Suggestions for assessing delirium with the ICDSC54
| 1. Altered level of consciousness: choose one from A to E | ||
| A. Exaggerated response to normal stimulation | SAS=5, 6, 7 or RASS =+1 to+4 | (1 point) |
| B. Normal wakefulness | SAS=4 or RASS=0 | (0 points) |
| C. Response to mild or moderate stimulation (follows commands) | SAS=3 or RASS=−1 to −3 | (0 points) |
| D. Response only to intense and repeated stimulation (eg, loud voice and pain) | SAS=2 or RASS=−4 | Stop assessment |
| E. No response | SAS=1 or RASS=−5 | Stop assessment |
| 2. Inattention | (1 point if any present) | |
| A. Difficulty in following commands or | ||
| B. Easily distracted by external stimuli or | ||
| C. Difficulty in shifting focus | ||
| Does the patient follow you with their eyes? | ||
| 3. Disorientation | (1 point if any abnormality) | |
| A. Mistake in either time, place or person | ||
| Does the patient recognise ICU caregivers who have cared for him/her and not recognise those that have not? What kind of place are you in? (list examples) | ||
| 4. Hallucinations or delusions | (1 point if any abnormality) | |
| A. Equivocal evidence of hallucinations or a behaviour due to hallucinations (hallucination=perception of something that is not there with NO stimulus) or | ||
| B. Delusions or gross impairment of reality testing (delusion=false belief that is fixed/unchanging) | ||
| Any hallucinations now or over past 24 hours? Are you afraid of the people or things around you? (fear that is inappropriate to the clinical situation) | ||
| 5. Psychomotor agitation or delay | (1 point for either) | |
| A. Hyperactivity requiring the use of additional sedative drugs or restraints in order to control potential danger (eg, pulling out intravenous lines or hitting staff) or | ||
| B. Hypoactive or clinically noticeable psychomotor slowing or delay | ||
| Based on documentation and observation during shift by primary caregiver | ||
| 6. Inappropriate speech or mood | (1 point for either) | |
| A. Inappropriate, disorganised or incoherent speech or | ||
| B. Inappropriate mood related to events or situation | ||
| Is the patient apathetic to current clinical situation (ie, lack of emotion)? Any gross abnormalities in speech or mood? Is patient inappropriately demanding? | ||
| 7. Sleep/wake cycle disturbance | (1 point for any abnormality) | |
| A. Sleeping less than four hours at night or | ||
| B. Waking frequently at night (does not include wakefulness initiated by medical staff or loud environment) or | ||
| C. Sleep ≥4 hours during day | ||
| Based on primary caregiver assessment | ||
| 8. Symptom fluctuation | (1 point for any) | |
| Fluctuation of any of the above items (ie, 1–7) over 24 hours (eg, from one hospital shift to another) | ||
| Based on primary caregiver assessment | ||
| Total ICSDC score (add 1–8) | ||
ICDSC, Intensive Care Delirium Screening Checklist; ICU, intensive care unit; RASS, Richmond Agitation Sedation Scale; SAS, Sedation Agitation Scale.