Table 1.

Methods of evaluation of disorders of sleep and wakefulness in Parkinson’s disease (ICSD II: International classification of sleep disorders II; ESS: Epworth sleepiness scale; PD: Parkinson’s disease; REM: REM sleep behavior disorder; RLS: Restless legs syndrome; PLMD: Periodic limb movement disorder)

	Objective Measures	Questionnaires
REM sleep behavior disorder	Polysomnography with assessment of atonia during REM sleep	REM Behavior disorder screening questionnaire (RBDSQ)[27]: 10-item questionnaire with scores ranging from 0 to 13. Sensitivity of English version in PD for ≥6 cutoff 68-90%, specificity 63-82.8%[30,33]
		REM Sleep Behavior Disorder questionnaire Hong Kong (RBDQ- HK)[34]: 13 item questionnaire. Sensitivity 82.2%, specificity 86.9% mixed (idiopathic and secondary) RBD population
		Mayo Sleep Questionnaire (MSQ)[35] item 1: Single question. Sensitivity in PD 90.3%, specificity 87.9% among PD patients meeting ICSDII criteria[30]
		RBD1Q[36]: Single question. Sensitivity 93.8%, specificity 87.2% in idiopathic RBD population (not validated in PD).
		Innsbruck REM Sleep Behavior Disorder Inventory[37]: 5 item questionnaire. In mixed (idiopathic and secondary) RBD population, sensitivity 91.4%, specificity 85.7%. For single RBD summary question, sensitivity 74.3%. specificity 92.9%.
Insomnia[38]	Polysomnography (in sleep maintenance insomnia, to exclude OSA or PLMD as a cause)	Parkinson’s disease sleep scale version-2[39]: Developed specifically for PD, version 1 recommended[38]. 15 item questionnaire
	Actigraphy[40,41]	Scales for Outcomes in Parkinson’s Disease Sleep[42]: Developed specifically for PD and recommended[38]. 6 item night-time questionnaire[42]. Includes nocturia item, which is an important component of any PD sleep questionnaire[43]
		Pittsburgh Sleep Quality Index[44] (not developed specifically for PD but among recommended scales[38])
Nocturia	New-onset nocturia and/or acute worsening warrants a urinanalysis[45]. Post-void residual volume should also be checked[45]. Assessment for benign prostatic hypertrophy, bladder calculi, and/or other urologic disorders that may be contributing to nocturia is essential. In select cases, and in consultation with urology, urodynamic and cystoscopy may be appropriate for some patients[45].	Parkinson’s disease sleep scale version-2[39] and Scales for Outcomes in Parkinson’s Disease Sleep (SCOPA)[42] both include a nocturia item. Other possible tools not yet validated in PD include bladder diaries and symptom questionnaires such as the Nocturia,Nocturnal Enuresis and Sleep-Interruptions Questionnaire (NNES-Q)[46,47] and the overactive bladder symptom score[48].
Restless legs syndrome	Suggested immobilization test (SIT). Mean leg discomfort cutoff of 11, yields a sensitivity of 91% and specificity of 72% for RLS diagnosis in PD [49].
Periodic limb movement disorder	Polysomnography (>5/hr in children and >15/hr in adults consistent with PLMD in appropriate clinical context)
Sleep disordered breathing	Diagnostic polysomnography (with additional in-lab monitoring as needed for positive airway pressure titration[50])	Berlin Questionnaire: 10 items; 3 categories: snoring behavior, daytime sleepiness, hypertension/BMI; High risk if positive in at least 2 categories Predicts respiratory disturbance index >5 with 86% sensitivity and 77% specificity in general population[51]
	Out of center sleep testing (OCST): effective in diagnosis, but may underestimate respiratory events per hour if EEG is not recorded[22]	STOP questionnaire: 4 questions: Snoring, Tiredness/Sleepiness, Observed cessation of breathing, blood Pressure. Considered high risk if answer positively for at least 2 questions Predicts AHI >5 with sensitivity of 65.6% in general population[52]
		STOP-BANG: STOP questionnaire plus BMI, Age, Neck circumference, Gender Predicts AHI >5 with sensitivity of 83.6% and AHI >30 with sensitivity of 100% in general population[52]
Circadian rhythm disorders	Actigraphy
	Dim Light Melatonin Onset: onset of melatonin secretion under dim light conditions
Excessive daytime sleepiness	Multiple sleep latency test (MSLT) (measures tendency to fall asleep over 5 nap opportunities[22])	Epworth Sleepiness Scale (ESS): subject rates tendency to doze off in 8 different situations over the past month; validated in PD[53,54]
	Maintenance of wakefulness test (MWT) (measures ability to stay awake over 4 trials[55])	Stanford Sleepiness Scale (SSS): 1 question item, subject rates level of alertness at time of assessment[56]
	Actigraphy	Scales for Outcomes in Parkinson’s disease-SLEEP-daytime sleepiness (SCOPA-SLEEP-DS): 6-question evaluation of daytime sleepiness designed for use in PD[42] Also validated in Thai[57]
		Parkinson’s Disease Sleep Scale (PDSS): items 14: “Do you feel tired and sleepy after waking in the morning?” and 15: “Have you unexpectedly fallen asleep during the day?”[58] Item 15 is an independent predictor of sleepiness in one study[59] but not another[60] Also validated in Italian, Chinese, Japanese, and Portugese[61- 64]
		Movement Disorders Society-Unified Parkinson’s Disease Rating Scale (MDS-UPDRS): item 1.8: “Daytime Sleepiness”[65] Shown to be effective screening tool for EDS, having good correlation with ESS[66]