The Epworth Sleepiness Scale: Validation of One-Dimensional Factor Structure in a Large Clinical Sample

Brittany R Lapin, James F Bena, Harneet K Walia, Douglas E Moul, Brittany R Lapin, James F Bena, Harneet K Walia, Douglas E Moul

Abstract

Study objectives: The Epworth Sleepiness Scale (ESS) is used by clinicians and researchers to determine level of daytime sleepiness. The number of factors included in the scale has been debated. Our study objective was to clarify the dimensionality of the ESS using a large clinical sample.

Methods: A retrospective cohort study included all patients presenting for care in a tertiary care sleep disorders center who answered all items on the ESS from January 8, 2008 to September 28, 2012. Dimensionality was assessed using scree plot, eigenvalues, factor loadings, principal factor analysis, and confirmatory factor analysis. Multigroup confirmatory factor analysis (MGCFA) evaluated dimensionality within 10 subgroups of clinical interest.

Results: The mean age of the 10,785 study participants was 50 (± 15) years with 49% female, and 81% white. The one-factor solution explained 63% of the variability in responses with high factor loadings (> .67 for all 8 items). The scree plot identified one factor with eigenvalue > 1. Results of confirmatory factor analysis demonstrated a one-factor solution had acceptable goodness of fit as assessed by root mean square error of approximation of .094 (90% confidence interval: .089-.099). MGCFA confirmed measurement invariance within all 10 demographic and clinical subgroups.

Conclusions: Our study confirmed the unidimensionality of the ESS in a large diverse clinical population. Results from this study can be used to justify the interpretation of the ESS within clinical populations, and supports valid comparisons between groups based on the ESS. Future studies are warranted to further understand the items comprising the ESS and potentially eliminate redundant items for increased efficiency in clinical settings.

Keywords: ESS; Epworth Sleepiness Scale; dimensionality; multigroup confirmatory factor analysis; patient-reported outcomes; sleepiness factor analysis; unidimensional.

© 2018 American Academy of Sleep Medicine.

Figures

Figure 1. Scree plot and parallel analysis…
Figure 1. Scree plot and parallel analysis for the 8 items in the ESS in Sample 1, n = 5,392.
The parallel analysis criterion identifies where observed eigenvalues fall below random chance. The optimal coordinate (OC) method identifies the number of eigenvalues based on regression, subject to a minimum value of 1, whereas acceleration factor (AF) is based on where changes in eigenvalues slow, subject to the same eigenvalue minimum of 1, as dictated by Kaiser rule. ESS = Epworth Sleepiness Scale.

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