Clinician-Focused Overview and Developments in Polysomnography

Polysomnography (PSG) represents a fundamental diagnostic tool used in the evaluation of sleep disorders. It represents a simultaneous recording of sleep staging, eye movements, electromyographic tone, respiratory parameters, and electrocardiogram. It is particularly helpful in the assessment of sleep-disordered breathing and its management, propensity for excessive sleepiness, complex behaviors during sleep, including motor disturbances of sleep, sleep-related epilepsy, and parasomnias. This review is intended to summarize the indications for PSG, the limitations and challenges of this diagnostic tool, indications for home sleep apnea testing options, and new developments and trends in polysomnography.

The polysomnogram is fundamentally important in the evaluation of sleep-disordered breathing in the setting of cardiovascular comorbidities and neurologic conditions such as neuromuscular disease, stroke, and epilepsy and in the evaluation of dream enactment behavior in the setting of REM sleep behavior disorder (RBD). Because RBD is predictive of neurodegenerative disorders, recent data highlights the importance of PSG in corroborating the diagnosis of RBD and identifying people who may be at risk. However, due to cost as well as limitations in access to care, further testing has been developed and implemented including the home sleep apnea test (HSAT). The evolution of consumer wearable devices has also been a growing trend in sleep medicine; however, few have received appropriate validation.

PSG has been used in both the clinical and research settings and remains the gold standard clinical diagnostic test for suspected obstructive sleep apnea (OSA) or central sleep apnea (CSA). Clinicians must be familiar with the basic indications for a PSG but also recognize when it is absolutely required. At this time, the PSG is essential in the evaluation of nocturnal hypoventilation disorders of sleep, periodic limb movements of sleep, and central nervous system hypersomnia (in the absence of CSF hypocretin) when combined with the multiple sleep latency test (MSLT) and is probably the only way to help differentiate among complex behaviors during sleep, especially in the setting of RBD. The capacity to establish an early diagnostic risk of potential dementia would be of critical importance once neuroprotective agents become available.