Sleep and Breathing

, Volume 15, Issue 4, pp 763–773 | Cite as

Repeating administration of Epworth Sleepiness Scale is clinically useful

  • Denis Martinez
  • Tiago Cataldo Breitenbach
  • Magali Santos Lumertz
  • Denise Lerias Alcântara
  • Neusa Sicca da Rocha
  • Cristiane Maria Cassol
  • Maria do Carmo Sfreddo Lenz
Original Article



We aimed to verify whether it is clinically useful to repeat the Epworth Sleepiness Scale (ESS) in individuals with suspected sleep-disordered breathing (SDB).


In this cross-sectional, prospective study, results of the repeated administration of the ESS were analyzed. In 929 consecutive patients, ESS was obtained as usual in the laboratory routine, immediately before the sleep study (ESS1) and was repeated in the morning, after the polysomnography (ESS2). ROC curve, classical psychometry, and item response theory (IRT) Rasch analysis were used to assess measurement properties of ESS.


The ESS1 score was (mean ± SD), 11 ± 5.1, and the ESS2, 13 ± 4.7 (p < 0.001). Change in ESS score is explained in multivariate analysis by age, but not by gender, educational level, change in Stanford Sleepiness Scale, symptoms of sleep disorder, or polysomnography results. Accuracy of an ESS score >10 to predict apnea–hypopnea index ≥5 increased from 56% (ESS1) to 72% (ESS2). IRT psychometric properties (unidimensionality, invariance, local independence) were maintained in ESS2.


Repeating the administration of the Epworth Sleepiness Scale in a clinical setting increases its score and diagnostic accuracy and correlation with SDB variables, without changing the psychometric properties of the scale. This experiment indicates the clinical usefulness of repeating the ESS. The scale can be repeated at a negligible cost, before dismissing individual patients on the basis of a low ESS score, discontinuing a potentially lifesaving diagnostic and therapeutic process.

Key words

Epworth Sleepiness Scale Hypersomnolence Sleep apnea Polysomnography Item response theory Sleep-disordered breathing 

Abreviations used in manuscript


Apnea–hypopnea index




Differential item functioning


Epworth Sleepiness Scale


ESS administered at evening, before polysomnography


ESS administered in the morning, after polysomnography


Item response theory


Obstructive sleep apnea–hypopnea syndrome




Arterial oxygen saturation


Sleep-disordered breathing



The authors declare that they have no conflict of interest.


  1. 1.
    Flemons WW (2002) Obstructive sleep apnea. N Engl J Med 347:498–504PubMedCrossRefGoogle Scholar
  2. 2.
    American Academy of Sleep Medicine (2005) The international classification of sleep disorders: diagnostic and coding manual, 2nd edn. American Academy of Sleep Disorders, WestchesterGoogle Scholar
  3. 3.
    Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, Schwab RJ, Weaver EM, Weinstein MD (2009) Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 5:263–276PubMedGoogle Scholar
  4. 4.
    Johns M (1999) Rethinking the assessment of sleepiness. Sleep Med Rev 2:3–15CrossRefGoogle Scholar
  5. 5.
    Martinez D, Lumertz MS, Lenz Mdo C (2009) Dimensions of sleepiness and their correlations with sleep-disordered breathing in mild sleep apnea. J Bras Pneumol 35:507–514PubMedGoogle Scholar
  6. 6.
    Tachibana N, Taniguchi M (2007) Why do we continue to use Epworth sleepiness scale? Sleep Med 8:541–542PubMedCrossRefGoogle Scholar
  7. 7.
    George PT (2001) Sleepiness, troika of consciousness cycle, and the epworth sleepiness scale. Sleep Breath 5:181–191PubMedCrossRefGoogle Scholar
  8. 8.
    Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14:540–545PubMedGoogle Scholar
  9. 9.
    Leineweber C, Kecklund G, Janszky I, Akerstedt T, Orth-Gomer K (2004) Snoring and progression of coronary artery disease: the Stockholm Female Coronary Angiography Study. Sleep 27:1344–1349PubMedGoogle Scholar
  10. 10.
    Tsara V, Serasli E, Amfilochiou A, Constantinidis T, Christaki P (2004) Greek version of the epworth sleepiness scale. Sleep Breath 8:91–95PubMedCrossRefGoogle Scholar
  11. 11.
    Izci B, Ardic S, Firat H, Sahin A, Altinors M, Karacan I (2008) Reliability and validity studies of the turkish version of the epworth sleepiness scale. Sleep Breath 2:161–168CrossRefGoogle Scholar
  12. 12.
    Thomas GN, Jiang CQ, Lao XQ, McGhee SM, Zhang WS, Schooling CM, Adab P, Lam TH, Cheng KK (2006) Snoring and vascular risk factors and disease in a low-risk Chinese population: the Guangzhou Biobank Cohort Study. Sleep 29:896–900PubMedGoogle Scholar
  13. 13.
    Beiske KK, Kjelsberg FN, Ruud EA, Stavem K (2009) Reliability and validity of a Norwegian version of the epworth sleepiness scale. Sleep Breath 13:65–72PubMedCrossRefGoogle Scholar
  14. 14.
    Chan EYT, Ng DK, Chan C, Kwok K, Chow P, Cheung JM, Leung SY (2009) Modified Epworth Sleepiness Scale in chinese children with obstructive sleep apnea: a retrospective study. Sleep Breath 13:59–63PubMedCrossRefGoogle Scholar
  15. 15.
    Bausmer U, Gouveris H, Selivanova O, Goepel B, Mann W (2010) Correlation of the Epworth Sleepiness Scale with respiratory sleep parameters in patients with sleep-related breathing disorders and upper airway pathology. Eur Arch Otorhinolaryngol. doi:10.1007/s00405-010-1250-y Google Scholar
  16. 16.
    Jiménez-Correa U, Haro R, González-Robles RO, Velázquez-Moctezuma J (2010) How is the Epworth Sleepiness Scale related with subjective sleep quality and polysomnographic features in patients with sleep-disordered breathing? Sleep Breath. doi:10.1007/s11325-010-0372-1 PubMedGoogle Scholar
  17. 17.
    Cho YW, Lee JH, Son HK, Lee SH, Shin C, Johns MW (2010) The reliability and validity of the korean version of the epworth sleepiness scale. Sleep Breath. doi:10.1007/s11325-010-0343-6 PubMedGoogle Scholar
  18. 18.
    Kumar S, Bhatia M, Behari M (2003) Excessive daytime sleepiness in Parkinson’s disease as assessed by Epworth Sleepiness Scale (ESS). Sleep Med 4:339–342PubMedCrossRefGoogle Scholar
  19. 19.
    DeZee KJ, Jackson JL, Hatzigeorgiou C, Kristo D (2006) The epworth sleepiness scale: Relationship to sleep and mental disorders in a sleep clinic. Sleep Med 7:327–332PubMedCrossRefGoogle Scholar
  20. 20.
    Sanford SD, Lichstein KL, Durrence HH, Riedel BW, Taylor DJ, Bush AJ (2006) The influence of age, gender, ethnicity, and insomnia on epworth sleepiness scores: a normative US population. Sleep Med 7:319–326PubMedCrossRefGoogle Scholar
  21. 21.
    Miletin MS, Hanly PJ (2003) Measurement properties of the Epworth sleepiness scale. Sleep Med 4:195–199PubMedCrossRefGoogle Scholar
  22. 22.
    Johns MW (1994) Sleepiness in different situations measured by the Epworth Sleepiness Scale. Sleep 17:703–710PubMedGoogle Scholar
  23. 23.
    Chervin RD (2003) Epworth sleepiness scale? Sleep Med 4:175–176PubMedCrossRefGoogle Scholar
  24. 24.
    Smith SS, Oei TP, Douglas JA, Brown I, Jorgensen G, Andrews J (2008) Confirmatory factor analysis of the Epworth Sleepiness Scale (ESS) in patients with obstructive sleep apnoea. Sleep Med 9:739–744PubMedCrossRefGoogle Scholar
  25. 25.
    Wirtz M, Böcker M (2007) Properties and benefits of applying the Rasch model in clinical diagnostics. Rehabilitation 46:238–245PubMedCrossRefGoogle Scholar
  26. 26.
    Embretson SE, Reise SP (2000) Item response theory for psychologists. Erlbaum, Mahwah, NJGoogle Scholar
  27. 27.
    Guyatt GH, Kirschner B, Jaeschke R (1992) Measuring health status: what are the necessary measurement properties? J Clin Epidemiol 45:1347–1351CrossRefGoogle Scholar
  28. 28.
    Wright JG, Feinstein AR (1992) A comparative contrast of clinimetric and psychometric methods for constructing indexes and rating scales. J Clin Epidemiol 45:1201–1218PubMedCrossRefGoogle Scholar
  29. 29.
    Takegami M, Suzukamo Y, Wakita T, Noguchi H, Chin K, Kadotani H, Inoue Y, Oka Y, Nakamura T, Green J, Johns MW, Fukuhara S (2009) Development of a Japanese version of the Epworth Sleepiness Scale (JESS) based on item response theory. Sleep Med 10:556–565PubMedCrossRefGoogle Scholar
  30. 30.
    Maassen GH (2004) The standard error in the Jacobson and Truax Reliable Change Index: the classical approach to the assessment of reliable change. J Int Neuropsych Soc 10:888–893Google Scholar
  31. 31.
    Smith S, Sullivan KA (2007) A reliable change index (RCI) for the Epworth Sleepiness Scale (ESS). Sleep Med 9:102PubMedCrossRefGoogle Scholar
  32. 32.
    Lenz MC, Martinez D (2007) Awakenings change results of nighttime ambulatory blood pressure monitoring. Blood Press Monit 12:9–15PubMedCrossRefGoogle Scholar
  33. 33.
    Kumru H, Santamaria J, Belcher R (2004) Variability in the Epworth Sleepiness Scale score between the patient and the partner. Sleep Med 5:369–371PubMedCrossRefGoogle Scholar
  34. 34.
    Nguyen AT, Baltzan MA, Small D, Wolkove N, Guillon S, Palayew M (2006) Clinical reproducibility of the Epworth Sleepiness Scale. J Clin Sleep Med 2:170–174PubMedGoogle Scholar
  35. 35.
    Knutson KL, Rathouz PJ, Yan LL, Liu K, Lauderdale DS (2006) Stability of the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Questionnaires over 1 year in early middle-aged adults: the CARDIA study. Sleep 29:1503–1506PubMedGoogle Scholar
  36. 36.
    Pien GW, Fife D, Pack AI, Nkwuo JE, Schwab RJ (2005) Changes in symptoms of sleep-disordered breathing during pregnancy. Sleep 28:1299–1305PubMedGoogle Scholar
  37. 37.
    Chin K, Fukuhara S, Takahashi K, Sumi K, Nakamura T, Matsumoto H, Niimi A, Hattori N, Mishima M, Nakamura T (2004) Response shift in perception of sleepiness in obstructive sleep apnea–hypopnea syndrome before and after treatment with nasal CPAP. Sleep 27:490–493PubMedGoogle Scholar
  38. 38.
    Zimmermann C, Kohler D, Schonhofer B (2000) Value of retrospective assessment of the Epworth Sleepiness Scale after long-term CPAP therapy in obstructive sleep apnea disorder. Pneumologie 54:572–574PubMedCrossRefGoogle Scholar
  39. 39.
    Philip P, Taillard J, Quera-Salva MA, Bioulac B, Akerstedt T (1999) Simple reaction time, duration of driving and sleep deprivation in young versus old automobile drivers. J Sleep Res 8:9–14PubMedCrossRefGoogle Scholar
  40. 40.
    Holty JE, Parimi N, Ballesteros M, Blackwell T, Cirangle PT, Jossart GH, Kimbrough ND, Rose JM, Stone KL, Bravata DM (2010) Does surgically induced weight loss improve daytime sleepiness? Obes Surg. doi:10.1007/s11695-010-0213-0 Google Scholar
  41. 41.
    Walter TJ, Foldvary N, Mascha E, Dinner D, Golish J (2002) Comparison of Epworth Sleepiness Scale scores by patients with obstructive sleep apnea and their bed partners. Sleep Med 3:29–32PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Denis Martinez
    • 1
  • Tiago Cataldo Breitenbach
    • 2
  • Magali Santos Lumertz
    • 3
  • Denise Lerias Alcântara
    • 4
  • Neusa Sicca da Rocha
    • 2
  • Cristiane Maria Cassol
    • 2
  • Maria do Carmo Sfreddo Lenz
    • 4
  1. 1.Division of Cardiology, Hospital de Clinicas de Porto Alegre (HCPA), Sleep ClinicUniversidade Federal do Rio Grande do Sul (UFRGS)Porto AlegreBrazil
  2. 2.Hospital de Clínicas de Porto Alegre (HCPA)Universidade Federal do Rio Grande do Sul (UFRGS)Porto AlegreBrazil
  3. 3.Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA)Porto AlegreBrazil
  4. 4.Sleep ClinicPorto AlegreBrazil

Personalised recommendations