Multiple Sleep Latency Test: when are 4 naps enough?

Study Objectives: The Multiple Sleep Latency Test (MSLT) is central to the diagnosis of narcolepsy and idiopathic hypersomnia. This study is the first to assess the impact of a 5-nap protocol on meeting MSLT-derived diagnostic criteria in a general cohort referred for MSLT, without selection bias. Methods: Data for all MSLTs performed at 2 tertiary sleep units in Australia betweenMay 2012 andMay 2018 were retrospectively assessed for the impact of the fifth nap on mean sleep latency (MSL) and sleep onset rapid eye movement periods. Results: There were 122 MSLTs included. The MSL was 8.7 +/- 5.1 minutes after 4 naps, compared with 9.2 +/- 5.2 minutes for 5 naps (P <.0001). In 8 cases, inclusion of the fifth nap changed the MSL to a value above the diagnostic threshold of 8 minutes. There were no instances in which the MSL moved to = 8minutes based on fifth nap data. A sleep onset rapid eye movement period occurred in the fifth nap in 9 patients and altered the interpretation in 2 cases. Conclusions: The fifth nap in an MSLT is associated with an increased MSL, although this difference is rarely clinically significant. In patients with borderline MSL or 1 sleep onset rapid eyemovement periodafter4 naps, a fifthnap can alter the outcome andshould be performed. However, formany cases, a 4-napMSLTprotocolwill suffice, potentially allowing resource savingswithout compromising diagnostic accuracy. We propose the adoption of a conditional 4-nap or 5-nap protocol based on specific criteria.