A-Step Supplemental Scoring Modules

Front 1

When scoring a polysomnogram, make __ passes

Back 1

2

Front 2

1st pass in scoring a polysomnogram is to

Back 2

recognize EEG waveforms and score stages and arousals, usually 30 sec window

Front 3

2nd pass in scoring a polysomnogram is to

Back 3

detect events - apneas and limb movements, usually 120 sec window

Front 4

6 Steps in scoring a polysomnogram:

Back 4

1 Recognize waveforms
2 Score stages
3 Score arousals and EEG abnormalities
4 Score respiratory events
5 Score limb movements
6 Identify ECG abnormalities

Front 5

The waveforms we can now recognize are combined with scoring rules to

Back 5

define sleep stages

Front 6

____ and 4 sleep stages are defined

Back 6

Waking

Front 7

What are the 4 sleep stages?

Back 7

N1-R&K stage 1
N2-R&K stage 2
N3-R&K stage 3, 4
R-R&K REM

Front 8

Measuring ___ & ____ for each waveform would require far more time than is available for scoring

Back 8

frequency and amplitude

Front 9

Each patient will have a slightly different...

Back 9

alpha frequency;
K complex waveform;
appearance of rapid eye movements

Front 10

Page through the record quickly before scoring to develop a _____ of how each stage looks prior to assigning stage scores

Back 10

mental picture

Front 11

Hypnograms lead us to expect Wake is usually followed by

Back 11

N1

Front 12

Hypnograms lead us to expect Most of N3 occurs

Back 12

in the first half of the night

Front 13

Hypnograms lead us to expect R occurs

Back 13

periodically through the night, usually with an interval of 90 minutes

Front 14

Hypnograms lead us to expect most of the time spent in R is in

Back 14

the second half of the night

Front 15

Hypnograms lead us to expect the transition from Wake to R is

Back 15

rare (it occurs in narcolepsy)

Front 16

When scoring sleep stages, score in ______ epochs

Back 16

30 second

Front 17

When scoring sleep stages, assign a ______ to each epoch

Back 17

stage

Front 18

When scoring sleep stages, if 2 more stages appear in the single epoch, assign the stage that

Back 18

takes up the most time

Front 19

Score W when

Back 19

more than 50% of the epoch has alpha rhythm in the occipital channel

Front 20

Alpha activity has to last more than ___ seconds in order to score as W

Back 20

15

Front 21

Recognize alpha activity by:

Back 21

Frequency: 8-13 Hz
Waveform: Sinusoidal
Distribution: Recorded over the occipital region

Front 22

Score epochs without alpha rhythm that you can see as W if any of these are present:

Back 22

.Eye blinks at a freq. of 0.5-2 Hz
.Reading eye movements
.The eyes move together quickly with normal or high chin muscle tone

Front 23

In subjects who have alpha when drowsy, score N1 if

Back 23

alpha rhythm is replaced by low amplitude, mixed frequency EEG for more than 50% of the epoch

Front 24

In subjects without alpha when drowsy (10% of people), score N1 starting with the earliest of any of the following:

Back 24

Theta activity (4-7) Hz with slowing of EEG frequencies by ≥ 1 Hz from W; or Vertex sharp waves; or Slow eye movements

Front 25

Sleep onset is..

Back 25

the start of the first epoch scored as any stage other than W

Front 26

A part of an epoch may be N1, but if the epoch is not scored N1 then

Back 26

sleep onset has not occured

Front 27

The following rules define N2 sleep:

Back 27

. Don't score N2 if the epoch is N3
. Score N2 if you see a K complex or a spindle during the first half of an epoch or the last half of the epoch before it

Front 28

What is a Spindles amp, freq, waveform, and distribution?

Back 28

Amplitude -- Not defined
Frequency -- 11-16 Hz
Waveform -- "Distinct"
Distribution -- Central

Front 29

What is a K Complexes amp, freq, waveform, and distribution?

Back 29

Amplitude -- Not defined
Frequency -- < 2 Hz
Waveform -- Neg. followd by Pos.
Distribution -- Frontal

Front 30

Patients with alpha, score W if

Back 30

Alpha > 50% of epoch

Front 31

Patients with alpha, score N1 if

Back 31

Alpha < 50% of epoch

Front 32

Patients with alpha, score N2 if

Back 32

K complex without arousal or sleep spindles

Front 33

Patients without alpha, score W if

Back 33

Eye blinks, or Reading eye movements, or Irregular eye movements + increased EMG

Front 34

Patients without alpha, score N1 if

Back 34

4-7 Hz EEG with slowing, or Vertex sharp waves, or Slow eye movements

Front 35

Patients without alpha, score N2 if

Back 35

K complex without arousal, or sleep spindles

Front 36

_____ is first epoch of any stage other than W.

Back 36

Sleep onset

Front 37

The following rule defines continuation of N2:

Back 37

Once you have started N2, you can continue scoring it even without K complexes or spindles

Front 38

Stop scoring N2 when an epoch is scored _______

Back 38

W, N3, or R

Front 39

End N2 when there is an

Back 39

arousal (change to N1 until a K complex without arousal or a sleep spindle occurs)

Front 40

End N2 when there is a major body movement followed by

Back 40

slow eye movements and low amplitude mixed frequency EEG (change to N1)

Front 41

Score R when you see all of the following:

Back 41

. Low amplitude, mixed frequency EEG
. Low chin EMG tone
. Rapid eye movements

Front 42

Continue to score R :

Back 42

even without rapid eye movement, if the EEG continues to show low amplitudes, mixed frequency activity, there are not K complexes or sleep spindles and the chin EMG remain low.

Front 43

Stop scoring R when any of the following occur:

Back 43

. An epoch is W or N3
. The chin EMG goes up and criteria for N1 are met (N1)
. An arousal occurs followed by slow eye movements (N1)
. A major body movement followed by slow eye movements (N1)
. K complexes without arousals or sleep spindles are seen in an epoch without rapid eye movements, even if chin EMG is low (N2).

Front 44

Analogy: Sleep is not like a _____, where it is either on or off.

Back 44

switch

Front 45

Analogy: Sleep is like an ____, where the floor are stages. It can take some time to get from one floor to another, and sometimes you can get ___ between floors.

Back 45

elevator

stuck

Front 46

During transition from N2 to R, many times parts of N2 (______ and _________) stop, but the parts of R that we use in scoring ( _____) do not ____.

Back 46

(K complexes and spindles) stop;

eye movements, EMG decrease and twitches-the phasic parts) do not
start right away.

Front 47

During transition from N2 to R, when N2 stops and R doesn't start right away, this leaves some epochs with

Back 47

an uncertain stage--low amplitude, mixed frequency EEG occurs in N1, N2 and tonic R, then we are left relying on partial clues

Front 48

Section 7.D. uses _____ of sleep stages to provide a stage score for the epochs between N2 and R

Back 48

elements

Front 49

When relying on Partial clues for transitions from N2 to R, score R for those epochs without

Back 49

K complexes or spindles

Front 50

When relying on Partial clues for transitions from N2 to R, if the EMG drops for an epoch and later there is a ___________________, score N2

Back 50

K complex or sleep spindle and there are no rapid eye movements

Front 51

When relying on Partial clues for transitions from N2 to R, if __________, score R

Back 51

if the EMG is low and there are not spindles or K complexes and later there are rapid eye movements

Front 52

A major body movement is when

Back 52

movement and muscle artifact obscure the EEG for more than half the epoch and you can't tell the stage

Front 53

Scoring of epochs with major body movements assumes that you can

Back 53

move during sleep without waking up

Front 54

When scoring major body movements, we no longer score

Back 54

Movement Time

Front 55

For epochs with major body movement, if you see any _____ score W

Back 55

alpha (even less than 15 seconds)

Front 56

for epochs with major body movement, if W occurs before or after the epoch with the major body movement, score the epoch as

Back 56

W

Front 57

Score epoch with major body movements as __________, UNLESS you see ANY alpha, or if W occurs before or after movement, in which both cases would be scored W.

Back 57

the epoch that follows it