ICDSC
The is an 8 point delirium scoring system, with a positive delirium being anything greater or equal to 4. Therefore it is essential for a total score to be tabulated for an overall delirium status to be assessed.
1. Altered Level of Consciousness (A-E)
A. Exaggerated response to normal stimulation (SAS = 5,6 or 7) = SCORE 1 POINT
B. Normal wakefulness (SAS = 4) = SCORE 0 POINTS
C. Response to mild or moderate stimulation (SAS = 3) = SCORE 1 POINT
D. No Response (SAS = 1) = *Stop assessment*
- SCORE 0 if LOC related to related to recent sedation/analgesia
E. Response only to intense and repeated stimulation (SAS = 2) = *Stop assessment*
The first criteria to be evaluated is level of consciousness. This is generally easy to assess and is typically routinely monitored using SAS (Sedation-Agitation Scores). Based on your SAS score assessment, if a patient has a score of 1-2 the patient is not responsive enough to assess for delirium and you can stop your assessment. For documentation purposes you simply need to indicate their SAS score and under Total put UTA (unable to asses).
If their SAS Score is a 3 or greater a delirium score can be tabulated regardless of use of sedatives. A SAS score of 5, 6 or 7 corresponding to exaggerated response to normal stimulation gets 1 point. A SAS of 4 means the patient is awake or is in a sleeping state from which they are easily aroused and gets 0 points.
A SAS of 3 corresponding to a patient that responds to mild or moderate stimulation can get a score of 1-0 depending on whether they were recently given any sedation or analgesia. If they have not been given any medication and they require stimulation for arousal that is inappropriate they should receive a score of 1, however if they are sedated but still arouse to mild or moderate stimulation that is appropriate they get a score of 0.
A. Exaggerated response to normal stimulation (SAS = 5,6 or 7) = SCORE 1 POINT
B. Normal wakefulness (SAS = 4) = SCORE 0 POINTS
C. Response to mild or moderate stimulation (SAS = 3) = SCORE 1 POINT
D. No Response (SAS = 1) = *Stop assessment*
- SCORE 0 if LOC related to related to recent sedation/analgesia
E. Response only to intense and repeated stimulation (SAS = 2) = *Stop assessment*
The first criteria to be evaluated is level of consciousness. This is generally easy to assess and is typically routinely monitored using SAS (Sedation-Agitation Scores). Based on your SAS score assessment, if a patient has a score of 1-2 the patient is not responsive enough to assess for delirium and you can stop your assessment. For documentation purposes you simply need to indicate their SAS score and under Total put UTA (unable to asses).
If their SAS Score is a 3 or greater a delirium score can be tabulated regardless of use of sedatives. A SAS score of 5, 6 or 7 corresponding to exaggerated response to normal stimulation gets 1 point. A SAS of 4 means the patient is awake or is in a sleeping state from which they are easily aroused and gets 0 points.
A SAS of 3 corresponding to a patient that responds to mild or moderate stimulation can get a score of 1-0 depending on whether they were recently given any sedation or analgesia. If they have not been given any medication and they require stimulation for arousal that is inappropriate they should receive a score of 1, however if they are sedated but still arouse to mild or moderate stimulation that is appropriate they get a score of 0.
2. Inattention
Score 1 point for any of the following abnormalities:
A. Difficulty in following commands OR
B. Easily distracted by external stimuli OR
C. Difficulty in shifting focus
This can be assessed in a few ways. When speaking to the patient, are they easily distracted? Does the patient follow you with their eyes or do their eyes seem to wander? You can also assess a command such as “raise this many fingers”.
NOTE: Commands such as “don’t pull out or bite down” on that tube are not the best assessment methods because the lack of compliance may be more to do with physical irritation rather than inattention.
Score 1 point for any of the following abnormalities:
A. Difficulty in following commands OR
B. Easily distracted by external stimuli OR
C. Difficulty in shifting focus
This can be assessed in a few ways. When speaking to the patient, are they easily distracted? Does the patient follow you with their eyes or do their eyes seem to wander? You can also assess a command such as “raise this many fingers”.
NOTE: Commands such as “don’t pull out or bite down” on that tube are not the best assessment methods because the lack of compliance may be more to do with physical irritation rather than inattention.
3. Disorientation
Score 1 point for any one obvious abnormality:
A. Mistake in either time, place or person
If a patient can speak you can ask them questions like “do you know where you are?”, “do you know what month it is”. You can assess if they recognize yourself or family member if they are present. If the patient is disoriented, they receive 1 point.
Score 1 point for any one obvious abnormality:
A. Mistake in either time, place or person
If a patient can speak you can ask them questions like “do you know where you are?”, “do you know what month it is”. You can assess if they recognize yourself or family member if they are present. If the patient is disoriented, they receive 1 point.
4. Hallucination - Delusion - Psychosis
Score 1 point for either:
A. Equivocal evidence of hallucinations or a behaviour due to hallucinations (Hallucination = perception of something)
B. Delusions or gross impairment of reality testing (Delusion = false belief that is fixed/unchanged)
This can be assessed by talking to the patient. Have you seen anything strange? Are they excessively fearful? If so, what are they fearful of. Often times patients recount hearing things or believing that people are conspiring against them.
For patients who are intubated and unable to speak this can be more of a challenge to assess. You can still ask them questions like: "Are you seeing anything that's scary?", "Have you seen or heard anything strange recently?". You can also look to see if they're grabbing at things that aren't there.
Score 1 point for either:
A. Equivocal evidence of hallucinations or a behaviour due to hallucinations (Hallucination = perception of something)
B. Delusions or gross impairment of reality testing (Delusion = false belief that is fixed/unchanged)
This can be assessed by talking to the patient. Have you seen anything strange? Are they excessively fearful? If so, what are they fearful of. Often times patients recount hearing things or believing that people are conspiring against them.
For patients who are intubated and unable to speak this can be more of a challenge to assess. You can still ask them questions like: "Are you seeing anything that's scary?", "Have you seen or heard anything strange recently?". You can also look to see if they're grabbing at things that aren't there.
5. Psychomotor Agitation or Retardation
Score 1 point for either:
A. Hyperactivity requiring use of additional sedative drugs or restraints in order to control potential danger (eg. Pulling lines) OR
B. Hypoactive or clinically noticeable psychomotor slowing or retardation
Often times we focus on the hyperactivity or agitation component which is obvious, such as pulling at lines or hitting staff. However we need to ensure that we are assessing for hypoactive symptoms as well. Does the patient seem to be less active than usual or are they hard to motivate to get moving after previously being more active? If they have either of these features they get a point.
Score 1 point for either:
A. Hyperactivity requiring use of additional sedative drugs or restraints in order to control potential danger (eg. Pulling lines) OR
B. Hypoactive or clinically noticeable psychomotor slowing or retardation
Often times we focus on the hyperactivity or agitation component which is obvious, such as pulling at lines or hitting staff. However we need to ensure that we are assessing for hypoactive symptoms as well. Does the patient seem to be less active than usual or are they hard to motivate to get moving after previously being more active? If they have either of these features they get a point.
6. Inapropriate Speech or Mood
Score 1 point for either:
A. Inappropriate, disorganized or incoherent speech OR
B. Inappropriate mood related to events or situation
If your patient is able to talk, you can assess this by asking questions such as will a stone float on water, or are there fish in the sea?. Or you can simply assess their general conversations and if they are appropriate or not. If your patient cannot speak or is intubated, an assessment of mood is important. Are they weepy for no apparent reason? Are they fearful? Hypoactive delirius patients often times say they remember feeling extreme fear while in the ICU. So does your patient wake up very startled? If any of these features are present they get 1 point.
Score 1 point for either:
A. Inappropriate, disorganized or incoherent speech OR
B. Inappropriate mood related to events or situation
If your patient is able to talk, you can assess this by asking questions such as will a stone float on water, or are there fish in the sea?. Or you can simply assess their general conversations and if they are appropriate or not. If your patient cannot speak or is intubated, an assessment of mood is important. Are they weepy for no apparent reason? Are they fearful? Hypoactive delirius patients often times say they remember feeling extreme fear while in the ICU. So does your patient wake up very startled? If any of these features are present they get 1 point.
7. Sleep/Wake Cycle Disturbance
Score 1 point for:
A. Sleeping less than 4 hours at night OR
B. Waking frequently at night (do not include wakefulness initiated by medical staff or loud environment) OR
C. Sleep > 4 hours during day
The ICU can be a very inhospitable environment for sleep. Noise, bright lights and continuous assessments can cause patients to have drastic changes to their sleep/wake cycle. Assess how well they sleep during night time hours. If the patient is sleeping less than 4 hours a night, or if they are waking up frequently in the night or if they are sleeping more than 4 hours during they day they would get 1 point.
Score 1 point for:
A. Sleeping less than 4 hours at night OR
B. Waking frequently at night (do not include wakefulness initiated by medical staff or loud environment) OR
C. Sleep > 4 hours during day
The ICU can be a very inhospitable environment for sleep. Noise, bright lights and continuous assessments can cause patients to have drastic changes to their sleep/wake cycle. Assess how well they sleep during night time hours. If the patient is sleeping less than 4 hours a night, or if they are waking up frequently in the night or if they are sleeping more than 4 hours during they day they would get 1 point.
8. Symptom Fluctuation
Score 1 point for
Fluctuation of any of the above items (ie 1-7) over hours (from one shift to another)
This is a catch all feature that evaluates overall symptom fluctuation of any of features 1-7. How stable mentally has your patient been over the last 24 hours? Delirium is defined as a fluctuating mental state. Therefore symptoms that were present in the past 24hrs and not present at the current time of assessment is not necessarily a sign of improvement, but could actually be a sign of delirium itself. If a patient has shown significant improvement, symptoms should be absent for longer than 24 hours, meaning that there mental status has now re-normalized to an improved state.
Score 1 point for
Fluctuation of any of the above items (ie 1-7) over hours (from one shift to another)
This is a catch all feature that evaluates overall symptom fluctuation of any of features 1-7. How stable mentally has your patient been over the last 24 hours? Delirium is defined as a fluctuating mental state. Therefore symptoms that were present in the past 24hrs and not present at the current time of assessment is not necessarily a sign of improvement, but could actually be a sign of delirium itself. If a patient has shown significant improvement, symptoms should be absent for longer than 24 hours, meaning that there mental status has now re-normalized to an improved state.