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Epworth Sleepiness Scale (ESS) - Adult Version
Please visit this website for more information about the instrument: Epworth Sleepiness Scale
Supplemental - Highly Recommended: Parkinson's Disease (PD)
Recommendations for use: Indicated for studies evaluating subjective sleepiness where the individuals rate their level of daytime sleepiness.
Supplemental: Mitochondrial Disease (Mito), Spinal Cord Injury (SCI), Sport-Related Concussion (SRC) Subacute (after 72 hours to 3 months), and Persistent/Chronic (3 months and greater post-concussion)
Exploratory: Sport-Related Concussion (SRC) Acute (time of injury until 72 hours)
Short Description of Instrument
The Epworth Sleepiness Scale (ESS) was developed in 1991 and is the most widely used subjective scale of daytime somnolence.
Translations are available in over 20 languages and the Scale can be completed in less than 5 minutes.
The ESS was developed as a trait to measure the tendency to fall asleep in eight specific situations (sitting and reading, watching TV, sitting inactive in a public place, being a passenger in a car for an hour, lying down in the afternoon, sitting and talking to someone, sitting quietly after lunch, stopping for a few minutes in traffic while driving).
It is a subjective tool of how sleepiness interferes with individuals' common daily activities. It consists of a simple self-administered questionnaire asking patients to rate the likelihood (from 0 to 3) of dozing or falling asleep in those eight situations. For each situation, patients estimate the likelihood of their falling asleep in a four-point scale (0= never doze to 3= high probability). Scores from each of the eight situations yield a total scoring ranging from 0 to 24. The higher the ESS score, the greater the sleepiness. The upper limit of normality is generally accepted as 10-12 points.
See Epworth Sleepiness Scale - Children and Adolescents Version (ESS-CHAD) for children and adolescents aged 5-18.
Comments/Special Instructions
The ESS does not evaluate the occurrence of sudden sleep onset episodes which is well-known in PD. Thus, new scales were developed to capture hypersomnolence in active situations like eating and driving (Hobson et al., 2002).
Scoring and Psychometric Properties
Scoring: Rated from 0-24, with high scores indicating worse sleepiness.
0 - 10: No Sleepiness
11 - 14: Mild sleepiness
15 - 17: Moderate sleepiness
18 or higher: Severe sleepiness
Psychometric Properties: The scale shows acceptable test-retest reliability. Studies have shown little to no correlation between ESS scores and the multiple sleep latency results, suggesting that the two tests measure different aspects of sleepiness, which remain to be elucidated.
Strengths: The ESS is indicated for studies requiring a subjective measure of 'sleep propensity' (i.e., sleepiness). It has been extensively used in the general population and many health conditions, such as PD. The ESS has also been used quite extensively in SCI studies. It is simple, self-administered, and can be completed in less than 5 minutes.
Weaknesses: More evidence supporting its psychometric properties in SCI is warranted. It asks participants to picture themselves in situations which they may experience rarely or never (e.g., driving, going to the theater). Semantic issues may also lead to confusion. Circadian variations in alertness are not captured with this scale. The eight situations are equally weighted, despite obvious differences in significance (e.g., driving versus going to the theater). There may be individual variation scores over time.
Generally, the ESS is more reliable when scores are abnormally high or very low. Many sleepy PD patients may score in the normal range because they do not actually fall asleep, despite being drowsy, either because of effective compensatory measures or lack of opportunity. It does not evaluate the occurrence of sleep attacks, which is a situation commonly experienced by PD patients.
Key References:
Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991 Dec;14(6):540-5.
Johns MW. A new perspective on sleepiness. Sleep Biol Rhythm, 2010; 8: 170-179.
Additional References:
Hobson DE, Lang AE, Martin WR, Razmy A, Rivest J, Fleming J. Excessive daytime sleepiness and sudden-onset sleep in Parkinson disease: a survey by the Canadian Movement Disorders Group. AMA. 2002 Jan 23-30;287(4):455-63.
Joorabbaf Motlagh S, Shabany M, Sadeghniiat Haghighi K, Nikbakht Nasrabadi A, Emami Razavi SH. Relationship Between Sleep Quality, Obstructive Sleep Apnea and Sleepiness During Day With Related Factors in Professional Drivers. Acta Medran. 2017 Nov;55(11):690-695.
Mollayeva T, Cassidy JD, Shapiro CM, Mollayeva S, Colantonio A. Concussion/mild traumatic brain injury-related chronic pain in males and females: A diagnostic modelling study. Medicine (Baltimore). 2017 Feb;96(7):e5917.
SCI-Specific References:
Boswell-Ruys CL, Lewis CR, Gandevia SC, Butler JE. Respiratory muscle training may improve respiratory function and obstructive sleep apnoea in people with cervical spinal cord injury. Spinal Cord Ser Cases. 2015 Jul 9;1:15010. Erratum in: Spinal Cord Ser Cases.2016 Jul 21;2:16019.
Campbell AJ, Neill AM, Scott DAR. Clinical Reproducibility of the Epworth Sleepiness Scale for Patients With Suspected Sleep Apnea. J Clin Sleep Med. 2018 May 15;14(5):791-795.
McCormick ZL, Chu SK, Binler D, Neudorf D, Mathur SN, Lee J, Marciniak C. Intrathecal Versus Oral Baclofen: A Matched Cohort Study of Spasticity, Pain, Sleep, Fatigue, and Quality of Life. PM R. 2016 Jun;8(6):553-62.
Sankari A, Bascom A, Oomman S, Badr MS. Sleep disordered breathing in chronic spinal cord injury. J Clin Sleep Med. 2014 Jan 15;10(1):65-72.
Sankari A, Martin JL, Bascom AT, Mitchell MN, Badr MS. Identification and treatment of sleep-disordered breathing in chronic spinal cord injury. Spinal Cord. 2015 Feb;53(2):145-9.
Thofner Hulten VD, Biering-Sorensen F, Jorgensen NR, Jennum PJ. Melatonin and cortisol in individuals with spinal cord injury. Sleep Med. 2018 Nov;51:92-98.
Document last updated March 2024