MD5; Teofilo Lee-Chiong MD6; Max Hirshkowitz PhD7; Daniel L. Loube MD8; Dennis Bailey DDS9; Richard B. Berry MD10; Sheldon Kapen MD11; Milton Kramer MD12

1VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Sepulveda, CA; 2Stanford University Center of Excellence for Sleep Disorders, Stanford, CA; 3Departments of Pediatrics and Neurology, Baylor College of Medicine, Houston, TX; 4Sleep Disorders Center, Baptist Medical Center, Little Rock, AR; 5Mayo Sleep Disorders Center, Mayo Clinic, Rochester, MN; 6National Jewish Medical and Research Center, Sleep Clinic, Denver, CO; 7Baylor College of Medicine and VA Medical Center, Houston, TX; 8Sleep Medicine Institute, Swedish Medical Center, Seattle, WA; 9Englewood, Colorado; 10Malcolm Randall VAMC/Univ. of Florida – Gainesville, Fla; 11VA Medical Center and Wayne State University, Detroit, MI; 12Maimoides Medical Center, Psychiatry Department, Brooklyn, NY and New York University School of Medicine, New York, NY

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Characterization of excessive sleepiness is an important task for the sleep clinician, and assessment requires a thorough history and in many cases, objective assessment in the sleep laboratory. These practice parameters were developed to guide the sleep clinician on appropriate clinical use of the Multiple Sleep Latency Test (MSLT), and the Maintenance of Wakefulness Test (MWT). These recommendations replace those published in 1992 in a position paper produced by the American Sleep Disorders Association. A Task Force of content experts was appointed by the American Academy of Sleep Medicine to perform a comprehensive review of the scientific literature and grade the evidence regarding the clinical use of the MSLT and the MWT. Practice parameters were developed based on this review and in most cases evidence based methods were used to support recommendations. When data were insufficient or inconclusive, the collective opinion of experts was used to support recommendations. These recommendations were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine.

The MSLT is indicated as part of the evaluation of patients with suspected narcolepsy and may be useful in the evaluation of patients with suspected idiopathic hypersomnia. The MSLT is not routinely indicated in the initial evaluation and diagnosis of obstructive sleep apnea syndrome, or in assessment of change following treatment with nasal continuous positive airway pressure (CPAP). The MSLT is not routinely indicated for evaluation of sleepiness in medical and neurological disorders (other than narcolepsy), insomnia, or circadian rhythm disorders. The MWT may be indicated in assessment of individuals in whom the inability to remain awake constitutes a safety issue, or in patients with narcolepsy or idiopathic hypersomnia to assess response to treatment with medications. There is little evidence linking mean sleep latency on the MWT with risk of accidents in real world circumstances. For this reason, the sleep clinician should not rely solely on mean sleep latency as a single indicator of impairment or risk for accidents, but should also rely on clinical judgment. Assessment should involve integration of findings from the clinical history, compliance with treatment, and, in some cases, objective testing using the MWT. These practice parameters also include recommendations for the MSLT and MWT protocols, a discussion of the normative data available for both tests, and a description of issues that need further study.

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