Sleep Medicine Curriculum for Neurology Residents

This curriculum, developed in collaboration with the AAN Consortium of Neurology Program
Directors and Graduate Education Subcommittee, provides a comprehensive outline of the
relevant educational goals for the future generation of adult neurologists learning sleep
medicine during residency. The clinical scope of this curriculum is common and uncommon
sleep disorders encountered in typical neurology practices. While the all-encompassing scope
of this outline covers more than is expected to be learned by neurology residents on a given
subspecialty rotation, the measurable objectives are included to provide program directors and
other rotation developers the means of evaluating whether a minimum competence in sleep was
attained in any combination of specific areas. Finally, as sleep medicine is a cross-disciplinary
neurologic subspecialty, the curriculum ends with a table highlighting overlapping conditions
between major sleep disorder categories and neurologic subspecialities.

Authors:

Lead Author
Logan Schneider, MD
[email protected]
Stanford/VA Alzheimer’s Center

Alon Avidan, MD, MPH, FAAN

David Geffen School of Medicine at UCLA

Muna Irfan, MD
University of Minnesota

Meena Khan, MD
The Ohio State University

Created: January 2020

Effective: February 2020 to February 2021

Approved by the American Academy of Neurology’s Graduate Education Subcommittee

 Sleep Medicine Curriculum for Neurology Residents

Part I. General Clinical Approach

Clinical evaluation:
History
Efficiently obtains a complete, relevant, and organized neurologic history
Performs comprehensive review of systems pertinent to ICSD-3 sleep-wake disorder
categories (sleep-related disordered breathing, hypersomnias, insomnias, parasomnias,
sleep-related movement disorders, circadian disorders)
Performs comprehensive review of systems probing medical conditions that are known
to impact sleep-wake disorders (e.g. cardiovascular, pulmonary, rheumatologic, renal,
psychiatric, etc.)
Obtains social history relevant to sleep-wake disorders (e.g. substance/medication use,
education/work schedule, etc.)
Obtains family history as it pertains to sleep-wake disorders with known heritability
Obtains exposure information where appropriate (e.g. H1N1 influenza or immunization, S.
pyogenes, head trauma)
Measurable objective:
1. Has developed at least a set of sleep-related screening questions to add to the
review of systems (compare to the AAN-provided pre-visit questionnaire for
sleep: https://www.aan.com/practice/electronic-health-records/ehr-templates/)
General physical examination
Efficiently performs a relevant general physical exam accurately incorporating all additional
appropriate maneuvers
Performs integumentary examination (hair, skin, nails)
Performs comprehensive examination of nasal and oral cavities
Performs thorough cardiopulmonary examination
Performs brief mental status examination, as appropriate
Measurable objective:
1. Can properly grade Mallampati, Friedman score, tonsils, and inferior turbinates.
2. Can properly perform orthostatic vital signs.
3. Can identify signs of decompensated heart failure (left: wet rales; right: JVD
distention, pedal edema).
4. Can identify signs of decompensated pulmonary disease (breathlessness,
tripodding, crackles/consolidation).
5. Can assess psychiatric risk (suicidality, substance abuse).
Neurological exam
Efficiently performs a relevant neurological exam accurately incorporating all additional
appropriate maneuvers
Performs fundoscopy
Performs movement disorder evaluation to assess for early signs of neurodegeneration
Performs appropriate screening neurocognitive exam, using validate measures, where
appropriate
 Measurable objective:
1. Can assess for IIH, when concern arises (e.g., AM headache in obese patients):
fundoscopy, peripheral vision, CN VI.
2. Can do fundamental movement disorder assessment (e.g. tone, rapid-alternating
movements, gait, postural stability) in patient reporting RBD.
3. Can choose appropriate cognitive screening measure in the setting of memory
concerns (e.g. Mini-Cog, MoCA, MMSE).
Clinical scales
Demonstrates familiarity with, maintains access to, and utilizes clinical scales where appropriate
Screening:
Sleep disorders symptom checklist-25
Mayo sleep questionnaire
AAN’s pre-visit questionnaire
Symptom-specific:
Performs Epworth sleepiness scale (ESS) or pediatric sleep questionnaire (PSQ)
routinely
Performs sleep-disordered breathing screening questionnaires (e.g. STOP-Bang,
Berlin)
Performs International RLS Study Group (IRLSSG) scale assessment and
assesses Clinical/Patient Global Impressions
Insomnia severity index (ISI)
Horne-Ostberg Morningness-Eveningness Questionnaire (MEQ)
Performs MMSE, as appropriate
Performs MoCA, as appropriate
Measurable objective:
1. Can choose appropriate assessment scale, based on suspected sleep disorder.
2. Can choose appropriate assessment scale, based on need to screen or monitor.

Diagnostic evaluation:
Neurophysiology
Interprets common polysomnographic, home sleep testing, multiple sleep latency testing,
maintenance of wakefulness testing, PAP titration, and EEG
Can appropriately determine when to order a home sleep test vs full polysomnogram
Can appropriately determine when to order MSLT and MWT in the evaluation of
disorders of sleep and wake
Demonstrates familiarity with EEG patterns characteristic of each of the primary sleep
stages - N1, N2, N3, and REMS - as well patterns suggestive of pathology - epileptiform
discharges, electrographic/convulsive seizures, etc.
Can interpret reported results of MSLT and MWT in the context of diagnosing and
treating sleep-wake disorders
Demonstrates familiarity with the scoring of common sleep breathing disturbances -
obstructive apnea, obstructive hypopnea, central apnea - as well as their resolution on
treatment studies
 Can identify other clinically-relevant features of sleep disorders: periodic limb
movements, loss of REMS atonia, bruxism
Can appropriately identify common ECG abnormalities: PVCs, PACs, heart block, AV-
conduction abnormalities, arrhythmias
Measurable objective:
1. Can differentiate between obstructive and central apneas on PSG.
2. Can differentiate between apneas and hypopneas on HST/PSG.
3. Can identify stage of sleep when presented with 10- or 30-second epochs
containing EEG, EOG, and EMG.
4. Can correctly identify arrhythmias on ECG: atrial fibrillation, ventricular fibrillation,
ventricular tachycardia.
Actigraphy and sleep diaries
Interprets actigraphy and sleep diary data
Appropriately understands how to differentiate between normal and abnormal sleep
patterns from actigraphy reports (summary statistics and actigraphic printout)
Appropriately interprets and makes clinical decisions based on sleep diary reports
Measurable objective:
1. Can develop personal schedule to shift for call/night-float.
2. Can collect and interpret sleep diaries (particularly as relates to neurologic
disorders such as headache).
Imaging
Interprets MR neuroimaging of brain
Recognizes indications for advanced imaging and other diagnostic studies, with a focus
on neuroanatomy of interest (hypothalamus, thalamus, brainstem)
Recognizes MRI findings specific to hypersomnia disorders with additional, focal
neurological findings
Measurable objective:
1. Can detail the limited circumstances necessitating MR neuroimaging (e.g., focal
neurologic deficits).
Cerebrospinal fluid
Performs lumbar puncture without direct supervision
Accurately interprets results of less common diagnostic testing
Describes the composition, formation, and fluid dynamics of the CSF
Recognizes CSF patterns in neuro-infectious and neuroimmune syndromes
Appropriately interprets CSF hypocretin/orexin levels
Measurable objective:
1. Can identify the diagnostic cut-points for CSF hypocretin values.
Additional diagnostic testing
Accurately interprets results of common diagnostic testing
Appropriately orders and interprets pulmonary function testing and arterial blood gas
results, where appropriate
Appropriately orders and interprets echocardiography, where appropriate
Appropriately orders and interprets iron studies (total iron, TIBC, and ferritin)
Appropriately orders salivary/urinary melatonin profiling, when necessary
 Appropriately orders and interprets HLA typing for narcolepsy investigation
Measurable objective:
1. Can interpret the results of HLA genotyping in the work-up of narcolepsy.
2. Can define a ferritin target in the treatment of RLS.

Treatment strategies and side effects:

Demonstrates sophisticated knowledge of treatment subtleties and controversies in the
management of sleep-wake disorders
Employs appropriate prescribing, prescription contract, and substance abuse/diversion
monitoring
Cognitive behavioral therapy for insomnia (CBTi)
Is aware of the principles of CBTi and appropriately refers chronic insomnia patients to
CBTi as a first line therapy.
Measurable objective:
1. Can identify the 3 treatments in the AASM Practice Guidelines with a
“Standard” level of recommendation in the treatment of insomnia: stimulus
control, relaxation training, and CBT.
Sedatives/hypnotics
Uses sedatives/hypnotics appropriately for acute and chronic insomnia patients
Demonstrates familiarity with sedative/hypnotic medications, appropriate indications, and
their neurological side effects (e.g. benzodiazepines, benzodiazepine receptor agonist
“Z-drugs”, doxepin, suvorexant, etc.)
Measurable objective:
1. Can choose an appropriate first-line sedative/hypnotic, based on patient’s risk
profile.
Stimulants
Demonstrates familiarity with stimulant medications, appropriate indications, and their
neurological side effects (e.g. ar/modafinil, amphetamine salts, pitolisant, solriamfetol,
etc.)
Measurable objective:
1. Can choose an appropriate first-line stimulant, based on patient’s risk profile.
Anti-cataplectic therapies
Demonstrates familiarity with anti-cataplectic medications, appropriate indications, and
their neurological side effects (e.g. sodium oxybate/γ-hydroxybutyrate, SNRIs, pitolisant,
etc.)
Measurable objective:
1. Can choose an appropriate first-line anti-cataplectic, based on patient’s risk
profile
Parasomnia therapies
Demonstrates familiarity with available treatments for NREMS and REMS parasomnias
Measurable objective:
1. Can choose an appropriate first-line medication, based on patient’s risk profile.
Restless leg syndrome therapies
 Demonstrates familiarity with available oral and parenteral iron replacement strategies,
as well as appropriate indications and monitoring
Demonstrates familiarity with α2δ-ligand medications, appropriate indications, and their
neurological side effects (e.g. gabapentin, pregabalin, gabapentin enacarbil, etc.)
Demonstrates familiarity with dopamine agonist medications, appropriate indications,
and their neurological side effects (e.g. pramipexole, ropinirole, rotigotine patch, etc.)
Demonstrates familiarity with narcotic medications, appropriate indications, and their
neurological side effects (e.g. tramadol, methadone, etc.)
Measurable objective:
1. Can determine when to use oral vs parenteral iron repletion.
2. Can choose an appropriate first-line medication, based on patient’s risk profile.
Circadian therapies
Demonstrates familiarity with appropriate indications and optimal management of light
and melatonin for circadian rhythm regulation
Measurable objective:
1. Can choose appropriate dose and timing of melatonin for circadian vs hypnotic
effects.
2. Can determine effects of light exposure at different times of the day, based on
knowledge of the phase response curve.
Positive airway pressure (PAP)
Accurately interprets positive airway pressure (PAP) data for assessment of efficacy or empiric
machine adjustment and/or further polysomnography/PAP titration
Selects appropriate PAP modality, based on the interpretation/report of a titration sleep
study and/or the patient’s sleep-related breathing disorder (e.g. bilevel for patients with
neuromuscular hypoventilation)
Appropriately interprets PAP compliance/treatment report data from a variety of
manufacturer devices.
Has familiarity with indications for less common modality and pressure settings available
on multiple manufacturers’ devices: bilevel, autobilevel, bilevel spontaneous/timed (S/T)
mode, autoservoventilation (ASV), average volume assured pressure support (AVAPS)
Is aware of the management of common problems encountered with PAP therapy, e.g.
aerophagia
Can identify and refer patients who may need PAP desensitization
Measurable objective:
1. Can define therapeutic targets for residual AHI (rAHI<5) and compliance (>4hrs
nightly, >70% of nights).
Additional treatment options intervention
Appropriately considers referral of patients with sleep-disordered breathing for surgical
interventions
Bariatric surgery
Soft-tissue and/or skeletal craniofacial surgeries
Hypoglossal nerve stimulator
Appropriately considers referral of patients with sleep-disordered breathing for dental
therapies
 Mandibular advancement device therapy
Rapid maxillary expansion
Appropriately considers alternative therapies for sleep-disordered breathing
Positional therapy
Dead space increases (via unhooked PAP mask), diamox for primary
normocarbic central sleep apnea.
Measurable objective:
1. Can identify at least one non-PAP therapy for the treatment of obstructive sleep
apnea.
Consultant referrals and allied health professionals
Appropriately refers patients with sleep-wake disorders for consultation (psychology,
psychiatry, movement disorders, autonomic disorders, neuropsychiatry, bariatric
surgery, oromaxillofacial surgery, ENT surgery, PT/OT/ST)
Patient and family resources
Effectively counsels patients and families regarding sleep-wake disorders and refers to
appropriate resources and support groups
American Sleep Apnea Association and MyApnea.org
Restless Legs Syndrome Foundation
Narcolepsy Network
Hypersomnia Foundation
Kleine-Levin Syndrome Foundation

Part II. Syndromes and specific sleep-wake disorders

Demonstrates sophisticated and detailed knowledge of pathophysiology, differential diagnosis,

mimics, diagnostic testing, and controversies in:
Insomnia
Acute Insomnia
Chronic Insomnia Disorder
Sleep-Related Breathing Disorders
OSA (Adult)
OSA (Pediatric)
CSA Syndromes
Sleep-Related Hypoventilation Disorders
Central Disorders of Hypersomnolence
Narcolepsy, Type 1
Narcolepsy, Type 2
Idiopathic Hypersomnia
Kleine-Levin Syndrome
Circadian Rhythm Sleep-Wake Disorders
Delayed Sleep-Wake Phase Disorder
Advanced Sleep-Wake Phase Disorder
Irregular Sleep-Wake Disorder
 Shift-work Sleep Disorder
Parasomnias
Disorders of Arousal from NREMS
REM-Sleep Behavior Disorder
Sleep-Related Movement Disorders
Restless Legs Syndrome
Periodic Limb Movement Disorder

Effectively manages common and uncommon sleep-wake disorders caused by, exacerbating,
and associated with neurologic disease (stroke, epilepsy, idiopathic intracranial hypertension,
headache, dysautonomia, movement disorders and neurodegenerative diseases, autoimmune
encephalitides, inpatient delirium). Below is a table of considerations for sleep-wake/circadian
disorders that might manifest in or affect conditions commonly encountered in some of the
neurological subspecialties:

Sleep disorder category

Neurology Insomnia Sleep-related breathing CNS hypersomnias Circadian Parasomnias Sleep-related

subspecialty disorders movement

disorders

Autonomic POTS Idiopathic Periodic limb

UARS/SDB hypersomnia movements of sleep

and RLS

Behavioral & Neurodegenerative OSA<>neurodegenerative MDD as Irregular sleep-wake REMS-behavior RLS

cognitive diseases diseases pseudodementia in dementias disorder

Neurocognitive effects

of Rx

Vascular OSA<>stroke Stroke<>fatigue

Central sleep apnea Brainstem & thalamic

infarcts

Child Behavioral insomnias ADHD & other neuropsych NT1 Normal circadian Night terrors RLS or PLMD

Neurodevelopmental Inborn errors of phase delay and NREMS

disorders metabolism management parasomnias vs

Autism Sz

Epilepsy Refractory epilepsies Cataplectic spells Circadian/infradian Sz Nocturnal

(NT1) variation hypermotor

epilepsy
 Headache & Behavioral insomnias IIH Cluster headache Exploding head

facial pain CO2<>AM headache Hypnic headaches syndrome

Other headache

syndromes

Inpatient (ICU, Delirium, TBI Post-op Coma, persistent Delirium

hospitalist, etc.) Acute stroke vegetative state,

minimally conscious

state

TBI

Movement PD/MSA and OSA, Irregular sleep-wake REMS-behavior RLS,propriospinal

disorders stridor,or CSA patterns disorder myoclonus

MS and Encephalitides (Ma2, RBD RLS in MS

immunology NMO, NMDA

encephalitis)

MS<>fatigue

Infectious Fatal familial insomnia,

diseases encephalitides

Neuromuscular Hypoventilation syndromes Myotonic dystrophy RLS in neuropathies

Educates others about diagnostic reasoning and management of sleep-wake disorders.