American Academy of Sleep Medicine

Five Things Physicians and Patients Should Question

Released December 2, 2014; Updated December 21, 2021. Last reviewed 2022.

  1. 1

    Don’t perform polysomnography in chronic insomnia patients unless there is concern for a comorbid sleep disorder.

    Chronic insomnia is diagnosed by a clinical evaluation that includes a thorough sleep history along with a medical, substance and psychiatric history. Some instruments can be helpful at the clinical encounter: these include self-administered questionnaires, sleep logs completed at home and symptom checklists. Polysomnography is not necessary for the diagnosis of chronic insomnia but is indicated in some specific circumstances; for example, when sleep apnea or sleep-related movement disorders are suspected, the initial diagnosis is uncertain, behavioral or pharmacologic treatment fails, or sudden arousals occur with violent or injurious behavior.

  2. 2

    Don’t offer hypnotics as the only initial therapy for chronic insomnia in adults. Use cognitive-behavioral therapy for insomnia (CBT-I), whenever possible, and use medications only when necessary.

    Cognitive-behavioral therapy for insomnia (CBT-I) involves a combination of behavioral modification, such as stimulus control and sleep restriction, and cognitive strategies, such as replacement of fears about sleep with more positive expectations. Clinical trials show that CBT-I can be equally or more effective than hypnotics over an extended period of time without associated side effects. Medication alone or in combination with CBT-I may be necessary for some patients, after considering prior treatment responses, availability of CBT-I resources, and patient preferences.

  3. 3

    Don’t prescribe medications to treat childhood insomnia unless behavioral interventions are unsuccessful or not indicated.

    Childhood insomnia often arises from environmental factors and is well-treated with education of the parents and child about establishing good sleep hygiene practices, wind-down routines, and adequate and appropriate sleep schedules. This approach is usually effective for insomnia symptoms in typically developing younger children. Behavioral interventions are also effective and long-lasting for insomnia in school- or teen-aged children with
    other medical, psychological, or neurodevelopmental disorders. No medications are approved by the US Food and Drug Administration for the treatment of childhood insomnia. Nonetheless, some children with significant developmental delay, cognitive impairment, or other medical/psychiatric disorders might not respond to behavioral therapies alone, so they may benefit from judicious use of sleep-promoting medications, which should be used with caution and close monitoring for efficacy and side effects.

  4. 4

    Don’t use polysomnography to diagnose restless legs syndrome.

    Restless legs syndrome (RLS) is a neurologic disorder that is a clinical diagnosis based on a patient’s description of symptoms and additional clinical history. Polysomnography is not necessary to make this diagnosis. If performed for other reasons, a polysomnogram that shows periodic limb movements of sleep is supportive of a diagnosis of RLS.

  5. 5

    Don’t routinely perform positive airway pressure (PAP) re-titration sleep studies in patients with sleep apnea who are PAP-adherent unless there is an indication that current therapy may be inadequate.

    Re-titration of PAP with overnight polysomnography is not indicated for adult patients with obstructive sleep apnea with stable weight whose symptoms are well-controlled by their current PAP treatment. A follow-up diagnostic or re-titration study can be used to reassess patients with recurrent or persistent symptoms, despite good PAP adherence, especially if they have gained substantial weight (e.g., 10% of original weight) since the last titration study. A new diagnostic or re-titration study may be indicated for patients who have lost substantial weight to determine whether PAP treatment is still necessary. A polysomnogram can be considered in a patient without symptoms or weight change, who is adherent to PAP but has unexplained PAP device-generated data.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Academy of Sleep Medicine (AASM) is the only professional society dedicated exclusively to the medical subspecialty of sleep medicine. As the leading voice in the sleep field, the AASM sets standards and promotes excellence in health care, education and research. Established in 1975 as the Association of Sleep Disorders Centers, the AASM has a combined membership of nearly 11,000 accredited member sleep centers and individual members, including physicians, scientists and other health care professionals.

To learn more about the AASM, visit

How This List Was Created

The Executive Committee of the American Academy of Sleep Medicine developed 21 candidate recommendations for ways in which medical waste could be minimized while care for patients with sleep disorders is improved. Members of the Executive Committee then voted to assign priorities to each, and the top five were selected. Final wording of the five statements were approved by the full Board of Directors of the American Academy of Sleep Medicine in 2014. The American Academy of Sleep Medicine developed rationale and references for each recommendation. The final statements, explanations and citations were approved by a final vote of the Board of Directors. The list was reviewed and updated by the Guidelines Advisory Panel with final revisions approved by the Executive Committee in 2021.

The AASM disclosure and conflict of interest policy can be found at


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