Chervin in his article Assessment of Daytime Sleepiness in 1973 states that

excessive daytime sleepiness is one of the most significant result of inadequate sleep. It
is defined as the strain in maintaning mental alertness. EDS is commonly encountered by
sleep medicine specialists as well as neurologists. In assesing EDS, the clinical history
plays the most vital role while physical examination plays only a minor role. Formal tests
are done when history is unclear. Due to experiencing sleepiness for so long some
individuals may consider EDS as innate and normal. Asking questions about the types of
situations in which sleepiness is likely to be a problem can help to clarify the reliability
and comparability of the historical information. In addition to this, questions about
sleepiness while driving are also important since automobile accidents, injuries and
deaths are consequences of EDS. Other complaints associated with sleepiness are
impaired memory, irritability and emotional liability. If possible, history should also be
acquired from patients family and bedpartner since signs of sleepiness may be more
evident to the family members than to the patient. However, traditional sleepiness
suggests that although complaints of sleepiness are likely to be present other patients
would rather call such symptoms as fatigue, tiredness or lack of energy. Further research
is necessary to better define how patients use these terms but clinicians should realize
that some overlap exists and examinations of EDS should include related symptoms.
In his article, Assessment of Daytime Sleepiness in 1973, Chervin discussed
various methods of testing excessive daytime sleepiness (EDS). Among the subjective
tests is Stanford Sleepiness Scale which provides a well validated, standardized way to
rapidly evaluate immediate sleepiness. The test asks the patient to select, from among
seven levels of sleepiness, the one level that best describes his/her sleepiness state.
Another subjective test is a more long-term evaluation provided by Epworth Sleepiness
Scale, which is now the most commonly used subjective standardized test for adult EDS.
However, some reports have failed to identify any statistically notable associations
between ESS scores and objective assessments of sleepiness. In short, the ESS may not
serve well as a substitute for objective neurophysiologic measures. Another instrument
with that can assess EDS is the Daytime Sleepiness Subscale contained in the SleepWake Activity Inventory. The scale shows reasonably good internal consistency and
scores may reveal a natural break in a population sample between persons with and
without adequate hours of sleep. Other methods such as nocturnal polysomnography
also provides some objective information about a patients sleepiness and Multiple Sleep
Latency test which is the gold standard objective test for EDS. There are also other
objective Tests for EDS including the comparison of the pupillometric recordings in
pathologically sleepy patients and controls. Diagnosis from a magnetic resonance
imaging in patient with EDS is also possible.
According to Chervin in his article, Assessment of Daytime Sleepiness in 1973, the
differential diagnosis for excessive daytime sleepiness (EDS) is extensive and resulting at
a final diagnosis often requires much more than collection of results from various
assessments at the bedside, home, medical facility or laboratory. Sound clinical
judgments shall be available to weigh and combine into an overall assessment of EDS
severity and likely causes. Complaints of sleepiness, tiredness, fatigue, or lack of energy
shall be as important as other results when tests fail to provide more standardized
confirmation of those complaints. Use of Epworth Sleepiness Scale (ESS) as a
standardized test grew rapidly since 1991 however investigators who attempted to

validate ESS against Multiple Sleep Latency Test (MSLT) or Maintenance of Wakefulness
Test (MWT) reported a somewhat discrepancy for the ESS as a clinical tool. Associations
of small magnitude between ESS scores and expected scores suggest that the clinical
usefulness of ESS alone, is limited. The MSLT was developed in part because of early
observations by sleep clinicians that a patient with a sleep disorder can be falling asleep
in the examination room while denying EDS and therefore no test should be expected to
match complaints precisely. But it should be noted that results of MSLT can be affected
by anxiety and direct effects of sleep disorders on sleep onset. The clinician must often
integrate other information with that obtained from tests of sleepiness. The clinical
evaluation of EDS should be constructed based o the needs of each patient and the
experience of the clinician. The evaluation must include a clinical history with
appropriate consideration of subjective and objective test results to provide the most
accurate impression of the severity of EDS and its likely causes.