Advanced Sleep Wake Phase Disorder
According to Up to Date, “A reasonable approach for patients with ASWPD is to use bright light therapy for one to three hours per night with an intensity of 2500 to 10,000 lux, beginning at the time that they usually experience evening sleepiness. We instruct patients to use a commercially available bright light source that filters ultraviolet light. Patients should sit about one to two feet from the bright light source. They can read or perform other activities and are not expected to stare directly at the light.”
American Academy of Sleep Medicine: Practice Parameters for the Clinical Evaluation and Treatment of Circadian Rhythm Sleep Disorders. (2007).
Prescribed sleep/wake scheduling, timed light exposure, or timed melatonin administration are indicated as treatments for patients with ASPD. [11.4] (Option)
This recommendation is based on available evidence and committee consensus. One level 4 study (78) achieved sleep advance with sleep scheduling.
There have been six studies using scheduled bright light as a treatment. One level 3 study (73) found evening light exposure no more effective than placebo in shifting circadian phase. A level 2 study (79) succeeded in reducing time in bed after awakening in the morning. Another level 2 study (74) that used ICSD criteria to determine ASPD presence succeeded in improving sleep variables but another level 2 replication of this study (75) did not. One level 4 (77) and one level 2 study (76) achieved post-treatment DLMO phase delays and improved sleep quality in patients with complaints of terminal insomnia.
Although there is a rationale for using melatonin for ASPD, there is no reported evidence in support of this treatment. Overall, the evidence for efficacy of these interventions is weak or conflicting, but the risks and costs entailed are low. As there are few alternatives, an individualized approach using one or more of these treatments with follow up to ascertain efficacy or side effects may be appropriate.
73. Palmer, CR, Kripke, DF, Savage, HC, Jr., Cindrich, LA, Loving, RT, and Elliott, JA. Efficacy of enhanced evening light for advanced sleep phase syndrome. Behavioral Sleep Medicine 2003;1:213-226.
74. Campbell, SS, Dawson, D, and Anderson, MW. Alleviation of sleep maintenance insomnia with timed exposure to bright light. J Am Geriatr Soc 1993;41:829-836.
75. Suhner, AG, Murphy, PJ, and Campbell, SS. Failure of timed bright light exposure to alleviate age-related sleep maintenance insomnia. Journal of the American Geriatrics Society 2002;50:617-623.
76. Lack, L, Wright, H, Kemp, K, and Gibbon, S. The treatment of early-morning awakening insomnia with 2 evenings of bright light. Sleep 2005;28:616-623.
77. Lack, L, and Wright, H. The effect of evening bright light in delaying the circadian rhythms and lengthening the sleep of early morning awakening insomniacs. Sleep 1993;16:436-443.
78. Moldofsky, H, Musisi, S, and Phillipson, EA. Treatment of a case of advanced sleep phase syndrome by phase advance chronotherapy. Sleep 1986;9:61-65.
79. Pallesen, S, Nordhus, IH, Skelton, SH, Bjorvatn, B, and Skjerve, A. Bright light treatment has limited effect in subjects over 55 years with mild early morning awakening. Perceptual & Motor Skills 2005;101:759-770.
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American Academy of Sleep Medicine Review: Circadian Rhythm Sleep Disorders: Part II, Advanced Sleep Phase Disorder, Delayed Sleep Phase Disorder, Free-Running Disorder, and Irregular Sleep-Wake Rhythm (2007)
ASPD
11.4.2 Timed Light Exposure
In the largest study to date, involving 47 older adults diagnosed with ASPD (although the specific criteria used to make this determination are not clear), “enhanced evening light” (averaging 265 lux) administered for 2 to 3 hours was no more effective than placebo in counteracting advanced sleep phase (as indicated by actigraphy). Nevertheless, patients reported a subjective benefit (level 3) [21]. The light treatment in this study (265 lux) was not as intense as bright light treatment (2000 to 10,000 lux) used in many other studies, and the timing was earlier than usual (15:00 to 17:00). Moreover, the degree of baseline circadian advancement, as assessed by aMT6 acrophases, was unclear, as the authors used unspecified reference standards culled from their other investigations.
Bright evening light exposure produced similarly lackluster results in a treatment trial in patients with complaints of early-morning awakenings, although no physiologic phase markers were utilized. The treatment was administered for 30 minutes, beginning approximately 1 hour before subjects’ habitual bedtimes, for a duration of 3 weeks (level 2) [27]. As compared to the sham treatment condition, those receiving active treatment described subjective improvement in early morning awakenings, as manifested by an approximately 20 minute decrease of time in bed subsequent to final morning arising. No other differences were observed with respect to the additional subjective variables, or with respect to any of the actigraphic variables.
Greater success was demonstrated in a study of subjects with ICSD-1-defined ASPD, utilizing evening light therapy (4000 lux, 2-hour duration, between 20:00 and 23:00 [8pm to 11pm]) for 12 consecutive days (level 2) [22]. A greater-than-two-hour CBTmin post-treatment delay was demonstrated, in association with an average delay in bedtime of 29 minutes, an approximately 13% increase in sleep efficiency, and a related decrease in wakefulness after sleep onset (WASO). Post-treatment sleep architecture changes were also noted in the form of increased REM latency, decreased percentage Stage 1 NREM sleep, and increased percentage Stage 2 NREM sleep. The control group demonstrated no significant changes in either sleep or circadian parameters.
However, in their most recent study, the same group, utilizing an essentially identical protocol failed to replicate many of these findings. Although treatment resulted in significant delays in both group CBTmin (94 minutes) and sleep onset (44 minutes), in addition to a significant increase in the phase angle of CBTmin and sleep midpoint by more than 1 hour, no other significant improvements in PSG-determined sleep parameters were obtained (level 2) [23]. Subsequently, patients received light therapy twice weekly for a 3-month period (maintenance treatment phase); they then demonstrated a trend toward reversion to the pre-treatment CBTmin (i.e., phase advance), and a lack of significant difference between any assessed parameter as compared with controls. Subjective sleep quality improved in the active group during maintenance treatment, but not in the control group. The authors proposed that the discrepancy in results may have been due to heterogeneous patient populations in their second study (a formal diagnosis of ASPD was not required, as it was in the first study), and/or unmonitored adherence to treatment.
Finally, capitalizing on the success of an earlier uncontrolled pilot investigation (level 4) [25] a different group recently designed a study specifically involving individuals with isolated early-morning awakenings and assessed the effects of two consecutive nights of light therapy (2500 lux, administered for four hours from 20:00 to 01:00 (level 2) [24]. Both active and sham treatment groups had much earlier baseline CBTmin values than the aforementioned studies for which physiologic markers were available (active treatment CBTmin approximately 02:00). The active group exhibited a significant post-treatment delay of CBTmin of over two hours. Baseline DLMO values (as assessed by urinary aMT6) were referenced only in a figure (without raw data available), but also exhibited average post-treatment phase delays of approximately two hours in the active group. Sleep parameters (as assessed by actigraphy and sleep logs) demonstrated a significant decrease in actigraphically-determined WASO in the active treatment group at both 1- and 4-week follow-up periods, in addition to subjective (but not objective) improvement in total sleep time at the end of the 4-week follow-up period (90 minutes as compared with baseline, and 45 minutes as compared with sham treatment). There were otherwise few meaningful significant group differences with respect to sleep onset or offset times.
Conclusions: The available data on the treatment of ASPD (and the treatment of insomnia utilizing phototherapy) consists exclusively of evening light therapy. While objective results are overall conflicting, subjective improvements have been consistently demonstrated. Comparison of treatment effects is limited by the heterogeneous nature of the patient population, perhaps in part influenced by the ambiguous criteria for ASPD in the ICSD, variable use of established circadian phase markers, differing intensity and durations of treatments, and nonsystematic assessments of treatment compliance. Future studies would benefit from addressing these factors, in the context of protocols that are cognizant of practical clinical scenarios (e.g,. an established duration of nightly or maintenance treatments). The use of blue light, addressed in Part I, may also significantly influence treatment factors, possibly allowing for increased potency of the stimulus and/or a reduction in required exposure time, potentially increasing practical clinical application (and patient acceptance) of this treatment modality [28].
11.4.3 Timed Melatonin Administration
There are no systematic reports of melatonin administration for ASPD, but consideration of the melatonin PRC provides a rationale for low-dose administration after early morning awakenings and upon final arising in the morning [29]. Conclusion: There are insufficient data to assess the safety and efficacy of timed melatonin administration in the treatment of ASPD.
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Auger, R.R., Burgess, H.J., Emens, J.S., Deriy, L.V., Thomas, S.M., Sharkey, K.M. (2015). Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine, 11, 10, 1199-236. Free PMC Article. [PDF]
ASWPD
5.1.4a The TF suggests that clinicians treat adult ASWPD patients with evening light therapy (versus no treatment).
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