Which is better for assessing sleep disorders, Stop-Bang (Stop-Bang questionnaire) or Epworth (Epworth Sleepiness Scale)?

STOP-BANG vs. Epworth Sleepiness Scale for Assessing Sleep Disorders

The STOP-BANG questionnaire is superior to the Epworth Sleepiness Scale (ESS) for screening obstructive sleep apnea (OSA), while the ESS is better for assessing daytime sleepiness and monitoring treatment response. Each tool serves different but complementary purposes in sleep disorder assessment.

Comparison of Assessment Tools

STOP-BANG Questionnaire

• Primary purpose: Screening for OSA risk
• Key strengths:
  • Recommended by VA/DOD guidelines as first-line screening tool for patients with sleep complaints 1
  • Assesses anatomical and clinical risk factors for OSA
  • Higher sensitivity for detecting moderate-to-severe OSA
  • Includes objective measures (BMI, neck circumference, age, gender)
  • Better for initial risk stratification before diagnostic testing

Epworth Sleepiness Scale (ESS)

• Primary purpose: Quantifying daytime sleepiness
• Key strengths:
  • Recommended by American Geriatrics Society for ongoing assessment of OSA treatment response 1
  • Validated tool for measuring subjective sleepiness
  • Useful for monitoring treatment effectiveness (improvement of ≥2 points indicates clinical response) 1
  • Helps identify patients requiring sleep specialist referral (scores ≥11) 2
  • Better for symptom monitoring and treatment evaluation

Clinical Decision Algorithm

1. Initial Screening (New patient with suspected sleep disorder):

   • Use STOP-BANG questionnaire to assess OSA risk
   • High score (≥3): Consider home sleep apnea testing or polysomnography
   • Low score but sleep complaints persist: Consider ESS

2. Symptom Assessment:

   • Use ESS to quantify daytime sleepiness severity
   • ESS score ≥11: Refer to sleep specialist for evaluation 2
   • ESS score <11 but with other concerning symptoms: Consider additional assessment

3. Treatment Monitoring:

   • Use ESS to track treatment response
   • Improvement of ≥2 points suggests effective intervention 1
   • No improvement: Consider treatment adjustment or alternative diagnosis

Evidence-Based Considerations

The VA/DOD Clinical Practice Guidelines specifically recommend the STOP questionnaire for initial risk stratification of OSA 1. Meanwhile, the American Geriatrics Society guidelines note that the ESS is the "most commonly used questionnaire" for assessing sleepiness and monitoring treatment response 1.

For patients with specific conditions, different approaches may be needed:

• For patients with sickle cell disease, the American Society of Hematology recommends against routine screening with polysomnography but suggests using validated tools like ESS to identify high-risk patients 1
• For patients with night sweats or unexplained symptoms, an ESS score ≥11 warrants referral for sleep specialist evaluation 2

Common Pitfalls to Avoid

1. Using only one tool: Both instruments measure different aspects of sleep disorders and should be used complementarily
2. Overreliance on questionnaires: Neither tool replaces objective testing when indicated
3. Ignoring clinical context: Certain medications, medical conditions, and cognitive status can affect the accuracy of self-reported measures
4. Missing comorbidities: Sleep disorders often coexist with other conditions that require separate assessment
5. Failure to reassess: Sleep disorders change over time and require periodic reevaluation

By selecting the appropriate assessment tool based on the clinical question at hand, clinicians can more effectively identify, diagnose, and manage sleep disorders, ultimately improving patient morbidity, mortality, and quality of life.