Table 2.
Suggestions for Assessing Delirium with the ICDSC
| 1. Altered level of consciousness Choose ONE from A–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 | (1 point) |
| D. Response only to intense and repeated stimulation (e.g. 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 for any abnormality) | |
| A. Mistake in either time, place or person | ||
| Does the patient recognize ICU caregivers who have cared for him/her and not recognize those that have not? What kind of place are you in? (list examples) | ||
| 4. Hallucinations or Delusions | (1 point for either) | |
| A. Equivocal evidence of hallucinations or a behavior 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 hrs? Are you afraid of the people or things around you? [fear that is inappropriate to the clinical situation] | ||
| 5. Psychomotor Agitation or Retardation | (1 point for either) | |
| A. Hyperactivity requiring the use of additional sedative drugs or restraints in order to control potential danger (e.g. pulling IV lines out or hitting staff) OR | ||
| B. Hypoactive or clinically noticeable psychomotor slowing or retardation | ||
| Based on documentation and observation over shift by primary caregiver | ||
| 6. Inappropriate Speech or Mood | (1 point for either) | |
| A. Inappropriate, disorganized 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 (do 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 (e.g. from one shift to another) | ||
| Based on primary caregiver assessment | ||
| TOTAL ICSDC SCORE (Add 1 – 8) | ________ | |
ICDSC, Intensive Care Delirium Screening Checklist; SAS, Sedation Agitation Scale; RASS, Richmond Agitation Sedation Scale. Modified from Devlin, et al., Combined didactic and scenario-based education improves the ability of intensive care unit staff to recognize delirium at the bedside. Crit Care 2008;12(1):R19.