Research on Sleep Quality and the Factors Affecting the Sleep Quality

of the Nursing Students

D. YILMAZ,1 F. TANRIKULU,2 and Y. DIKMEN2

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Abstract

Purpose: This research has been conducted in order to examine the quality of sleep and the
factors affecting the sleep quality.Material/Methods: The sample of this descriptive research is
comprised of 223 volunteer students studying at Uludağ University Faculty of Health Sciences
Department of Nursing. Research datas have been collected through personal features survey
and Pittsburg Sleep Quality Index(PSQI). Results: The average result derived from the sample is
6.52±3.17. To briefly explain the average of the component scores: subjective sleep quality
1.29±0.76, sleep latency 1,55±0.94, sleep duration 0.78±0.99, habitual sleep activity 0.47±0.90,
sleep disturbances 0.99±0.09, use of sleeping medication 0.12±0.48, daytime dysfunction
1.29±0.90. It has been observed that there is a meaningful discrepancies between average PSQI
results and smoking habits of the students, total daily sleeping hours, efficient waking up times,
average daily coffee consumption(p<0.05). According to the analyses there is no meaningful
discrepancies between the age,gender, where the students live,snoozing during the morning
classes, the existence of chronic diseases and daily average tea consumption.
(p>0.05)Conclusions: According to the findings in the light of this research; nursing students
have low sleep quality.

Keywords: Sleep quality, Pittsburgh Sleep Quality Index, nursing students

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Introduction

Sleep, which is directly related to health and quality of life, is a basic need for a human being to
continue his bio-psycho-social and cultural functions [1]. Sleep affects the quality of life and
health,which is also perceived as an important variable[2,3]. Feeling energetic and fit after
sleeping is descriped as the sleep quality [4]. The fact that, nowadays the complaints about
sleep disorder being prevalent, low sleep quality being an indicator of many medical diseases
and there is strong relationship between physical ,psychological wellness and sleep; sleep
quality is an important concept in the clinic practices and related researches on sleep [5].

Sleeping disorders is a common health problem among adolescants and young adults [6]. There
is a general belief that university students do not sleep enough [7]. It has been reported that the
the amount and the quality of the sleep of university students has been changed in past few
decades and the sleep disorders has been inclined [8]. In the related researches is found that
sleeping disorder among university students in various frequencies and amounts [9,10,11]. Low
quality of sleep harms not only the academic success but also behavioral and emotional
problems [12], negative emotional status, increase in alcohol and smoking habits[13,14]. In
another research, it has been found that, there is a link between sleep quality and pschological
wellbeing; more psychological diseases are observed among university students with low sleep
quality [15]. Additionally it is recorded in the medical literature that, sleep quality is affected
from the external factors such as gender, academic success, academic background, general
health, socio-economic status and the stress level of the person [1,4,7,16].

Nursing students may have sleep issues due to their program being though, time and effort-
requiring [3,11]. Because of this matter, students who cannot sleep enough may have various
physical,social, psychological problems. Therefore, it is much more important to indicate the
sleep quality of the students and the factors affecting. There is a demand for this kind of
research since there is only limited amount of related research

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Aim of Study

This research is conducted in order to examine the sleep quality of the Nursing students and the
factors affecting it.

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Material and Method

Subjects
The research sample of this descriptive and cross-sectional research is derived from the
population of students studying at Uludag University Faculty of Health Sciences Department of
Nursing in the Spring Semester of 2016-2017 academic year (N=450). The sample of the
research is 223 volunteer students.

Instrument

In the research data collection process, personal features survey and Pittsburg Sleep Quality
Index(PSQI) has been used. Survey,which is prepared by the researchers scanning the related
medical literature, comprises of 11 survey questions. These questions are aimed to indicate the
introductory information of the students and the varibles affecting the sleep quality(age,
gender, semester, aree of residence, existence of chronic diseases, caffeine consumption level,
smoking habits).

Pittsburg Sleep Quality Index(PSQI) usef for examination of the sleep quality of the students; is a
scale which assesses the sleep quality and the sleeping disorder in the last one month. Pittsburg
Sleep Quality Index (PSQI) is devised by the Buysee et al. [17] is adapted to Turkish by the
Agargun et al. [18] and internal consistency coefficient is calculated as 0.80. In the examination
process of PSQI,19 issues are scored. PSQI has 7 internal components such as subjective sleep
quality, duration of sleep, habitual sleeping activity, sleep disturbance, sleep delay, use of
sleeping drugs and daytime dysfunctions. Each component is scored between 0-3. Total score
varies between 0-21, total PSQI score being <5 shows high sleep quality, >5 indicates low sleep
quality [18].

Statistical Analysis

In the data assessment process; frequency, percentage, arithmetic average and Cronbach’s
alpha is measured. The total score average of the sample was calculated and the normality test
was applied to determine the normal distribution of the sample scores According to this
analysis, it is observed that the sample scores does not comply with the normal
distribution(Kolmogorov-Smirnov Z=0.143, p<0.05);nonparametric tests such as Mann-Whitney
U and Kruskall Wallis were used to examine the difference between the independent variables
and sample averages.Scores are provided as average±standard deviation and p<0.05 is
considered as statistically meaningful results
Ethical Concerns

For the use of the assessment, written permissions are taken via e-mail. For the purpose of the
conduct of the survey, written approval from the research commission of the related institution
is taken(Decision no: 2017/7). Before application and the approval was obtained from them,
students were informed about the research and data collection tools.

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Results

According to the research, average age of the stundets is 20.03±1,73, 68,6% of them are
women. 50.2% of the students are in I. year, 19.7% are in II. year, 18.4% in III. year,%11.7 of
them are in IV. year. 17% of the students have smoking habits, 56.5% of the sleep 6-7 hours per
day. 26% of the students consumes 4-7 cups of tea per day, 19.3% of them uses 2-3 cups of
coffee, 46.6% of them wake up energetic after sleep, 19.9% of them have no chronic disease,
41.3% of them snooze during morning lectures.

The total PSQI average of the students is calculated as 6.52±3.17 and the ratio of the students
with sleep quality average higher than 5 is 56.1%.(Table 56.1%.(Table1,1, Table Table2)2) The
students internal component score averages are given below: subjective sleep quality
1.29±0.76, sleep latency 1,55±0,94, sleep duration 0.78±0.99, habitual sleep activity 0.47±0.9,
sleep disturbances 0.99±0.09, sleeping drug use 0.12±0.48 and daytime dysfunctions
1.29±0.9(Table 1)

Table 1

PSQI total and internal component score averages of the sample

PSQI Components X ±SS

Subjective Sleep Quality 1.29 ±0.76

Sleep Latency 1.55 ± 0.94

Sleep Duration0.78 ± 0.99

Habitual Sleeping Activity 0.47 ± 0.90

Sleep Disturbances 0.99 ± 0.09

Sleeping Drug Usage 0.12 ± 0.48

Daytime Dysfunctions 1.29 ± 0.90

Total PSQI 6.52 ±3.17

Table 2

PSQIscore averages of the sample

n %

5 and below 98 43.9

above 5 125 56.1

Although total PSQI score average being above 5, only 56.1% of the students' PSQI averages
were above 5.According to this result nearly half of the students’ sleep quality can be
considered as low sleep quality (Table (Table22).

In Table Table33 personal features of the nursing stdents, the relationship between these
features and PSQI scores. According to the table,a statistically meaningful relationship between
PSQI score averages amd smoking habit, total daily sleeping hours, waking up energetic and
daily average coffee consumption(p<0.05); no meaningful relationship is found between PSQI
scores and age, gender, semester level, area of residence, preexistence of chronic diseases,
snoozing during morning lectures, daily average tea consumption(p>0.05)

Table 3

>Table 3. Personal feature distribution of the sample students and the relationship between
personal features and PSQI scores (n:223)

Personal Features n % Test Results

Gender U*=1.36

Male 70 31.4 p=0.174

Female153 68.6

Age (Gender) 20.03±1.73 r **=0.094

p=0.160

Semester Year

1.Year 112 50.2

2.Year 44 19.7 KW***=6.050

3.Year 41 18.4 p=0.109

4.Year 26 11.7

Area of Residence

With Family 65 29.1 KW***=3.58

İn Dormitory 120 53.8 p=0.310

Alone at Home 10 4.5

Sharing flat 28 12.6

Preexistence of Chronic Diseases

Yes 18 8.1 U*=1.21

No 205 91.9 p=0.226

Smoking Habits

Smoking 38 17 U*=2.54

Non-smoking 185 83 p=0.011

Snoozing during the Lecture Hours

Yes 92 41.3 KW***=1.59

No 35 15.7 p=0.45
Sometimes 96 43

Waking Up Energetic

Yes 29 13 KW***=26.43

No 90 40.4 p=0.00

Sometimes 104 46.6

Total Sleeping Hours

4-5 hours 29 13 KW***=40.06

6-7 hours 126 56.5 p=0.000

8-9 hours 57 25.6

9 hours and above 11 4.9

Tea Consumption KW***=2.92

0-3 cups 151 67.7 p=0.231

4-7 cups 58 26

8 cups and above 14 6.3

Coffee consumption KW***=10.75

0-1 Cup 172 77.1 p=0.005

2-3 Cup 43 19.3

4 Cups and above 83 3.6

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*Mann Whitney U Analysis

**Correlation Analysis

***Kruskal Wallis Analysis

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Discussion

According to the results of this research which we conducted in order examine the affecting
nursing students’ sleep quality and the factors affecting; 56.1% of the students have PSQI
average of 5 and lower. In the light of this research, we can infer that more than half of the
students have low sleep quality.In a similar research in the United States of America, it is
observed than 71% of the students have at least one sleeping disorder [19]. According to a
similar research conducted by Karatay and colleagues [4] 56% of the nursing students have low
sleep. According to Aysan and colleagues’ research [3] students with sleep quality scores higher
than 5 comprises 59% of the sample. Similar research in the medical literature points out that
university students have low quality of sleep [10,16,20,21,22,23]. Our research results justifies
the results of researches given above. It is understood from the results of our research that low
sleep quality is an important issue for the nursing students. Extraordinarly apart from our
research, according to some similar researches conducted in Turkey less than half of the
university students studying in Turkey have sleeping disorders [14,16]. We interpret that, this
difference may be caused by the choice of a different sample of students.

According to the results of the study, there was a significant difference between students' sleep
quality and smoking habits, total sleep hours, resting status in the morning and average daily
coffee consumption (Table (Table3).3). It is reported that sleeping is important in terms of the
health of young adults [3] and it is said that young people need sleep for an average of 9-10
hours per [4,24]. In this study, students who wake up well-rested and sleeping 6-7 hours per day
have higher sleep quality.These findings also supports the medical literature.According to
Karatay et al. [4], Sari et al. [14] and Vail-Smith and colleagues’ [8] studies,smoking students
have lower sleep quality compared to non-smokers.It is known that cigarette contains nicotine
which has stimulant effect and it is known that smoking before sleep especially makes it difficult
to fall asleep and affects sleep quality negatively. On the other side according to Shcao et al. [25
caffeine containing drinks harms sleep quality. Our study also show parallelism with these
findings.

According to the results of this research, it is found that there was no relation between the sleep
quality and the age, sex, class level, area of residence, sleepiness in morning classes, presence of
chronic diseases and average daily tea consumption (Table (Table3).3). Age and gender have
been found to be among the factors that may affect sleep quality of individuals, though some
studies have shown that some factors such as age, gender, class level and place of residence do
not affect sleep quality [3,16]. In this study, it is interpreted that the age factor to be ineffective
in sleep quality may be caused by the are in a similar age group.According to researches
examining the correlation between gender and sleep quality, females have lower sleep quality
than males [3,5,7]. Additionally, first year students’ sleep quality may be harmed by these
factors; such as their first year curriculum being though, being deprived of family attention,
adaptation efforts for a new social environment.Furthermore, considering that the
environmental factor on sleep quality is also very effective, it can be assumed that the students
living in dormitory stay more crowded rooms and the sleep quality is lower than the other
students.Consequently, our research does not justify the medical literature.

Lund and colleagues[26] pointed out that physical and psychological problems have negative
effects of sleep quality.In our study, it is observed that preexistence of chronic diseases does not
effect sleep quality. In Saygili and colleagues’ research [16] students with chronic diseases have
lower sleep quality. Sari and colleagues [14] showed that students confirming to have chronic
illnesses have lower sleep quality but this result does not reflect a statistically meaningful
relationship between sleep quality and existence of a chronic disease.It is known that chronic
diseases related to the respiratory system, especially asthma, are frequently caused by sleep
problems and affect sleep quality negatively [16]. The results are not consistent with the
literature due to the fact that students who included in the study have declared illnesses which
have ambiguous relationship with the sleep quality; since the variety of the chronic diseases are
not questioned in this research.

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Conclusion

According to the findings in the light of this research; nursing students have low sleep quality.
Additionally, students who do not smoke, sleeps 6-7 hours per day and consuming beverages
with caffeine less have a better quality of sleep.To raise awaeness among university students
and about the concept of sleep quality and the factors affecting the sleep quality and to
increase the quality of sleep quality; panel discussions,seminars and conferences focusing on
the relationship between alcohol/caffeine consumption, smoking and the quality of sleep are
suggested.
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Acknowledgments

All authors had equal contribution

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Brief Insomnia and Quality of Sleep Scale (BIQSS): Reliability
and validity in higher education students
Author links open overlay panelA.Gomes1D.Marques1J.Tavares2M.Azevedo3

https://doi.org/10.1016/j.sleep.2013.11.315Get rights and content

Introduction

The present work aims to characterize in higher education students the reliability and validity of
a brief self-reported measure to assess insomnia complaints and perceived sleep quality
(Gomes et al., 2001, 2005, 2011), used from more than a decade by our research team
members, and henceforth labeled the Brief Insomnia and Quality of Sleep Scale (BIQSS).

Materials and methods

In study 1, the 7-items scale now termed BIQSS was developed, as part of a larger self-response
questionnaire on higher education sleep-wake patterns, and its internal consistency and item
homogeneity were analyzed based on the answers of 1654 undergraduates. In study 2, focused
mainly on validity, 323 undergraduate and master degree students completed the BIQSS
together with the PSQI (Buysse et al., 1989). Using an additional question on perceived sleep
problems, item discriminative power and ROC analyses were also performed. Higher BIQSS
scores equate to poorer sleep, and each item is rated in a 5 point scale from 0 to 4 (or in
reversed way when appropriate), thus total score may range from 0 to 28.

Results

Internal consistency was assessed by Chronbach alpha, which was.73 in study 1 and .78 in study
2. Corrected item-total correlations ranged from .32 to .57 (study 1), and from .40 to .60 (study
2). All items contributed to the internal consistency of the scale, as shown by drops in
Chronbach alpha values when excluding each item. As to validity (study 2), the correlation
coefficient between the BIQSS and the PSQI score was r = 0.65 (p < 0,001). Students that
reported a sleep problem (n = 40) obtained significantly higher BIQSS scores in comparison to
those who deny having any sleep problem, and all items were able to discriminate between
them. In ROC analysis, the Area Under the Curve (AUC) was .832, indicating moderate
precision/acuity.

Conclusion

The BIQSS is composed by a small number of items, is very easy to administer in higher
education students, and seems to possess reasonable reliability, validity, and acuity. Therefore,
it may constitute a convenient tool to screen for insomnia and poor sleep complaints, both for
research purposes and in clinical settings. Further studies are now needed in other samples.

Acknowledgements

Successive research studies leading to the present work have been supported by different
entities: Dep. of Education – Univ. Aveiro; Projects LEIES (FCG), SPASHE (FCT); Research Unit
CCPSF and CIECC (FCT).

A Review of Scales to Evaluate Sleep Disturbances in

Movement Disorders
Mónica M. Kurtis,1,* Roberta Balestrino,2 Carmen Rodriguez-Blazquez,3 Maria João Forjaz,4
and Pablo Martinez-Martin3

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This article has been cited by other articles in PMC.

Abstract

Patients with movement disorders have a high prevalence of sleep disturbances that can be
classified as (1) nocturnal sleep symptoms, such as insomnia, nocturia, restless legs syndrome
(RLS), periodic limb movements (PLM), obstructive sleep apnea (OSA), and REM sleep behavior
disorder; and (2) diurnal problems that include excessive daytime sleepiness (EDS) and sleep
attacks. The objective of this review is to provide a practical overview of the most relevant
scales that assess these disturbances to guide the choice of the most useful instrument/s
depending on the line of research or clinical focus. For each scale, the reader will find a brief
description of practicalities and psychometric properties, use in movement disorder cohorts
and analyzed strengths and limitations. To assess insomnia, the Pittsburgh Sleep Quality Index,
a generic scale, and three disease-specific scales: the Parkinson Disease Sleep Scale (PDSS), the
PDSS-2, and Scales for outcomes in Parkinson’s disease (PD)-Sleep-Nocturnal Sleep subscale are
discussed. To evaluate nocturia, there are no specific tools, but some extensively validated
generic urinary symptom scales (the Overall Bladder Questionnaire and the Overactive Bladder
Symptom Score) and some PD-specific scales that include a nocturia item are available. To
measure RLS severity, there are currently four domain-specific generic scales: The International
Restless Legs Scale, the Johns Hopkins Restless Legs Severity Scale, the Restless Legs Syndrome-
6 measure, a Pediatric RLS Severity Scale, and the Augmentation Severity Rating Scale (a scale
to evaluate augmentation under treatment) and several instruments that assess impact on
quality of sleep and health-related quality of life. To evaluate the presence of PLM, no clinical
scales have been developed to date. As far as OSA, commonly used instruments such as the
Sleep Apnea Scale of the Sleep Disorders Questionnaire, the STOP-Bang questionnaire, and the
Berlin Questionnaire are reviewed. Three scales have been extensively used to assess EDS: the
generic Epworth Sleepiness Scale, the Stanford Sleepiness Scale, and the PD-specific Scales for
outcomes in PD-Sleep-Daytime sleepiness subscale. To date, only the Inappropriate Sleep
Composite Score specifically evaluates propensity to sleep attacks.

Keywords: Parkinson’s disease, Parkinsonism, chorea, dystonia, insomnia, nocturia, restless

legs, sleep apnea

Introduction

Sleep problems such as insomnia, nocturia, restless legs syndrome (RLS), periodic limb
movements (PLMs), REM sleep behavior disorder (RBD), obstructive sleep apnea (OSA), and
excessive daytime sleepiness (EDS) are prevalent in the general population and in movement
disorder patients. Insomnia, for example, is a salient problem in Parkinson’s disease (PD) (1),
multiple system atrophy, progressive supranuclear palsy, and corticobasal degeneration (2), but
also in patients with hyperkinetic disorders such as Huntington’s chorea, neuroacantocytosis,
and Tourette syndrome (3). Daytime sleepiness (DS) is one of the main features of Lewy body
dementia and is also problematic in PD (4) and may be particularly influenced by treatment
with dopamine agonists as well as levodopa.

Sleep disturbances affect quality of rest and health-related quality of life (HRQoL) and may lead
to problems during the waking hours, such as EDS, fatigue, and memory and attention
difficulties. Nocturnal disturbances alter blood pressure, oxygen, and carbon dioxide blood
levels and are thus well-established risk factors for cardio-cerebrovascular diseases. On the
other hand, DS and sleep attacks impair social and working function and are highly dangerous if
subjects are driving a vehicle, with evident implications beyond the patient.

Therefore, diagnosis and treatment of sleep disorders is a priority for clinicians but also for
health policy makers. Diagnosis of insomnia is based on the subject’s perception of sleep quality
while diagnosis of nocturia, and RLS is based on careful clinical history and evaluation. Many
instruments have been designed to detect these problems, measure their severity, evaluate
their effect on quality of life, and assess their change in time or after intervention. The
diagnostic criteria of other sleep disturbances, such as PLMs, RBD, and OSA, are defined by
polysomnographic (PSG) data. For EDS and sleep attacks, objective tests such as the Sleep
Latency Test (MSLT) and the Maintenance of Wakefulness Test (MWT) are used. PSG is not a
useful ancillary test to diagnose EDS, although it can be useful to identify underlying sleep
disorders (5). However, these laboratory tests are highly demanding in terms of cost, human
resources, and other logistics required; therefore, questionnaires and scales have been
developed for screening patients and thus make recommendations for further testing.

Questionnaires are patient-based instruments that allow for the evaluation of signs and
symptoms that cannot be observed in the clinic (i.e., insomnia or nocturia) and may include
subjective features based on the patient’s perception and judgment of the symptom and its
impact on his/her life. As such, they are considered patient-related outcomes and have the
advantage of shifting the focus to the patient, a requirement in the current biopsychosocial
model of patient-centered medicine.

The objective of this review is to provide the clinician and researcher with an overview of the
scales that are currently available to screen and measure the severity of these sleep
disturbances (except RBD, which is the focus of another article in this issue). All the reviewed
scales are questionnaires and are organized by type (generic, disease-specific, and HRQoL) and
chronologically by year of publication. After a practical description of each scale including
diagnostic accuracy (for screening instruments, where available), the psychometric properties
and application in different movement disorder cohorts are discussed, along with the
instruments’ advantages and disadvantages.

Methods

The literature search was based on the pubmed database and included articles published
before January 31, 2018 and written in English, Italian, French or Spanish. The combined MeSH
search terms used were: (“insomnia” OR “nocturia” OR “restless legs” OR “periodic leg
movements” OR “obstructive sleep apnea” OR “excessive daytime sleepiness” OR “sleep
attacks” OR “sleep disturbance”) AND (“Parkinson’s disease”). A similar search strategy was
performed with the following terms: “multiple system atrophy,” “dementia with lewy bodies,”
“progressive supranuclear palsy,” “corticobasal degeneration,” “dystonia,” “chorea,”
“Huntington’s chorea,” “tics,” “Tourette.” The identified articles were perused for the use of
scales or questionnaires for screening or diagnosis of the sleep disturbances under review, and
their references were also searched for other sleep disturbance scales. For each identified
measuring instrument, psychometric properties were noted from the original developers of the
instrument and completed with further clinimetric investigations when available. With all
identified generic scales, a similar search strategy was used to identify their use in the different
movement disorder populations mentioned above. The extracted information was initially
discussed and agreed by two authors (Mónica M. Kurtis and Roberta Balestrino), and their
consensus was reviewed by the other authors to obtain a final agreement of the most relevant
scales.
Nocturnal Sleep (NS) Disturbances
Insomnia

The diagnostic criteria of “insomnia syndrome” include the following: (1) difficulty falling
asleep, awakenings during the night or waking up too early, (2) despite adequate sleep
circumstances, and (3) symptoms during wakefulness, such as attention problems or fatigue,
due to the lack of sleep (6). Thus, the diagnosis depends on self-reported outcomes, not on a
specific amount of sleep or other objective sleep measures. Insomnia can be classified as
primary or secondary; however, it is often hard to establish the cause, effect, or coexistence of
conditions that are associated with insomnia such as psychiatric disorders. Thus, the term
“comorbid” is preferable to “secondary.” Insomnia is a frequent complaint in movement
disorder patients and has been extensively studied in PD, chorea, and antibody-mediated
encephalopathies manifesting with movement disorders.

Pittsburgh Sleep Quality Index (PSQI)

Scale Description

The PSQI is a generic, 19 items self-rated scale designed to measure overall sleep problems (7).
A score above 5 distinguishes between “good” and “poor” sleepers with a high sensitivity and
specificity (7, 8) (Table (Table11).

Table 1

Scales that evaluate insomnia in movement disorders.

Scale Overview ScoringCut off Diagnostic accuracy Time frame Administration

Languages

PSQI (7) Generic

Assesses overall sleep quality 19 items are combined to form seven component scores
(subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep
disturbances, use of sleeping medication, and daytime dysfunction). Items are scored from 0 to
3 (no difficulty to severe difficulty). Total scores range from 0 to 21, where higher scores
indicating more severe difficulties in the different areas >5 “bad sleepers”

Sensitivity 90–98%

Specificity 84–86%

(7, 8) Previous month Self-rated

10 min Public domain

English

Spanish

PDSS (17) PD specific

Measures nocturnal problems and daytime sleepiness 15 items rated on visual analog scale
(0–10). Range 0–150, where higher scores indicate more severe sleep problems. Weighted
toward severity >82

AUC: 0.85 (95% CI 0.78–0.91)

Sensitivity 75%

Specificity 80%

(18) Previous week Self-rated

10 min Public domain

English

Japanese

Spanish

Portuguese

PDSS-2 (21) PD specific

NS problems 15 items scored from 0 (never) to 4 (very frequent). Range 0–60, where higher
scores indicate more sleep problems ≥15

Sensitivity 72.1%

Specificity 72.9%

(21) Previous week Self-rated

10 min Public domain

English

Spanish
SCOPA-Sleep-NS (11) PD specific

Measures NS problems and sleep quality The NS subscale has 5 items scored from 0 (not at
all) to 3 (very much). Range 0–15. Higher scores indicate more severity. One item on sleep
quality is rated on 7-point scale, 0 (very well) to 7 (badly) >7

AUC 0.96 (CI 0.93–0.98)

Sensitivity 97%

Specificity 80–88%

(11, 18) Previous month Self-rated

5 min Public domain

Dutch

English

Spanish

Thai

Open in a separate window

AUC, area under the curve; CI confidence interval; NS, nocturnal sleep; PDSS, Parkinson Disease
Sleep Scale; PSQI, Pittsburg Sleep Quality Index; SCOPA, Scales for outcomes in PD; PD,
Parkinson’s disease.

Psychometric Properties

The scale has shown high internal consistency and homogeneity (Cronbach’s alpha = 0.80–0.83)
(7, 9). A factor scoring model based on three different domains (sleep efficiency, perceived
sleep quality, and daily disturbances) is suggested (10). This scale shows strong correlation with
SCOPA-Sleep but not with PSG, except for sleep latency (7, 11).

Use in Different Movement Disorder Populations

The scale has been extensively used in primary insomnia, dementia, depression and anxiety but
also in movement disorders such as PD (12), MSA, PSP (13), and Huntington’s disease (14). It
has shown sensitivity to change in PD cohorts after interventions such as deep brain stimulation
(15) and pharmacological treatment (16).
Strengths and Limitations

The PSQI is a generic scale with strong psychometric attributes that has been used in different
movement disorders populations and reliably measures overall sleep problems. The scale was
“recommended” by the MDS Task Force that reviewed clinical scales assessing sleep in PD as a
screening tool and a measure of severity for overall sleep problems (10). The PSQI has the
limitations of a self-rated scale (unreliable in dementia populations), although it does include 5
items to be filled out by the caregiver that are not included in the total score. It is heavily
weighted toward sleep habits and does not adequately cover other sleep disturbances such as
motor problems at bedtime (akinesia, dystonia, or chorea), RLS, REM Sleep Behavior Disorder
(RBD) or DS. Furthermore, questions addressing respiratory disturbances and awakening may
be confounders since they may be secondary to different problems, and scoring is complex.

Parkinson Disease Sleep Scale (PDSS)

Scale Description

The PDSS (17) is a PD-specific, 15 item self-rated scale that preferentially evaluates NS
problems, with only one item pertaining to DS [see Nocturnal Sleep (NS) Disturbances]. Each
item is rated on a 0–10 visual analog scale (VAS), total score ranging from 0 to 150. A cutoff
score above 82 indicates the presence of NS problems with acceptable sensitivity and specificity
(18) (Table (Table11).

Use in Different Movement Disorder Populations

The PDSS has been extensively used in PD and there is some experience in a dystonia cohort
including patients with generalized, segmental, and focal dystonia (19).

Psychometric Properties

The PDSS has been validated in PD patients in all stages (20). Internal consistency and test–
retest reliability are high [Cronbach’s alpha = 0.77 and intraclass correlation coefficient (ICC) = 
0.94, respectively] (17). Floor and ceiling effects are low, and there is significant correlation
between 11 of the 15 items (20). The PDSS has shown strong correlation with the SCOPA-Sleep-
NS (18).

Data From Different Populations

The PDSS has been widely used in different PD populations and distinguishes between PD
patients and controls and drug naïve, mild and long-standing PD patients.
Strengths and Limitations

The PDSS has demonstrated good psychometric characteristics. The scale is “recommended” by
the MDS Task Force as a screening tool and severity measure for sleep symptoms in PD as it
includes most of the patient’s possible disturbances (10). However, patients require explanation
on how to score the VAS, and the scale does not include information from the caregiver. It does
not address respiratory difficulties such as sleep apnea and specific sleep disturbances such as
RBD and RLS are partially addressed but wording is ambiguous. Finally, the scale only has one
item regarding DS and thus is not recommended to assess diurnal sleep problems in PD.

Parkinson Disease Sleep Scale-2

Scale Description

The PDSS-2 (21) is the second version of the PDSS and has two main differences with the first
version of the PDSS (see above): items are scored on a Likert scale (from 0 = never to 4 = very
frequent), and all 15 items evaluate NS problems. Total scores range from 0 to 60, and higher
scores indicate higher severity. A cut of score above or equal to 15 distinguishes “bad” sleepers
from good sleepers with acceptable diagnostic accuracy (21) (Table (Table11).

Psychometric Properties

The scale has shown acceptable inter-item correlations (>0.30) and internal consistency
(Cronbach’s alpha, 0.73). Test–retest reliability is also satisfactory (ICC = 0.80). Factor analysis
resulted in a strong main factor that justifies summing all the items into a total scale, but also a
three factors solution explaining 42.75% of variance, which suggested a hierarchical scale
structure. The three subscales are night-time motor problems, PD-specific symptoms, and
sleep-specific symptoms (21).

Strengths and Limitations

Like the previous version, the PDSS-2 has shown good psychometric characteristics and has
been extensively used in PD and is thus recommendable for screening and measuring severity
of sleep disturbances in PD. This Likert scaling is easier for patients to understand, although
scoring in item 1 is inverted which may be confusing.

SCOPA-Sleep (NS Subscale)

Scale Description

The Scales for Outcomes in PD-Sleep (SCOPA-Sleep) (11) is a PD-specific scale that includes 12
items to measure sleep quality, NS disturbances, and DS. The NS subscale includes 5 items on
insomnia, multiple awakenings, sleep efficiency, and duration plus one single item on overall
sleep quality. A cutoff score of 7 has demonstrated excellent sensitivity and satisfactory
specificity (11, 18) (Table (Table11).

Psychometric Properties

The internal consistency of the NS subscale is high (Cronbach’s alpha = 0.88–0.84), and test–
retest reliability is excellent (ICC = 0.94) (11). Factor analysis revealed one factor accounting for
68.1% of the variance, thus demonstrating that this subscale measures a single construct (11).
The SCOPA-Sleep-NS has shown strong correlations with other instruments such as the PSQI (r 
= 0.83) (11) and the PDSS (r = 0.60) (18).

Strengths and Limitations

The NS subscale of the SCOPA-Sleep has shown strong psychometric properties and has been
extensively used, discriminating between subjects and controls and PD patients in different
stages. The subscale is a “recommended” tool for screening and for measuring severity of
overall sleep problems in PD (10). However, sensitivity to change has not been investigated and,
similarly to the PDSS, the scale lacks specific items addressing RLS and RBD.

Multidomain Scales

Some multidomain PD-specific scales, such as the Non-Motor Symptom Questionnaire

(NMSQuest) (22), the Non-Motor Symptom Scale (NMSS) (23), and the Movement Disorder
Society Unified Parkinson Disease Rating Scale (MDS UPDRS) part 1B (24) include a single item
that evaluates insomnia. The NMSS is a rater-based scale that evaluates both severity and
frequency of thirty different non-motor symptoms seen in PD, considering the past month. Item
5 has been used to evaluate difficulty falling asleep or staying asleep in other hypokinetic
disorders such as MSA and PSP (25). The NMSQuest and the MDS UPDRS part 1B are both self-
rated questionnaires. Question 23 on the NMSQuest evaluates difficulty falling asleep or
maintaining sleep while item 1.7 of the MDS UPDRS asks the patient to give an overall score on
sleep quality in the past 7 days. Another disease-specific scale for another parkinsonism, the
Progressive Supranuclear Palsy Rating Scale (26) includes one item on sleep difficulty, rated
from 0 to 4, in the activities of daily living part. These scales have demonstrated excellent
psychometric characteristics, although the validity and reliability of single items has not been
tested yet.

Conclusion

Only the PSQI can be recommended for screening and assessing severity of insomnia in any
type of movement disorders since it is a generic scale with satisfactory psychometric properties
and extensive use. There are three PD-specific scales that can be recommended in patients with
this disease. There are single items on PD-specific multidomain scales that assess insomnia, but
these single items have insufficient psychometric data on validity and reliability.

Nocturia

Nocturia is defined as “waking up to pass urine during the main sleep period,” and it is a
common phenomenon although patients tend to under-report this symptom (27). Nocturia can
be due to different causes, such as renal, urological, vascular, or neurological diseases and
medications, and etiology ranges widely by gender and age group. Similarly to other sleep
disturbances, consequences of nocturia include lower sleep quality with eventual daytime
consequences. Furthermore, nocturia is associated with falls and bone fractures, therefore
increasing morbidity and, in elderly populations, mortality (27). Nocturia is highly frequent in
patients with PD and can exacerbate sleep fragmentation among this population (28).

Overactive Bladder Questionnaire (OAB-q)

Scale Description

The OAB-q (29) is a generic, self-rated, 33 items scale developed to measure symptoms of
overactive bladder (OAB), which include urinary frequency, nocturia, and urgency, with or
without incontinence. The scale is made up of two subscales: a symptom bother scale (8 items),
rated 1 (not at all) to 6 (a very great deal) and an HRQoL scale (HRQoL) (25 items), rated 1 (none
of the time) to 6 (all the time). Two items of the symptom bother scale assess nocturia, and five
of the HRQoL scale are related to sleep. The time frame is the past 4 weeks. It takes about 20–
25 min to complete. A shorter form, the OAB-q SF, made up of 19 items (6 symptom bother
items and 13 HRQoL items) was developed by the original authors and includes nocturia (1
item) and impact on sleep quality (2 items) (30).

Psychometric Properties

Factor analysis provided a four factors solution for the HRQoL items (one of them being sleep)
(29). Internal consistency is high with subscale Cronbach’s alpha-values ranging from 0.86 to
0.94 (29). The questionnaire has also demonstrated adequate test–retest reliability (31) and
satisfactory responsiveness (32). The shorter form has also shown appropriate convergent
validity, discriminant validity, internal reliability, reproducibility, and responsiveness to change
(30).

Scale Use in Movement Disorders

In PD, the OAB-q has been used to evaluate the correlation of bladder dysfunction and motor
impairment (33), while its short form has been used to evaluate the effect of percutaneous
posterior nerve stimulation on detrusor (34) but no published experience in other movement
disorder cohorts was found.

Strengths and Limitations

The OAB-q has been extensively used due to its robust psychometric characteristics and
because it assesses severity of symptoms and impact on quality of life. It can be found in
several languages and a short form is available. However, studies demonstrating sensitivity to
change of the OAB-q are lacking. The psychometric properties of the items on nocturia have not
been investigated nor their impact on sleep quality. Finally, data in movement disorders
patients are only available for PD patients.

Overactive Bladder Symptom Score (OABSS)

Scale Description

The OABSS (35) is another generic, self-rated scale with 4 items that include: daytime urinary
frequency (scored 0–2), nocturia (from 0, never wake up to urinate, to 3, wake up ≥3 times to
urinate), urgency (0–5), and incontinence (0–5). Thus, the total score ranges from 0 to 15,
where higher scores indicate more severity. The time frame is the past week, and the
questionnaire takes about 3–4 min to complete.

Psychometric Properties

In patients with OAB, each symptom score correlated positively with the total OABSS (rS = 0.10–
0.78), and the scale showed good internal consistency (Cronbach’s alpha = 0.74) and high test–
retest reliability (weighted kappa coefficients were 0.80–1.0 for each symptom score and 0.86
for OABSS). The OABSS showed moderated correlations with quality of life scores assessed by
the King’s Health Questionnaire (r = 0.20–0.49). The OABSS discriminated patients with OAB
from controls and showed sensitivity to change after therapeutic intervention (35).

Use in Movement Disorders

The OABSS has been recently used in two PD cohorts to evaluate urinary symptoms, including
nocturia. Mito et al investigated PD patients without treatment and found moderate
correlations between OABSS and the UPDRS motor scores (rS = 0.39), particularly with the
akinetic-rigid subscore (rS = 0.47) (36). Another study investigated the correlation between
urinary disturbances and falls in 90 patients with PD and did not find a relationship between
nocturia and falling (37). To the best of our knowledge, the scale has not been used in other
movement disorders.
Strengths and Limitations

The OABSS is a fast and easy to use scale that has demonstrated content and construct validity
and internal consistency in measuring urinary disturbances in OAB syndrome. However, the
psychometric properties of the single item on nocturia have not been sufficiently investigated,
and data for movement disorders populations are limited to PD.

Urinary Symptom Profile (USP)

Scale Description

The USP is a 13 item, self-rated scale that evaluates three dimensions of urinary disturbances:
stress urinary incontinence, OAB, and low stream symptoms (38). The OAB domain includes two
items on nocturnal urinary symptoms. The time frame includes symptoms in the past 4 weeks.

Psychometric Properties

The scale has demonstrated robust psychometric qualities with good internal consistency,
convergent validity, and test–retest reproducibility. In the validation study, USP dimension
scores were good predictors of urinary disorder presence and identification and correlated with
micturition diaries (38).

Use in Movement Disorders

To the best of our knowledge, the scale has only been used in a population of functional
movement disorders patients who reported lower urinary tract symptoms (39).

Strengths and Limitations

Although this is the first scale to comprehensively assess the main dimensions of urinary
disturbances in both sexes and the psychometric properties are more than adequate, the UPS
has scarcely been studied in movement disorders patients. The nocturia items have not been
investigated separately to evaluate their psychometric properties.

Other Generic Urinary Symptom Scales

There are four generic questionnaires designed to assess lower urinary tract symptoms
associated with benign prostatic enlargement in men that have excellent psychometric
properties (validity and reliability) and include an item on nocturia. Of these, the most
extensively used, probably due to simplicity and fast completion, is the American Urological
Association symptom score (40), also known as the International Prostate Symptom Score. The
Danish Prostate Symptom Score (41) and the International Continence Society (ICS) ICSmale
questionnaire (42) are very complete but requires more time and harder to score. The
shortened version of the latter, the ICSmale Short Form (43), provides a good alternative and
has been used in a Huntington’s disease population (44).

PD-Specific Multidomain Scales

The NMSQuest (22), the NMSS (23), and the SCOPA-Autonomic (45) include an item on
nocturia. Item 24 on the NMSS and item 9 on the NMSQuest evaluate whether the patient has
to get up during the night to urinate. The SCOPA-Autonomic is a tool that evaluates the range
of dysautonomic symptoms that most affect PD patients and item 13 evaluates the frequency
of nocturia. These single items have not been properly investigated to establish their
psychometric properties and reliability to screen for and measure severity of nocturia in PD.

Conclusion

There is no scale designed solely for the evaluation of nocturia and its effect on sleep. The
available measurements include generic scales that measure lower urinary tract dysfunction,
including nocturia, and PD-specific scales that address a range of non-motor symptoms that are
prevalent in this movement disorder, including nocturia.

Restless Legs Syndrome

Restless legs syndrome is a neurological disorder characterized by the presence of unpleasant

sensations that patients describe as creeping, crawling, itching, tingling, pulling, or painful
sensations, more commonly, but not exclusively, in the lower limbs. Moving the interested limb
or standing up, walking or stretching can release these sensations, thus the name of the
disease. RLS is relatively common, with prevalence rates ranging from 3.9 to 15% in the general
population; is more common among Caucasians and older people, although it can affect
children as well (46). Approximately 10% of patients seek medical help, and the most common
complaints are difficulty in sleeping/daytime activities and an overall lower HRQoL (47). The
diagnostic criteria have been recently revised by the International Restless Legs Syndrome
Study Group (48).

There are three scales to assess the severity of RLS, one scale to assess the augmentation
phenomenon, three scales that assess HRQoL and two scales that assess the impact of RLS on
sleeping and on daily functioning, although just one has been validated (Table (Table2).2). One
pediatric scale has been designed but has not been validated. Two PD multidomain scales have
an item to assess symptoms that are compatible with RLS.
Table 2

Scales that evaluate restless legs syndrome.

Scale Overview ScoringCut off Diagnostic accuracy Time frame Administration

Languages

JHRLSS (49) RLS specific

Assesses the usual time of onset/severity of symptoms 1 question on what time of day the
RLS appears, with answers ranging from 0 (no symptoms) to 3 (day and night symptoms) No
established cutoff Lifetime (50% of days) Clinician rated

1 min English

IRLS (51) RLS specific

Most used scale to assess severity of RLS 10 items in total. Answers range from “no RLS or
impact (0)” to “very severe RLS or impact (4)”

2 subscales: symptoms and symptoms impact

Total score that ranges from 0 to 40 No established cutoff Previous week Clinician rated

10 min English, Japanese, Hindi, Brazilian Portuguese, and translations performed by MAPI
Research Trusta

RLS-6 (55, 56) RLS specific

Assess severity of RLS at different times of a 24 h period 6 items, scored on a 0–10 scale (0 = 
no symptom, 10 = very severe). No total score, separate scores for 4 domains: sleep quality
(items 1 + 6); RLS at night time (items 2 + 3); daytime manifestations during relaxation (item 4);
and during activity (“RLS mimics”) (item 5) No established cutoff Previous week Clinician rated

10 min English

ASRS (57) RLS specific

Measures RLS before and after dopaminergic treatment 3 items cover where symptoms
begin and the onset. Each item is scored “0” (improvement after treatment), worsening score
ranges between 1 (“mild”) and 8 (“severe”). Total score ranges from 0 to 24 following an
algorithm ≥5

Sensitivity 82%
Specificity 92%

(57) Previous week Clinician rated

10 min for the scale and 5 min to calculate the score English and translations performed
by MAPI Research Trustb

RLS-QLI (58) RLS specific

Measures impact of RLS on HRQoL 17 items in 4 domains: daily function, social function, sleep
quality, and emotional well-being. Scores for each domain can be calculated as explained in the
scale. Total scores range between 0 and 100 (lower scores mean lower HRQoL) No
established cutoff Previous month Self-rated

15 min for the scale and 5 min for the score English

ARLSQoL (60) RLS specific

Measures impact of RLS on daily life, emotional well-being, social life and work 18 items. 10
items are scored on a 5-point scale, and form a single summary score, the overall life impact
score (lower scores indicate worse HRQoL). The remaining 8 items are recorded as either a
numerical value or a dichotomous response and concern daily activities (one question), sexual
interest (two questions) and work (five questions) No established cutoff Previous 4 weeks
Self-rated

10 min Dutch, Finnish, French, German, Greek, Hungarian, Italian, Hindi, and Japanese

KRLS-QoL (62) RLS specific

Measures impact of RLS on HRQoL 12 items, 5 domains (effects of RLS symptoms; disturbed
sleep and its effects; effects of other features; handling the RLS symptoms; overall impact on
QoL). First 11 items are scored from 0 (no impairment at all) to 5 (extreme impairment). Item
12 summarizes the impact on quality of life No established cutoff Previous 4 weeks Self-
rated

10 min English

PSQ-RLS (63) RLS specific

Assesses impact of RLS on sleeping and on daily functioning 5 single item domains
(overall quality of sleep, ability to function during the day, frequency of RLS symptoms,
awakening at night due to RLS, length of awakening in the night due to RLS symptoms). 4 Items
are assessed with a Likert scale (1–4 or 1–5); one Item is an open-ended question on the
number of nights per week with RLS symptoms No established cutoff Previous week Self-
rated

5 min English

Open in a separate window

IRLS, International Restless Legs Scale; JHRLSS, Johns Hopkins Restless Legs Severity Scale; ASRS,
Augmentation Severity Rating Scale; ARLSQoL, Restless Legs Syndrome Quality of Life
Questionnaire/Abetz; RLS-QLI, Restless Legs Syndrome Quality of Life Instrument; KRLS-QoL,
Kohnen Restless Legs Syndrome Quality of Life Questionnaire; PSQ-RLS, Post-Sleep
Questionnaire for RLS; RLS-6, Restless Legs Syndrome-6; HRQoL, health related quality of life;
RLS, restless legs syndrome.

aTranslations: Afrikaans for South Africa, Arabic for Saudi Arabia, Cebuano for the Philippines,
Czech for Czech Republic, Danish for Denmark, Dutch for Belgium (Flemish), Dutch for the
Netherlands, English for Canada, English for the Philippines, English for the UK, Farsi for Iran,
Finnish for Finland, French for Belgium, French for Canada, French for France, French for
Switzerland, German for Austria, German for Germany, German for Switzerland, Greek for
Greece, Hungarian for Hungary, Italian for Italy, Italian for Switzerland, Japanese for Japan,
Korean for Korea, Mandarin for China, Mandarin for Taiwan, Norwegian for Norway, Polish for
Poland, Portuguese for Portugal, Russian for Russia, Serbian for Serbia, Slovak for Slovakia,
Spanish for Spain, Spanish for the USA, Swedish for Sweden, Tagalog for the Philippines, and
Turkish for Turkey.

bTranslations: Czech for Czech Republic, Dutch for the Netherlands, Finnish for Finland, German
for Austria, German for Germany, Italian for Italy, Polish for Poland, Spanish for Spain, Swedish
for Finland, and Swedish for Sweden.

Johns Hopkins Restless Legs Severity Scale (JHRLSS)

Scale Description

The JHRLSS is a short scale used to assess the usual time of onset and severity of symptoms of
RLS and consists one sole item (49) (Table (Table22).

Psychometric Properties

This scale showed a strong correlation with sleep efficiency, as assessed by an all-night
polysomnogram (rS = 0.60) and moderate correlation with Periodic Limb Movements (PLMs)
per hour of sleep (rS = 0.45). The JHRLSS inter-rater reliability was excellent: Spearman’s rank
coefficient was 0.91, and Cramer’s V for inter-rater agreement was 0.87 (49).
Data From Different Populations

It has been validated in an adult population of RLS patients, with symptoms at least 5 
days/week (50). We did not find any data regarding its use on other populations.

Strengths and Limitations

The JHRLSS is an easy and fast instrument to administer to obtain additional information on
RLS. It showed correlation with objective measures of the disease. In a revision of instruments
to assess the severity of RLS performed by the MDS Task Force (50), this scale was rated as
“suggested” for RLS patients with frequent symptoms (5 days a week or more) since no data on
its responsiveness were available. There are no published data on populations other than adults
with RLS. Importantly, the demarcation point for “evening” (6:00 p.m.) might need to be
adjusted based on geographic and cultural characteristics of the population. It does not provide
information on other important aspects of the disease such as severity, impact on sleep, or
HRQoL.

International Restless Legs Scale (IRLS)

Scale Description

The IRLS (51) is a 10-item questionnaire with two subscales, one assessing symptoms and one
evaluating how bothersome they are to the patient. It is probably the most widely used tool to
evaluate severity and impact on quality of life of RLS (Table (Table22).

Psychometric Properties

Factor analysis showed two factors, “Severity of symptoms” and “Life Impact,” with a total of
64.3% of the variance explained. Internal consistency was satisfactory (Cronbach’s alpha = 0.93–
0.95) and corrected item-total correlations acceptable (>0.40). Reliability was adequate: after 2 
weeks, the ICC was 0.87, and inter-rater reliability was 0.93–0.97. It showed strong correlation
with other scales such as the Clinician’s Global Impression of Severity (CGIS) (0.73–0.74) and the
Patient Global Impression (0.78–0.82). The IRLS differentiates a group of RLS patients from a
normal control group and a sleep-disorder control group (51). The scale has demonstrated
responsiveness (52).

Data From Different Populations

The scale was originally validated in an adult population of RLS patients. It has been used to
study prevalence of RLS in PD and controls (53) and to compare the prevalence or RLS in
different movement disorders: PD, PSP, and MSA (13). The scale has also been recently used in
Huntington’s disease (54).

Strengths and Limitations

This scale was rated as “recommended” by the MDS Task Force (50). It is the primary
instrument used to determine RLS severity, applied in different populations including
movement disorder patients. It is available and validated in many different languages. However,
the scale does not provide information on RLS symptom severity during different times of the
day or under different circumstances.

Restless Legs Syndrome-6 (RLS-6)

Scale Description

The RLS-6 is a specific measure to assess the severity of RLS that was developed more than a
decade ago (55) and has been recently validated (56). This 6 items scale is divided into four
domains assessing RLS symptoms during different times and situation of the day (Table
(Table22).

Psychometric Properties

The RLS-6 has adequate internal consistency (Cronbach’s alpha = 0.79). The factor analysis
showed one factor explaining 55% of the variance (item 5 excluded). Moderate to high
correlations were obtained between RLS-6 domains and IRLS subscores (0.25–0.70) and
between RLS-6 domains and IRLS total score (0.35–0.74). The RLS-6 displayed a satisfactory
ability to discriminate between patients in different severity categories as assessed by the IRLS
and CGIS, and was responsive to treatment, with responsiveness coefficients ranging from 0.38
to 0.49, except for the RLS mimics domain (56).

Data From Different Populations

The RLS-6 has been validated in adults of both genders with RLS. To the best of our knowledge,
there are no data on other populations, and this scale has not yet been used in movement
disorders patients.

Strengths and Limitations

In a revision of instruments to assess the severity of RLS performed by the MDS Task Force (50),
this scale was rated as “suggested,” since validation data had not been published. However,
validation data are currently available, demonstrating good psychometric properties and good
responsiveness (56). It is a complementary scale to be used with the IRLS as it provides
information on symptom severity at different times of the day and night and during activities.
However, there are no data on its reproducibility and stability.

Augmentation Severity Rating Scale (ASRS)

Scale Description

The ASRS was designed as a quantitative measure of the severity of augmentation (a

paradoxical worsening of RLS symptoms from dopaminergic therapy) during clinical studies
(57). It consists of 3 items that evaluate where (body part) and when RLS symptoms start and
should be administered at baseline (before treatment) and after treatment. The scale has
satisfactory sensitivity and specificity values (57) (Table (Table22).

Psychometric Properties

The ASRS showed acceptable internal consistency (Cronbach’s alpha of 0.62). Factor analysis
showed only one factor. The worst augmentation score under treatment showed a strong
correlation with the independent rating of an expert (0.72), and the ASRS scores were
significantly different between subjects with and without augmentation according to experts’
opinion. The correlation between the CGIS for augmentation and the ASRS total score was
moderate (0.53). Test–retest reliability was satisfactory (0.72); the inter-rater reliability analysis
was excellent (0.94) (57).

Data From Different Populations

It has been validated in an adult population of RLS patients of both genders. No data on
patients with other movement disorder and associated RLS are available.

Strengths and Limitations

The ASRS is a specific tool to measure augmentation in RLS patients who have been treated
with dopaminergic agents. In the MDS Task Force review (50), this scale was rated as
“recommended” to measure augmentation. The scale must be administered before and after
the start of dopaminergic therapy. The main disadvantage is that it has not been correlated
with objective measures of augmentation.

Restless Legs Syndrome Quality of Life Instrument (RLS-QLI)

Scale Description

The RLS-QLI is another self-administered questionnaire designed to measures the impact of RLS
on HRQoL (58). This 17-item questionnaire is divided into four domains considering impact on
daily activities and sleep (Table (Table22).
Psychometric Properties

Factor analysis showed 4 factors. The RLS-QLI has satisfactory internal consistency and
reliability: for the subscales, Cronbach’s alpha was 0.85–0.91 test–retest reliability coefficients
ranged 0.81–0.93. It showed weak to moderate correlations with SF-36 subscales (0.26–0.62)
and moderate-to-strong correlations with the total IRLS score (−0.71, −0.62) (58).

Data From Different Populations

The RLS-QLI has been validated in adult patients of both genders, without a confirmed diagnosis
of RLS. We did not find data regarding its use in other populations.

Strengths and Limitations

The MDS Task Force (59) rated this scale as “suggested.” It showed good psychometric
properties; however, it has only been tested in a population without a confirmed diagnosis of
RLS, and its responsiveness has not been assessed.

Restless Legs Syndrome Quality of Life Questionnaire/Abetz (ARLSQoL)

Scale Description

ARLSQoL (60) is a self-administered scale to measure the impact of RLS on HRQoL. This 18-item
questionnaire is made up of two subscales, one evaluating overall impact and the other
assessing different spheres of patients’ life (i.e., work, sexual, and social) (Table (Table22).

Psychometric Properties

There is one factor for the 10 items that are grouped in the summary score. The ARLSQoL
showed excellent internal consistency (Cronbach’s alpha = 0.82–0.92) (60, 61) and satisfactory
stability, with ICCs of 0.79, −0.84 (60). Correlation coefficients were moderate between the
scale summary score and the Mental Component Score of the SF-36 (r = 0.50) and with the IRLS
(r = −0.67 to −0.68). The ARLSQoL was able to distinguish between patients with mild, moderate
or severe symptoms according to their reports, between levels of sleep problems assessed by
the MOS Sleep Scale and between levels of global health status determined by a CGIS (60, 61).

Data From Different Populations

It has been validated in an adult population of RLS patients of both genders. To the best of our
knowledge, no data on other populations are available.
Strengths and Limitations

This is a quick, easy and self-administered instrument to evaluate HRQoL in RLS. It has shown
acceptable psychometric properties. However, its responsiveness has not been evaluated. In
the MDS Task Force revision of scales to assess HRQoL in RLS (59), this scale was rated as
“recommended.”

Kohnen Restless Legs Syndrome Quality of Life Questionnaire (KRLS-QOL)

Scale Description

The Kohnen Restless Legs Syndrome Quality of Life Questionnaire (KRLS-QOL) is a self-
administered questionnaire to assess the HRQoL in patients with RLS. This 12-item
questionnaire is divided into five domains evaluating the effect of RLS, how they are handled
and overall impact (Domain 5) (Table (Table2)2) (62).

Psychometric Properties

The exploratory factor analysis identified two factors explaining 56.85% of the variance
(“Impaired health by symptoms” and “Burden of symptoms”), but the parallel factor analysis
advised to consider only one dimension in the scale.

This scale showed acceptable internal consistency and reproducibility (Cronbach’s alpha = 0.88).
For test–retest reliability, kappa values were 0.43–0.64 (item 4), and the ICC for the KRLS-QoL
Index was 0.73. The KRLS-QoL showed moderate-to-strong correlations with the IRLS total score
(0.68) and its subscores (0.50–0.73), moderate to low correlations with the RLS-6 (0.33–0.57),
and with the CGI (0.42). KRLS-QoL-Domain 5 had moderate to high correlations with the IRLS
total score (0.60) and subscores (0.49–0.59), moderate to low with the RLS-6 (0.26–0.49), and
CGIS (0.37). KRLS-QoL Index and Domain 5 significantly increased their scores with increasing
RLS severity levels based on the IRLS and CGIS scores (62). Responsiveness parameters (effect
size) showed large effect with an effective treatment, and strong correlations with change in
other scales (62).

Data From Different Populations

The KRLS-QoL has been validated in an adult population of RLS patients of both genders. No
data on other populations are available.

Strengths and Limitations

In the review by the MDS Task Force (59), this scale was rated as “suggested” since the
validation study had not been published. However, the KRLS-QoL has now been validated and
demonstrated good psychometric properties (62), therefore it can be considered a
“recommended” instrument to assess the impact of RLS on HRQoL and to measure
responsiveness to therapy.

Post-Sleep Questionnaire for RLS (PSQ-RLS)

Scale Description

The PSQ-RLS is a self-administered questionnaire to assess the impact of RLS on sleep and daily
functioning (63). This 5-item questionnaire considers number and length of night-time
interruptions of sleep due to RLS (Table (Table22).

Psychometric Properties

The PSQ-RLS showed a weak to moderate convergent validity with the following related scales:
the IRLS (51), the RLSQoL (61), the Profile of Mood States (64), and sleep domains of the MOS
Scale (65). In a study, PSQ-RLS scores did not include systematic measurement errors associated
with personal attributes (race, gender, and ethnicity), had adequate discriminate validity across
RLS severity groups, and showed satisfactory responsiveness in a 3-month treatment period
(63).

Data From Different Populations

The PSQ-RLS has been validated in an adult population of RLS patients of both genders. No data
on other populations are available.

Strengths and Limitations

The PSQ-RLS is an instrument that can be used to assess the impact of RLS on quality of sleep. A
review of instruments that assesses HRQoL in RLS (59) noted that the scale had not been used
by other investigators beyond its designers and its internal consistency and stability had not
been explored, which justified the scale’s rating as “listed.” Subsequently, the scale has been
used by other investigators, but the missing psychometric properties have yet to be published.

Restless Legs Syndrome-Next Day Impact Questionnaire (RLS-NDI)

The RLS-NDI is a self-administered questionnaire to assess the impact of RLS on sleep and daily
functioning. The RLS-NDI is composed of 14 items rated on an 11-point Likert-type scale. It is
designed to be administered in the evening with a 12-h recall, to assess the impact of RLS on
the same day. It has shown a good content validity, but no further data on its psychometric
properties are available (66).
Pediatric Restless Legs Syndrome Severity Scale (P-RLS-SS)

The P-RLS-SS was designed to measure RLS severity in children (67). This scale is composed of
41 items (17 morning and 24 evening items) and a parent questionnaire composed of 20 items.
Its importance relies in being the only instrument to assess RLS severity in children; however it
has not been validated, and no data on its psychometric properties are available.

Multidomain Scales That Assess RLS

For PD, there are two multidomain scales that assess the range of non-motor symptoms that
are prevalent in this disease, the NMSS (23) and the NMSQuest (68). Both instruments include
one item for RLS assessment when the patient is lying down or inactive: item 6 of the NMSS and
item 26 of the NMSQuest.

Conclusion

There are two scales (IRLS and RLS-6) that can be recommended to assess the severity of RLS,
since they have the appropriate psychometric properties and have been extensively used.
There is a recommended scale (ASRS) to assess the augmentation phenomenon. Two scales
(KRLS-QoL and ARLSQoL) can be recommended to assess HRQoL in RLS. There is currently no
recommended scale to evaluate RLS in the pediatric population. There are single items on PD-
specific multidomain scales that assess RLS but there is insufficient evidence to evaluate their
psychometric reliability or clinical applicability. Just one of the discussed scales (IRLS) has been
used in several movement disorders.

Periodic Leg Movements (PLMs)

PLMs are sleep-related movements characterized by a stereotyped and periodic pattern. They
are relatively common in the general population, particularly in the elderly (69) and can occur in
isolation or be associated with RLS or other movement disorders (70). The golden standard to
diagnose PLMs is overnight PSG, and two sets of standards for recording and scoring are
available: one by the International Restless Legs Syndrome Study group and the World
Association of Sleep Medicine (71); the other by the American Academy of Sleep Medicine (72).
As PSG is a cumbersome and costly test, alternative assessment tools are currently under
evaluation: leg-worn actigraphy (73), contactless devices to measure movement and respiration
during sleep (74) and analysis of electrocardiographic data (75) among others. Currently, there
is no available questionnaire or scale to measure PLMs.

Obstructive Sleep Apnea

Obstructive sleep apnea is a common sleep-related disorder characterized by repetitive

episodes of complete or partial collapse of the upper airway which cause breath cessation.
Despite being frequently underdiagnosed, its prevalence is reported to be 6–17%, varying
according to age, sex, and body mass index (BMI). The gold standard for diagnosis is based on
PSG recording of events of apnea (breathing pauses lasting 10 s or more) and hypopnea
(reduction in respiratory airflow, without apnea, associated with oxygen desaturation or
arousal from sleep). The apnea-hypopnea index (AHI) per hour is calculated to determine the
presence and severity of OSA (based on standard scoring: AHI > 5 mild, AHI > 15 moderate, AHI 
> 30 severe) (76).

There are three questionnaires that have been designed as screening tools for OSA. The
severity of OSA can be assessed by two extensively used generic scales for sleep disorders, and
two specific scales have been developed to assess HRQoL in OSA. Scales that assess OSA are
summarized in Table Table33.

Table 3

Scales that evaluate obstructive sleep apnea.

Scale Overview ScoringCut off Diagnostic accuracy Time frame Administration

Languages

WSQ (77) Generic on sleep disorders

Investigates snoring, obstructive apnea, and sleeping problems 32 items. 10 questions on

sleep disorders due to breathing, 5 questions on sleep disorders, 5 questions on medical
history, and 12 questions on life habits. Multiple-choice responses with different scoring based
on the question Score of >3 point for snoring or choking (78)

In general population

Any OSA stage

Sensitivity 79–95%

Specificity 46–64%

PPV 46–28%

NPV 89–97%

Moderate OSA

Sensitivity 87%

Specificity 40%
PPV 11%

NPV 97%

(80) 3 months (81) Self-rated

30 min French, English, and Polish

Scoring instructions provided by authors (81)

SA-SDQ (82) Generic scale subscale

Assesses sleep disturbances due to sleep apnea and sleep apnea risk factors 8 questions
about sleep disturbances and 4 other items related to weight, smoking status, age, and body
mass index (BMI). Each question is scored on a scale 0–5 (0 = never, 5 = always); the total score
ranges 0–60 In sleep clinic patients

36 for men

32 for women

Sensitivity 85–88%

Specificity 76–81%

PPV 31–72%

NPV 87–99%

(82) Lifetime Self-rated

8 min English and Dutch

MAP index (84) OSA specific

Screening questionnaire for OSA 3 frequency questions (loud snoring, snoring or gasping,
cessation of breathing, or struggle for breath) and gender, age, and BMI are calculated.
Formulas are explained in the reference. MAP index ranges between 0 and 1 In sleep clinic
patients

Mild OSA [apnea-hypopnea index (AHI) = 5]

Cutoff 0.46

Sensitivity 76.8%
Specificity 71.8%

Moderate OSA (AHI = 15)

Cutoff 0.48

Sensitivity 83.3%

Specificity 64.3%

Severe OSA (AHI = 30)

Cutoff 0.65

Sensitivity 61.8%

Specificity 79.2%

(85) Last month and lifetime risk factors Self-rated

5 min for the scale and 5 min for scoring English

Berlin questionnaire (87) OSA specific

Screening questionnaire for OSAS 10 items, 3 domains: snoring severity, excessive daytime
sleepiness, history of high blood pressure or obesity. Multiple-choice questions, for each
question there is different scoring. Categories 1 and 2 are positive if total score is ≥2; Category 3
is positive if high blood pressure or if BMI > 30 kg/m2. Scoring: high risk: ≥2 categories with
positive score; low risk: 1 or no categories with positive score High risk score in sleep clinic
patients

Sensitivity 79–82%

Specificity 32–39%

(88) Lifetime Self-rated

10 min English Arabic, Chinese, Dutch, French, Greek, Indian, Korean, Malay, Persian,
Portuguese, Serbian, Thai, and Turkish

STOP-BANG questionnaire (94) OSA specific

Screening questionnaire for OSAS There are four items on symptoms (STOP: Snoring,
Tiredness, Observed apnea, and high blood Pressure) and four demographic items (Bang: BMI,
age, neck circumference > 17"/43 cm in male or >16"/41 cm in female, gender)
Yes/no format. Scoring

– Low risk of OSA if “Yes” to 0–2 questions

– Intermediate risk if “Yes” to 3–4 questions

– High risk if “Yes” to 5–8 questions or “Yes” to 2 or more of 4 STOP questions + male

gender/BMI > 35 kg/m2/neck circumference

>3

In sleep clinic patients

For any OSA

Sensitivity 90%

Specificity 49%

NPV 46%

PPV 91%

For moderate OSA

Sensitivity 94%

Specificity 34%

NPV 75%

PPV 72%

For severe OSA

Sensitivity 96%

Specificity 25%

NPV 90%

PPV 48%

(99) Lifetime Self-rated

5 min English anda

SAQLI (101) OSA specific

Measures impact on HRQoL of OSA 40 or 45 items and 4 or 5 domains: daily functioning (11
items), social interactions (13 items), emotional functioning (11 items), symptoms (five items).
The 5th domain, treatment-related symptoms (5 items), can be added for adverse events of
treatment. Items are scored with a Likert scale 0- to 7-point scale: “all the time” to “not at all.”
Score ranges from 0 to 280/315 No established cutoff 4 weeks Clinician rated

40–45 min English, Spanish, Persian Portuguese, and Japanese

QSQ (104) OSA specific

Measures impact on HRQoL of OSA 32 items; five domains: (1) hypersomnolence; (2) diurnal
symptoms; (3) nocturnal symptoms; (4) emotions; and (5) social interactions. Each item is
scored on a 0–7 scale. Mean score per item within each domain, equal weighting No
established cutoff Not specified Self-rated

30 min English, French, Chinese, Spanish, Brazilian, and Portuguese

Open in a separate window

SA-SDQ, Sleep Apnea Scale of the Sleep Disorders Questionnaire; WSQ, Wisconsin Sleep
Questionnaire; MAP, Multivariable Apnea Prediction; SAQLI, Calgary Sleep Apnea Quality of Life
Index; QSQ, Quebec Sleep Questionnaire; HRQoL, health related quality of life.

aChinese, Persian, Portuguese, Greek, French, Spanish, Afrikaans, Arabic, Bulgarian, Chinese,
Czech, Dutch, Filipino, German, Hungarian, Italian, Korean, Malay, Polish, Romanian, Sami,
Taiwanese, Turkish, and Arabic.

Wisconsin Sleep Questionnaire (WSQ)

Scale Description

The WSQ is a generic questionnaire to investigate snoring, obstructive apnea, and sleeping
problems in general (Table (Table3)3) (77, 78). It is one of the most cited questionnaires for OSA
(79). It has a high sensitivity and a low specificity, especially for diagnosing moderate OSA, and
an excellent negative predictive value (Table (Table3)3) (80).

Psychometric Properties
The internal consistency in each domain of the scale was satisfactory (Cronbach’s alpha = 0.67–
0.81), reliability was acceptable: at retest after 3 months, the kappa values were 0.28–0.60, the
Cohen kappa was >0.60 (81).

Data From Different Populations

This scale has been used in the general population and in a sleep disorders population. It has
not been used in movement disorders to the best of our knowledge.

Strengths and Limitations

This is a widely used scale for assessing different aspects of OSA. It has demonstrated robust
psychometric properties with a high sensitivity. However, its specificity is low, and it has not
been used in movement disorders patients.

Sleep Apnea Scale of the Sleep Disorders Questionnaire (SA-SDQ)

Scale Description

The SA-SDQ is part of a generic questionnaire on sleep disorders, the Sleep Disorders
Questionnaire. This subscale includes questions about sleep disturbances and demographic
data. The sensitivity and specificity of this scale are acceptable, the negative predictive value
was high (Table (Table3)3) (82).

Psychometric Properties

The scale has shown good internal consistency: Cronbach’s alpha was 0.85, and the item-total
correlation ranged from 0.19 to 0.71. The intercorrelations with other subscales from the SDQ
were weak (<0.35), and the scale could distinguish patients with sleep apnea from patients with
other sleep disorders (narcolepsy, periodic limb movements, and psychiatric sleep disorder).
The test–retest reliability after 4 months was acceptable (0.84) (82).

Data From Different Populations

The SA-SDQ has been validated in both genders, in patients with sleep disorders and with
epilepsy (83). To the best of our knowledge, there are currently no studies that report its use in
movement disorders populations.

Strengths and Limitations

This scale has satisfactory psychometric properties. It accurately diagnoses patients with sleep
apnea events and sleep apnea related conditions. However, no data were found on the
responsiveness of this scale and its use in movement disorders.

Multivariable Apnea Prediction (MAP) Index

Scale Description

The MAP index is a specific instrument used for screening sleep apnea (84) (see Table Table33
for details). There is also an objective MAP index, only based on symptom frequency. The index
showed acceptable sensitivity with lower specificity for detecting any OSA, and good specificity
with poorer sensitivity for detecting severe OSA (85) (Table (Table33).

Psychometric Properties

The MAP index showed a moderate correlation with the AHI (r = 0.59). The objective MAP
showed a strong correlation with the MAP index, but a poorer correlation with the AHI (85).
The MAP index showed good internal consistency (Cronbach’s alpha = 0.88–0.93), and
satisfactory test–retest reliability (84).

Data From Different Populations

This scale has been used in adults of both genders in a sleep disorder population. To the best of
our knowledge, it has not been used in movement disorders.

Strengths and Limitations

This is a quantitative index to assess the risk of OSA. It has shown good psychometric
properties. However, its use is limited since it is not useful in patients with a BMI > 40 or with
mild cognitive impairment (84, 86), and there is no experience in movement disorder
populations.

Berlin Questionnaire

Scale Description

The Berlin questionnaire (87) is a specific self-administered measure used to screen for sleep
apnea that includes 10 items that can be divided into 3 domains. This instrument has shown
adequate sensitivity but very low specificity (88) (Table (Table33).

Psychometric Properties

This questionnaire has shown satisfactory internal consistency in validation studies for different
languages and populations (Cronbach’s alpha = 0.68–0.98) and acceptable test–retest reliability
0.74–0.98 (89–92). In the original validation study, the internal consistency was adequate
(Cronbach’s alpha = 0.86–0.92) (87).

Data From Different Populations

The Berlin questionnaire has been validated in different populations including sleep clinic
patients, patients before surgery, patients with cerebrovascular diseases/risk factors, multiple
sclerosis patients, general population and others (89, 91, 93). It has also been used in
movement disorders populations, in particular: PD, PSP, MSA (13), and Huntington’s disease
(54).

Strengths and Limitations

The Berlin questionnaire is an easy and short instrument to screen for OSA. It has been widely
used in different populations, including movement disorders populations. It has been translated
into different languages. Its limitations include low specificity.

STOP-Bang Questionnaire
Scale Description

The STOP-Bang questionnaire is a specific self-administered questionnaire for screening OSA

that includes questions about four symptoms and demographic data (94) (Table (Table3).3).
Other versions of this scale are available: there is a shorter version (4-item STOP
Questionnaire), a weighted version (wSTOP-Bang) and a continuous version (cSTOP-Bang) (95).

Psychometric Properties

In the original validation of the questionnaire, internal consistency was not assessed because
the four questions STOP reflected four different dimensions of OSA morbidity (94). However,
other investigators validating language version found moderate internal consistency
(Cronbach’s alpha ranging from 0.62 to 0.7) (96, 97). Test–retest reliability has been adequate
(97) and high (94, 98). The STOP-Bang questionnaire has an excellent sensitivity, but a low
specificity; showing high positive and negative predictive values (99) (Table (Table33).

Data From Different Populations

The STOP-Bang questionnaire has been validated in adult patients in both genders; it has been
used to screen for OSA in preoperative clinics, sleep clinics, workers at risk, kidney failure
patients and in the general population (99), but, to the best our knowledge, not in movement
disorders.

Strengths and Limitations

The STOP-Bang questionnaire is an easy and short measure to screen for OSA. It has been
extensively used in different populations and has been translated into numerous languages. It is
highly sensitive, but not specific; specificity can be raised using the continuous version (cSTOP-
Bang), adding more variables (e.g., serum bicarbonate level) or modifying the cutoff; however,
in the latter case, sensitivity drops drastically (95, 99, 100).

Calgary Sleep Apnea Quality of Life Index (SAQLI)

Scale Description
The Calgary SAQLI is a specific, self-administered scale used to measure HRQoL in patients
affected by sleep apnea (101). It is a long questionnaire (40 or 45 items, if the examiner wants
to assess treatment-related symptoms) (Table (Table33).

Psychometric Properties

The scale has satisfactory internal consistency (Cronbach’s alpha = 0.88–0.92 for the total scale
and 0.70–91 for the subscales) and high reliability (ICC after 2 weeks = 0.92). The SAQLI showed
no correlation with the respiratory disturbance index, a measure of severity of OSA, a weak
correlation (−0.26) with the Epworth Sleepiness Scale (ESS), and moderate-to-strong
correlations (0.39–0.71) with the sleep domains of the SF-36 (102). The SAQLI showed
satisfactory responsiveness (103).

Data From Different Populations

This scale has been used in adults of both genders in a sleep disorder population. It has not
been used in movement disorders, to the best of our knowledge.

Strengths and Limitations

This is a specific scale for assessing HRQoL in OSA. It offers a global evaluation of aspects of life
on which OSA can impact, it has good psychometric properties, and it has been translated into
different languages. However, this scale showed poor correlation with other measures of sleep
apnea, sleep, and quality of life.

Quebec Sleep Questionnaire (QSQ)

Scale Description

The QSQ (104) is a specific, self-administered questionnaire that evaluates HRQoL in patients
with OSA through 32 questions (Table (Table33).

Psychometric Properties
Internal consistency and reliability were satisfactory: Cronbach’s alpha was 0.76–0.94, and the
ICC after 7 months ranged from 0.82 to 0.91 in the domains. It showed moderate-to-strong
convergent validity with the following scales: Functional Outcomes in Sleep Questionnaire
(FOSQ), Symptom Checklist-90, and ESS (−0.64). There was a high correlation with the Beck
Depression Inventory (BDI) (104). The scale responsiveness has been assessed in an OSA
population undergoing CPAP treatment (104).

Data From Different Populations

The QSQ was validated in a sleep clinic population, in adult patients of both genders. It has not
been used in movement disorders to the best of our knowledge.

Strengths and Limitations

The QSQ is a fast and specific tool to assess HRQoL in OSA; it showed satisfactory psychometric
properties and responsiveness. However, it showed a high correlation with the BDI, which can
be a confounding factor. It has not been used in movement disorder patients.

Multidomain Scales That Assess OSA

The PSQI is a self-rated scale designed to measure generic sleep disturbances (7); items 5d and
5e of the PSQI assess, respectively, the inability to breathe comfortably and the occurrence of
loud coughs or snores during sleep in the past month.

Conclusion

The Berlin questionnaire is the only scale that has been used in movement disorders
populations. This questionnaire has been validated, has shown good psychometric properties,
and has been widely used. The STOP-Bang questionnaire has similar characteristics but has not
been used in movement disorders. Good psychometric properties have also been identified in
another screening questionnaire (MAP index) and severity assessment tools such as the WSQ,
SA-SDQ. Both the SAQLI and the QSQ are validated specific questionnaires to assess HRQoL in
OSA, but they have not been used in movement disorders.
Go to:

Diurnal Sleep Disorders: EDS and Sleep Attacks

Other sleep disturbances found in movement disorders affect the waking hours, such as EDS
and sleep attacks. EDS is a symptom rather than a primary disease and can be the consequence
of sleep deprivation, sleep disturbances as discussed above, medications or substance abuse,
metabolic, neurological and psychiatric diseases or, more rarely, narcolepsy. In PD, for example,
the pathophysiology of EDS is multifactorial and related to NS disturbances, other causes of
sleep fragmentation (motor symptoms, painful dystonia, and dyskinesias), the
neurodegenerative process itself and to medications. In fact, dopaminergic agents can disrupt
sleep and induce somnolence, and sedation and drowsiness have been reported as adverse
events of dopamine agonists (105).

Excessive daytime sleepiness and sleep attacks can be reported by patients or their relatives
and can be assessed with self-reported scales or with objective tests such as the MSLT and the
MWT. Since these laboratory tests are time consuming and costly, scales have been developed
to detect and evaluate the severity of EDS and sleep attacks.

Stanford Sleepiness Scale (SSS)

Scale Description

The SSS is a generic scale that measures the current state of sleepiness (106, 107). It is based on
a single item rated on a Likert-type scale from 0 to 7, with higher scores indicating more
subjective sleepiness.

Psychometric Characteristics

Data on the validity and reliability of the scale are sparse (108). The original publication claims
high reliability (106). In healthy subjects, sensitivity to change has been reported (109, 110).
The scale shows no correlation with the ESS which may be expected as the measured constructs
are different.

Scale Use in Movement Disorders

The scale has been used to assess the induction of sleep by levodopa in PD versus MSA (111)
and diminished homeostatic sleep drive in PSP (112). To the best of our knowledge, there are
no available data in other movement disorders.

Strengths and Limitations

The SSS is an extensively used scale due to its availability in many languages and simplicity. It is
useful for rating the sleepiness state of the individual at the time of testing. The MDS Task Force
on sleep disturbances in PD concluded that the SSS is a “suggested” scale for rating sleepiness
and to measure severity at a specific moment (10). However, an obvious limitation is the lack of
data on psychometric characteristics of the scale.

Epworth Sleepiness Scale

Scale Description

The ESS (113) is a generic scale that measures the risk of falling asleep during daily activities.
This scale evaluates the possibility of dozing off in 8 every-day situations. Several cutoff scores
with different sensitivities and specificities have been proposed to indicate subjects at higher
risk of falling asleep involuntarily (114) (Table (Table44).

Table 4

Scales that evaluate excessive daytime sleepiness in movement disorders.

Scale Overview ScoringCut off Diagnostic accuracy Time frame Administration

Languages

SSS (106) Generic

Measures current state of sleepiness1 item. Seven point Likert-type scale No established cutoff
At this time Self-rated Public

English

French
Spanish

ESS (113) Generic

Measures sleep propensity in daily situations 8 items, rated 0 (would never doze) to 3
(high chance of dosing). Range of total score 0–24 >7

Sensitivity 75%

Specificity 50%

>10

Sensitivity 52%

Specificity 72%

(115) Recent times (1–4 weeks) Self-rated

8 min Public

English

German

Spanish

Chinese

ISCS (114) Generic

Measures sleep propensity and sleep attacks in active tasks 6 items, rated 0 (would never
doze) to 3 (high chance of dosing). Range 0–18. Two additional questions regarding sudden
sleep onset and blank spells >1 Since disease onset Externally rated

10 min English

SCOPA-Sleep-DS (11) PD specific

Measures sleepiness and possibility of sleep attacks in daily activities DS includes 6 items
scored from 0 (never) to 3 (often). Range 0–18 >4

Sensitivity 90%

Specificity 82% Previous month Self-rated Public

Dutch
English

Spanish

Open in a separate window

DS, daytime sleepiness; ESS, Epworth Sleepiness Scale; ISCS, Inappropriate Sleep Composite
Score; SCOPA, Scales for outcomes in PD; SSS Stanford Sleepiness Scale; SCOPA-Sleep-DS,
SCOPA-Sleep Daytime Sleepiness; PD, Parkinson’s disease.

Psychometric Properties

Internal consistency of the ESS is high (Cronbach’s alpha = 0.88), and the scale has
demonstrated acceptable reliability (r = 0.56). Floor and ceiling effects are practically absent
(115). ESS shows adequate convergent validity with sleep latency measured during the MSLT
and during overnight PSG (115), as well as SCOPA-Sleep Daytime Sleepiness (SCOPA-Sleep-DS)
subscale scores in the PD patients (11).

Scale Use in Movement Disorders

The ESS has been extensively used in populations with diverse sleep disorders, such as sleep
apnea, narcolepsy, and idiopathic hypersomnia (113, 115) and idiopathic RBD (116). It also has
been widely used in PD (10) and in other hypokinetic disorders such as MSA (117, 118). In
addition, there is experience with this scale in hyperkinetic disorders such as Huntington’s
disease (14, 119, 120), dystonia (19, 121, 122), and essential tremor (123–125).

Strengths and Limitations

The ESS has adequate psychometric properties and has been extensively used by many groups
in diverse movement disorder cohorts to evaluate sleep propensity. It is recommended for
screening and evaluating severity of DS in the PD population (10). It has also shown sensitivity
to change after intervention. However, the scale does not include information from a caregiver,
partner or other outside source; and thus, the information provided may be limited, possibly
underestimating risk, since the patient may often be unaware of dozing off. The item “while in
the car” is ambiguous since it does not specify whether the person is in the driver or
passenger’s seat. The EES does not include an item on risk of falling asleep while driving nor
does it screen for the risk of sudden sleep attacks.
Inappropriate Sleep Composite Score (ISCS)

Scale Description

Two modified versions of the ESS were proposed by the Canadian Movement Disorders Group
to fill the gaps of the previous scale, thus developing the ISCS (114). This scale is made up of 6
items, two from the ESS and four additional new items. If sleepiness is present, the patient is
asked if dozing off occurs gradually or unpredictably and about the incidence of blank spells.

Psychometric Properties

The scale was developed with the objective of evaluating the predictors for sudden-onset sleep,
particularly while driving, among patients with PD. It was tested in 638 mild PD patients of
whom 420 were currently drivers. There was a high floor and no ceiling effect. Unfortunately,
the original article does not provide any validation or reliability data and the scale has not been
investigated (although has been used) by other groups.

Strengths and Limitations

The ISCS assesses the propensity of falling asleep during clearly active situations, such as talking
or driving. The MDS Task Force reviewing sleep scales in PD gave this scale the rank of
“suggested” to evaluate DS and sleep attacks and recommends its use in conjunction with the
ESS (10). The scale has no published psychometric analysis, and terminology may lead to
confounders since “sudden blank spells” may be due to sleep attacks, but also to syncope or
partial seizures.

SCOPA-Sleep-Daytime Sleepiness subscale

Scale Description

The DS subscale of the SCOPA-Sleep scale (11) includes 6 items on unexpected sleep attacks,
dozing off in daily situations and difficulty staying awake. Items are scored from 0 to 3, with
total scores ranging from 0 to 18 points where higher scores indicate more severe problems.
Psychometric Properties

The internal consistency of the SCOPA-Sleep-DS subscale is good (Cronbach’s alpha = 0.91–0.75)

(11, 18). The subscale showed robust test–retest scores (ICC = 0.89) (11). Factor analysis
revealed that one factor explains 69.1% of the variance for this subscale. Scores of the SCOPA-
Sleep-DS have shown high correlations with the ESS (r = 0.81, p < 0.001) (11).

Strengths and Limitations

The DS subscale of the SCOPA-Sleep has strong psychometric properties and has been
extensively used, discriminating between subjects and controls and PD patients in different
stages. The subscale is a “recommended” tool for screening and for measuring severity of DS
and sleep attacks in PD (10). However, sensitivity to change has not been investigated.

PDSS Item 15

Scale Description

The PDSS (17) is a PD-specific, 15-item scale that preferentially evaluates NS problems, with one
item pertaining to DS: item 15 (Table (Table11).

Use in Different Movement Disorder Populations

Besides being extensively used in PD patients, there are also some available data in dystonia
patients (19).

Psychometric Properties

Item 15 on the PDSS considers DS. This single item has shown a strong correlation with SCOPA-
Sleep-DS (18) and the ESS in one study (17) and a moderate correlation (0.23) in another study
(20). Patients scoring low on this item (mean 4.7) have shown abnormal sleep patterns in
overnight PSG results (126).

Strengths and Limitations

This single item has shown strong correlations with longer DS questionnaires and may thus be
useful for screening for DS. However, other psychometric properties and diagnostic accuracy
have not been tested.

Multidomain Scales to Assess DS

Some multidomain scales such as the NMSQuest (22), the NMSS (23), and the MDS UPDRS part
1B (24) include a single item that evaluates DS. Item 3 on the NMSS, similarly to item 22 on the
NMSQuest, evaluates if the patient dozes off unintentionally during daytime activities such as
during meals or watching TV. Item 1.8 is the second item of part 1B on the MDS UPDRS
considering non-motor symptoms of daily life. The patient indicates whether he/she has had
trouble staying awake during the day in the last week. The limitations to the use of these single
items are due to unknown psychometric properties, including lack of data regarding correlation
with other scales and sensitivity to change.

Go to:

Discussion

Sleep disorders are receiving increased attention in movement disorders due to the high impact
on patient HRQoL and caregiver burden as well as the growing knowledge of the underlying
pathophysiological mechanisms. There are currently multiple questionnaires that can be used
to screen and measure the severity of the most frequent sleep problems that affect movement
disorder patients, and they have been summarized in this review. Selection of the most
appropriate instrument for assessment of insomnia, nocturia, RLS, OSA, and EDS should be
guided by the appropriateness of the scale for the objective of the study, availability,
psychometric attributes, responsiveness, and previous experience in similar populations. In
interpreting the results of questionnaires, the clinician should consider the presence of
psychological factors like fatigue, impulsivity or depression that may influence completion, the
timing of administration of the scale (for example, on or off state for PD patients) and cognitive
impairment (127).

Several gaps have been identified that need to be addressed to adequately research the
incidence, prevalence, and severity and impact of sleep disorders in populations with
movement disorders.
The majority of available questionnaires are generic instruments with established psychometric
properties in the general population but no validity or reliability data available in different
movement disorder populations. Generic scales have the disadvantage of potentially not
assessing areas of specific interest and may lack sensitivity to detect change in a given disease
(128). For example, in evaluating insomnia, the well-established PSQI is currently the best
option for patients with movement disorders other than PD (where disease-specific scales are
available). However, it does not consider any motor symptoms, such as chorea, dystonia, tics,
and other hyperkinetic movements, as well as sensitivity disturbances, such as akathisia, or RLS,
that may prevent patients from falling asleep. The paucity of data available in different
movement disorders populations for these generic scales is striking. For example, the
prevalence of RLS in PD is still controversial due to confounders and overlap of symptoms such
as dystonia, akathisia, and sensory symptoms. Validation data of the RLS scales in PD, and other
forms of parkinsonism, would be helpful to decide if the current instruments are valid tools or
additional measures need to be designed taking into account disease-specific symptoms that
may mimic RLS. RLS is probably more frequent in ET (129) and cranio-cervical dystonia (130)
than controls; however, none of the current scales have been validated in these populations.

Even in sleep disorders such as insomnia, where there are disease-specific scales for PD that are
recommendable, none of them appropriately evaluate common disturbances associated with
this disease such as PLMs, or sleep apnea, nor do they address motor akinesia or motor
fluctuations during sleep. Most of the available scales do not consider the input of a witness,
which is highly valuable in sleep disturbances, since self-perception has been reported to differ
from laboratory evidence (131) and neuropsychiatric difficulties may make the patient
unreliable.

For RLS evaluation, several unmet needs should be considered. To date, none of the scales that
measure severity are self-administered (unlike those that consider impact on HRQoL), and the
scale designed to evaluate the pediatric population still lacks psychometric data, and validity
data in different movement disorders are sparse.

Currently, there are no questionnaires or scales designed to address some common sleep
disorders in movement disorders such as sun-down confusion, disordered breathing and PLM.
Nocturia is one of the most prevalent and bothersome symptoms for patients, yet it is only
considered by 1–2 items in multidomain scales that have not been individually analyzed for
their psychometric properties. Similarly, psychometric data on the scales that screen or
evaluate the severity of sleep attacks, which can be potentially lethal if the person is driving,
manipulating machinery or using a cutting tool, are lacking.

Go to:

Conclusion

To advance in the research of sleep and movement disorders, scientific methodology based on
adequate diagnosis is of key importance. This review covers a number of questionnaires that
can aid in the screening and appraisal of the most frequent nocturnal and diurnal sleep
disturbances that affect movement disorder patients. However, disease-specific scales are only
available for PD and even in this “best case scenario,” some prevalent symptoms such as sleep
apnea or nocturia are insufficiently addressed. Thus, we recommend the development of
movement disorder, condition-specific scales addressing the most important and characteristic
sleep disturbances and their correlates as well as the revision of existing movement disorder
scales, such as the Unified Multiple System Atrophy Rating Scale or the Unified Huntington’s
Disease Rating Scale, to add a sleep domain. We also advocate for the development of
guidelines to steer adequate application of existing instruments, including interpretation of
results and significant change due to treatment or other causes, with the objective of improving
the management of sleep disturbances in each movement disorder entity. They should include
a recommended combination of assessments using different raters (health professional,
patient, and caregiver) as well as advice for when further laboratory testing (PSG or MSLT)
should be performed.

Go to:

Author Contributions

MK: conception and design, drafting of manuscript, interpretation of data, and revision of the
manuscript. RB: drafting of manuscript and interpretation of data. CR-B and MF: interpretation
of data and critical revision of the manuscript. PM-M: conception and design, interpretation of
data, and critical revision of the manuscript.

Go to:
Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or
financial relationships that could be construed as a potential conflict of interest.

Go to:

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Statistical Classification of Diseases and Related Health Problems, Tenth Revision; and Research
Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition criteria:
results from the America Insomnia Survey
Thomas Roth 1, Catherine Coulouvrat, Goeran Hajak, Matthew D Lakoma, Nancy A Sampson,
Victoria Shahly, Alicia C Shillington, Judith J Stephenson, James K Walsh, Ronald C Kessler

Affiliations expand

PMID: 21195389 DOI: 10.1016/j.biopsych.2010.10.023

Abstract

Background: Although several diagnostic systems define insomnia, little is known about the
implications of using one versus another of them.

Methods: The America Insomnia Survey, an epidemiological survey of managed health care
plan subscribers (n = 10,094), assessed insomnia with the Brief Insomnia Questionnaire, a
clinically validated scale generating diagnoses according to DSM-IV-TR; International Statistical
Classification of Diseases, Tenth Revision (ICD-10); and Research Diagnostic
Criteria/International Classification of Sleep Disorders, Second Edition (RDC/ICSD-2) criteria.
Regression analysis examines associations of insomnia according to the different systems with
summary 12-item Short-Form Health Survey scales of perceived health and health utility.

Results: Insomnia prevalence estimates varied widely, from 22.1% for DSM-IV-TR to 3.9% for
ICD-10 criteria. Although ICD insomnia was associated with significantly worse perceived health
than DSM or RDC/ICSD insomnia, DSM-only cases also had significant decrements in perceived
health. Because of its low prevalence, 66% of the population-level health disutility associated
with overall insomnia and 84% of clinically relevant cases of overall insomnia were missed by
ICD criteria.

Conclusions: Insomnia is highly prevalent and associated with substantial decrements in

perceived health. Although ICD criteria define a narrower and more severe subset of cases than
DSM criteria, the fact that most health disutility associated with insomnia is missed by ICD
criteria, while RDC/ICSD-only cases do not have significant decrements in perceived health,
supports use of the broader DSM criteria.