Demographic-Aware Transfer Learning for Sleep Stage Classification in Clinical Polysomnography

Automated sleep staging is commonly approached as a supervised machine learning problem, with deep learning methods dominating recent research. While machine learning models achieve near-human level agreement with human-scored reference sleep stages, their decisions are typically opaque and not designed to follow clinical scoring rules. We propose a transparent alternative: a deterministic, rule-based sleep staging method that explicitly operationalizes the American Academy of Sleep Medicine's (AASM) scoring logic as executable code, coupled with epoch-level natural-language justifications derived from an explanation trace. We evaluate the approach on 50 polysomnography recordings with a 10-scorer majority-vote consensus as reference. Across all recordings, the method agreed with the majority-vote reference in 60.5% of epochs ($κ=0.42$), with substantially higher agreement on a dataset used during development (77.1%, $κ=0.61$). Agreement with the reference was highest for sleep stage N2 (recall 83.5%) and moderate for sleep stage R (recall 68.7%), while Wake and N1 recall were low. Despite lower agreement with the reference than contemporary deep learning models, the method provides deterministic decisions and natural language explanations aligned with AASM scoring rules, making it a complementary tool for auditing, debugging, and governing deep learning-based sleep staging.

Sleep stage classification is important for the diagnosis and management of sleep disorders, yet most automatic staging studies evaluate models against a single reference hypnogram despite known inter-scorer variability. This study investigates whether multi-scored datasets can be used to construct more reliable reference labels from the collective behavior of multiple experts. We use the publicly available DOD-H and DOD-O datasets. EEG (C3-M2) and chin EMG signals were segmented into 30-s epochs, and 30 features were extracted from each modality, yielding 60 features for EEG+EMG. We propose a learning-based hypnogram (LBH) that models the stage-specific behavior of each scorer using confusion matrices derived from machine-learning models. After column normalization, these matrices estimate the probability of each true sleep stage given each scorer's label; probabilities are aggregated across scorers to assign the final label for each epoch. LBH was evaluated with random forest, support vector machine, and multilayer perceptron classifiers under EEG-only and EEG+EMG settings, and compared with the dataset hypnogram (DH) and best-scorer hypnogram (BSH). LBH consistently improved overall performance. The best results were obtained with random forest and EEG+EMG, reaching 86.07% accuracy, 85.46% precision, and 85.29% F1-score on DOD-H, and 86.04% accuracy, 85.21% precision, and 84.70% F1-score on DOD-O. These findings suggest that personalized scorer modeling can improve reference hypnogram construction without discarding information from individual experts.

Automated sleep staging is increasingly used in large-scale studies to derive sleep-architecture endpoints: total sleep time, REM latency, sleep efficiency, and bout-duration statistics. Deep learning models achieve epoch-level accuracy approaching inter-rater agreement, yet often produce hypnograms that violate physiological invariants, such as rare transitions (e.g., direct Wake -> REM) or excessively fragmented sequences. Such violations can bias downstream sleep metrics, regardless of overall accuracy. We propose StageGuard, a plug-and-play, backbone-agnostic structured-inference framework that wraps any neural sleep-staging backbone with physiology-informed priors. StageGuard combines (1) a differentiable soft transition penalty that discourages physiologically rare transitions during training, and (2) a semi-Markov constrained decoder with a duration-augmented state space that jointly enforces transition penalties and minimum bout durations at inference. Unlike hard-prohibition methods, it admits rare transitions when emission evidence is overwhelming, leaving informative pathological events recoverable rather than blocked. StageGuard constrains staging outputs to satisfy known physiological priors rather than modeling sleep generatively. We quantify the validity gap using transition-violation rate (TVR) and fragmentation index (FI) and demonstrate that, across six backbones and four datasets, StageGuard reduces TVR to physiologically plausible levels and lowers FI by 56-62%, while maintaining or slightly improving classification accuracy. Crucially, improved constraint satisfaction translates into 59-79% lower error on derived sleep-architecture statistics not directly optimized by the method, and recovers the direction and effect size of expert-defined subgroup differences (OSA severity, age) more faithfully than the unconstrained baseline.