Utility of the pictorial Epworth sleepiness scale in the adult Down syndrome population

•The pictorial aspect of the Epworth Sleepiness Scale (pESS) may be more appropriate for adults with Down Syndrome, has yet to be evaluated.•Alternative questions taking into account abilities, technological advances and lifestyle limitations in this group of patients may be more useful.•An amended scale using pictures to reach a low literacy group should not include a question about reading.•Questions could be developed as substitutes in the ESS, dependent on the group being studied, in a similar fashion to the paediatric modification of the ESS.