II. Indications
- Delirium Evaluation
III. Technique:
- Step 1: Altered Mental Status change from baseline or fluctuating course over prior 24 hours
- Positive
- Go to Step 2
- Negative
- Stop - Negative for Delirium
- Positive
- Step 2: Inattention present
- Technique
- Examiner: "Squeeze my hand when you hear the letter A"
- Examiner says the following letters (with 4 A's), one at a time "S-A-V-E-A-H-A-A-R-T"
- Positive -More than 2 errors (missed at least 2 A's)
- Go to step 3
- Negative
- Stop - Negative for Delirium
- Technique
- Step 3: Altered Level of Consciousness present
- Assign Richmond Agitation Sedation Scale (RASS) Score Positive (RASS score abnormal, not 0)
- Stop - POSITIVE for Delirium
- Negative (RASS Score 0)
- Go to Step 4
- Step 4: Disorganized Thinking
- Questions
- "Will a stone float on water?"
- "Are there fish in the sea?"
- "Does one pound weigh more than two pounds?"
- "Can you use a hammer to pound a nail?"
- Command
- Examiner: "Hold up this many fingers"
- Examiner holds up 2 fingers
- Patient should hold up 2 fingers with one hand
- Examiner: "Now do the same thing with the other hand"
- Examiner does not demonstrate this time
- Patient should hold up 2 finger on the opposite hand
- Alternatively (if patient unable to move both hands): "Now hold up 3 fingers"
- Examiner: "Hold up this many fingers"
- Positive (2 or more errors)
- POSITIVE for Delirium
- Negative (0 or 1 error)
- Negative for Delirium
- Questions
IV. Efficacy: Delirium Diagnosis
- Test Sensitivity: 72% (68% if non-physician performs)
- Test Specificity: 99%
V. Resources
- Vanderbilt ICU Delirium