II. Indications

  1. Delirium Evaluation

III. Technique:

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

IV. Efficacy: Delirium Diagnosis

  1. Test Sensitivity: 72% (68% if non-physician performs)
  2. Test Specificity: 99%

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