Staging by the Book: Automatic Sleep Stage Classification Using Scoring Rules

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.

Automated sleep staging assigns discrete stage labels to successive time epochs throughout an overnight recording; conventionally each window spans at least 30 seconds, reflecting the minimum temporal resolution of the clinical scoring standard. Wearable photoplethysmography (PPG) has attracted sustained interest as an ambulatory alternative to laboratory-based polysomnography, which relies on electroencephalography (EEG) and other recording modalities that are impractical outside clinical environments. Yet PPG-based staging trails EEG-based methods by a substantial margin, and we argue this gap largely reflects a mismatch between signal and task. Within a stable stage, PPG's inter-stage feature differences are more subtle than those in EEG; yet at stage boundaries, PPG's principal cardiovascular features, heart rate variability and pulse morphology, shift sharply within seconds. The conventional practice of assigning one label to each 30-second epoch therefore suppresses feature that is concentrated near boundaries. We address this gap in two steps. First, we develop a label expansion pipeline based on Hidden Semi-Markov Models that converts coarse epoch labels into sec-level annotations. To assess whether these expanded labels are reliable enough for downstream supervision, we validate them on a separate expert-reviewed dataset and through an auxiliary sleep-wake task whose labels are independent of the expansion pipeline. Second, we use the resulting sec-level supervision on MESA to improve conventional four-class epoch-level staging across four architecturally diverse baselines by 3.7--5.7,pp in accuracy against the original epoch labels, with supplementary zero-shot evaluation on CFS showing that the transfer benefit persists under cohort and annotation-protocol shift.