referral criteria from primary care - daytime sleepiness in adults

Last edited 04/2020

The Epworth Sleepiness Scale is a means of assessing the significance of daytime sleepiness (excessive daytime sleepiness (EDS)).

On a scale of 0-3, how likely are you to doze off or fall asleep in each of the following situations? (0 - never, 1 - slight chance, 2 - moderate chance, 3 - high chance)

  • sitting and reading
  • watching television
  • sitting , inactive in a public place (e.g. a meeting or at the theatre)
  • as a passenger in a car for 1 hour without a break
  • lying down in the afternoon to rest when circumstances permit
  • sitting and talking to someone
  • sitting quietly after a lunch without alcohol
  • in a car, while stopped for a few minutes in traffic

The total score (out of 24) allows an assessment of the severity of sleepiness.

  • an ESS >10 indicates EDS and >17 indicates severe EDS (2)

In consideration of referral to specialist care for adults with excessive daytime sleepiness (1,2):

  • patients with excessive daytime sleepiness (i.e. a high Epworth score) should be referred to a physician with an interest in sleep disorders if they have suspected obstructive sleep apnoea, narcolepsy or idiopathic hypersomnia, or if general measures have proved ineffective
  • refer patients for further assessment by sleep specialists in secondary care where the cause of excessive daytime sleepiness is unclear, or where specific treatments (such as CPAP therapy) are required
  • careful assessment and referral for further investigation of individuals can result in substantial improvements in quality of life because effective treatments exist for sleep disorders that cause excessive daytime sleepiness
  • specific advice on referral criteria to secondary care in the UK is provided by the National Institute for Health and Care Excellence (NICE)
  • urgent referral to a sleep centre is recommended if a patient has sleepiness while driving, working with machinery, is employed in an occupation of particular risk such as a pilot, bus or lorry driver, or if they have signs of respiratory or heart failure, or coexistent chronic obstructive pulmonary disease
  • other patients can be referred routinely if they have excessive sleepiness as defined by the ESS, or where there are concerns about employment


  • as with any condition in which excessive sleepiness may affect driving safety, advise patients not to drive if they are excessively sleepy
  • in the UK the Driver and Vehicle Licensing Agency (DVLA) specifically highlights obstructive sleep apnoea syndrome as a cause of sleepiness which may affect driving, and individuals with moderate or severe obstructive sleep apnoea and excessive sleepiness must not drive, and must inform the DVLA of their diagnosis if they hold a driving licence


  1. Drug and Therapeutics Bulletin (2004); 42(7):52-56.
  2. Brown J, Makker KM. An approach to excessive daytime sleepiness in adults. BMJ 2020;368:m1047