Original ArticleValidation of the Mayo Sleep Questionnaire to screen for REM sleep behavior disorder in an aging and dementia cohort
Introduction
Several sleep disorders associated with neurologic disease can negatively impact mood, cognitive functioning, and quality of life. Such sleep disorders include rapid eye movement (REM) sleep behavior disorder (RBD), periodic limb movements during sleep (PLMS), restless legs syndrome (RLS), sleepwalking (SW), obstructive sleep apnea (OSA), sleep related leg cramps (SRLC), and insomnia. These disorders are treatable and such treatment often results in improved quality of life and improved management of the coexisting neurologic disorder. Hence there is an increasing interest in identifying and treating patients with these conditions.
Current practice in the assessment of sleep disorders involves the clinical interview of patients and their bed partners, physical examination, and, in those suspected to have certain sleep disorders, polysomnography (PSG). The history and examination usually require 30–60 min for a sleep medicine clinician to complete. PSG is clearly necessary for establishing the diagnosis of RBD, OSA, and PLMS, but the procedure requires appropriate monitoring equipment, including time synchronized video recordings, specially trained technologists, bed availability in a sleep laboratory, and clinicians who can interpret the data. The procedure is costly (>$1000 per study at most centers for a clinical PSG), especially for patients with limited insurance coverage. Subjects must be willing and able to sleep in a sleep laboratory and undergo monitoring. Some patients with coexisting neurologic disorders are too cognitively or physically impaired to tolerate and undergo an adequate study, are too uncooperative to permit all monitoring equipment to remain in place, are at risk for falls during the night, or are institutionalized. While home monitoring may be appropriate for the diagnosis of uncomplicated OSA in some patients, RBD and PLMS cannot be accurately assessed in this way. For clinical and especially research purposes, it would be desirable to screen for the presence of key sleep disorders, using a validated measure, by querying the bed partners of patients who are cognitively impaired, severely disabled or deceased, with PSG remaining as the gold standard for confirming their presence and determining their severity. Seeing how impractical it is to perform PSGs in large numbers of subjects in epidemiologic sleep disorder studies, using a simple, short, reliable, and accurate measure to screen for the presence of various sleep disorders would be highly valuable.
These issues led us to develop the Mayo Sleep Questionnaire (MSQ) in 2001, which is a 16-item measure that poses questions about RBD, PLMS, RLS, SW, OSA, and SRLC. The primary goal of this measure was to assess RBD with adequate sensitivity and specificity. There were two versions initially developed—one completed by the patient and one completed by his/her bed partner/informant. Our early pilot data using the MSQ through 2002 [1], [2], in which responses on the MSQ were compared with the findings on PSG, indicated that the sensitivity and specificity were higher for the bed partner/informant version compared to the patient version, regardless of whether the patient was cognitively impaired or not. Since 2002, we have therefore only used the bed partner/informant version of the MSQ. The MSQ was designed to be used for clinical and research purposes in a variety of settings such as a Behavioral Neurology Clinic (which involves patients with cognitive/behavioral changes); a Movement Disorder Clinic (which involves patients with parkinsonism and other movement disorders); a Sleep Disorders Center; a research program involving community-dwelling nondemented aged individuals; and a research program involving individuals with normal cognition, mild cognitive impairment, dementia, or parkinsonism. The pilot data were collected on individuals evaluated in a Behavioral Neurology Clinic and Sleep Disorders Center [1], [2]. In this paper, we report validation data on the MSQ compared to PSG focused on RBD. Validation of the MSQ compared to PSG-confirmed data regarding PLMS and OSA, and also MSQ data compared to established clinical diagnostic criteria for RLS, SW, and SRLC, are presented as supplementary data. Because of the relevance of RBD pertaining to aging and neurodegenerative disease, the sample includes normal control subjects and patients with cognitive impairment and/or parkinsonism who are participants in the Mayo Alzheimer’s Disease Research Center at Mayo Clinic Rochester or Mayo Clinic Jacksonville.
Section snippets
Mayo Sleep Questionnaire
The MSQ is a concise 16 question scale (some questions are ignored depending if certain questions are answered affirmatively or not) that screens for the presence of RBD, PLMs, RLS, SW, OSA, and SRLC. The MSQ was copyrighted in 2009 by the Mayo Foundation for Medical Education and Research. As stated on the measure, permission is granted for non-commercial use in the context of patient care and research provided that no fee is charged. It is therefore available to the public at no expense. It
Demographic features and clinical diagnoses
The study sample was comprised of 176 subjects, with the core demographic features and clinical diagnoses shown in Table 1. Most subjects were male, and most were in the 60–80-year-old age range. All subjects had bed partners who completed the MSQ, of whom 96% were spouses and the remainder were unwed companions (opposite sex in seven, same sex in one). Eight (4%) were normal controls; all others had some degree of cognitive impairment or dementia, with the diagnoses of MCI, AD, and DLB
Discussions
Features of a useful screening test include high sensitivity and adequate specificity, good safety, low cost, easy administration, minimal inconvenience or discomfort upon administration, and acceptability of patients and clinicians. In this patient population, the MSQ satisfies all these criteria for RBD.
Disclosures
Bradley F. Boeve, MD was an investigator in a clinical trial sponsored by Cephalon, Inc. Jennifer R. Molano, MD, Tanis J. Ferman, PhD, Glenn E. Smith, PhD, Siong-Chi Lin, MD, Kevin Bieniek, Wail Haidar, MD, Maja Tippmann-Peikert, MD have nothing to disclose. David S. Knopman, MD served on a Data Safety Monitoring Board for Sanofi Aventi, and was an investigator in clinical trials sponsored by Elan Pharmaceuticals and by Forest Laboratories. Neill R. Graff-Radford, M.B.Ch.B., consultant to
Conflicts of Interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: doi:10.1016/j.sleep.2010.12.009.
Acknowledgements
Supported by Grants P50 AG16574 and RO1 AG15866 from the National Institute on Aging, IIRG-05-14560 from the Alzheimer’s Association, and the Robert H., Clarice Smith and Abigail Van Buren Alzheimer’s Disease Research Program of the Mayo Foundation. We thank our staff at the Mayo Center for Sleep Medicine and Mayo Alzheimer’s Disease Research Center for their evaluation and education/counseling for many of the patients in this report. We particularly extend our gratitude to the patients and
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