1. Actigraphy & Sleep Teresa M. Ward, RN, PhD Associate Professor
Department of Family & Child Nursing
University of Washington

2. Objectives
Review the measures of actigraphy and the clinical implications to use actigraphy.
Discuss the advantages and disadvantages of actigraphy.
Review actigraphy data
Discuss the pros and cons of different actigraph watches.

3. Actigraphy What is Measures:
Small wristwatch-like device that uses an accelerometer to detect body movement.
Data are downloaded and analyzed using algorithms programmed in the computer software.
Software converts body movement counts into sleep and wake.
Non domninant wrist
Ankle in young children
Directly on the skin or over t shirt or sock

4. Clinical Implications for Actigraphy
Prolonged sleep latency
Prolonged or multiple night awakenings
Excessive daytime sleepiness
Delayed sleep phase syndrome
Wear for at least 7 days—given that 2 dys may be bad or forgot to put on
7 nights—weekend and wkday data.
No swimming, bathing, showering, contact sports

5. Advantages More objective than parent report and/or sleep diaries.
Assessment of sleep-wake patterns for days to weeks.
Assess sleep-wake patterns in the “natural” environment.
Less expensive and less intrusive than overnight polysomnography.

6. Disadvantages
Does not provide data on sleep stage or cardio-respiratory events.
Can not be used to diagnose sleep disorders (e.g., sleep disordered breathing, periodic limb movement disorder, narcolepsy).
Lost data (patient adherence, technical problems, equipment failure)

7. Actigraphy
Inactive JIA
Active JIA

9. Bland Altman Plots for TST: Low & High Thresholds
BA plots represent graphically the difference b/t PSG & Acti (Y axis) against the avg of the 2 meas on the X axis. Mean difference represents the bias between the 2 measures. The SD of the bias (see broken lines) provides an estimate of the varibility of the difference b/t acti & PSG. The BOLDED LINE depicts if there was NO difference b/t acit and PSG for TST at a specific threshold. as you can see– in the low threshold for TST– there was a positve bias for all 3 groups indicating that acti overestimated TST. Whereas in the HIGH threhsold–there was a negative bias indicating that ACTI underestimated TST.
For each of the sleep parameter comparisons, the average of actigraphy at a specific threshold and PSG was plotted on the X-axis, and the difference between actigraphy at a specific threshold and PSG was plotted on the Y-axis for each group. A positive bias thus indicates an overestimation of the variable with actigraphy; a negative bias indicates an underestimation of the variable with actigraphy.
Ward et al., J Sleep Research (2011)

10. Bland Altman Plots for TST: Medium Threshold
Acti was more accurate in estimating TST and WASO at the medium threshold. Had the least amount of bias for all 3 groups.
Ward et al., J Sleep Research (2011)

11. Bland Altman Plots for WASO: Low & High Thresholds
Ward et al., J Sleep Research (2011)

12. Bland Altman Plot for WASO: Medium Threshold
Ward et al., J Sleep Research (2011)

13. Types of Devices Rechargeable battery
ACTIWATCH 2 (AW2)
Rechargeable battery
Need to mail the watch back to the manufacturer to change the battery.
Epoch length 15 sec, 30 sec, 1 min, 2 min or 5 min
Battery life 30 1 min epochs
Event marker
White light sensitivity
ACTIWATCH 64
You change the battery
Epoch lengths 30 sec or 1 min
Battery life 3 months
Water proof
Event marker
Phillips no longer supports this device.
Act 64—battery cheap
15 sec epochs– 7.5 dys
30 sec= 15dys
1 min=30 dys
actiwatch2—16grms
Diffi to predict when battery will die.

14. Types of Devices Actiwatch Spectrum Classic, Plus & PRO
Rechargeable Battery~ within 2 hours
Battery life ~ 8months—depends on epochs t
Epoch lengths 15 sec, 30 sec, 1 min, 2min, or 5 min
Water proof
Event marker
Measures white, red, green, & blue light
Audible off wrist detection sensor Galvanic
skin response (GSR)

15. Ambulatory Monitoring Inc. (AMI)
Motionlogger

16. Interested in Using Actigraphy
Consult colleagues who have experience with actigraphy.
lessons learned
many brands, but not all are validated and reliable
different algorithms are used to score sleep-wake.
Use in conjunction with a sleep diary (paper or electronic).
Peer reviewed literature.
Manufacturer (Phillips or AMI)

17. Resources
Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007.Morgenthaler T, Alessi C, Friedman L, Owens J, Kapur V, Boehlecke B, Brown T, Chesson A Jr, Coleman J, Lee-Chiong T, Pancer J, Swick TJ; Standards of Practice Committee; AmericanAcademy of Sleep Medicine. Sleep. 2007; 30(4):
Polysomnography and actigraphy concordance in juvenile idiopathic arthritis, asthma and healthy children. Ward TM, Lentz M, Kieckhefer GM, Landis CA. J Sleep Res Feb;21(1):113-21
Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. Marino M, Li Y, Rueschman MN, Winkelman JW, Ellenbogen JM, Solet JM, Dulin H, Berkman LF, Buxton OM. Sleep Nov 1;36(11):

18. Resources
Validating the Children's Sleep Habits Questionnaire Against Polysomnography and Actigraphy in School-Aged Children. Markovich AN, Gendron MA, Corkum PV. Front Psychiatry Jan 6;5:188.
Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. Werner H, Molinari L, Guyer C, Jenni OG. Arch Pediatr Adolesc Med Apr;162(4):350-8.
Sleep/wake patterns derived from activity monitoring and maternal report for healthy 1- to 5-year-old children. Acebo C, Sadeh A, Seifer R, Tzischinsky O, Hafer A, Carskadon MA. Sleep Dec;28(12):
Concordance of polysomnographic and actigraphic measurement of sleep and wake in older women with insomnia. Taibi DM, Landis CA, Vitiello MV. J Clin Sleep Med Mar 15;9(3):