Adult ICU Delirium Guideline
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Delirium Assessment
Delirium should be assessed using the Intensive Care Unit-Delirium Screening Checklist (ICU-DSC)
Delirium should be assessed every shift based on symptoms throughout the shift or the previous 24 hours
The ICU-DSC score should be recorded on the flow sheet along with the SAS score. If the ICU-DSC can’t be completed due
to level of consciousness then ICU-DSC N/A should be recorded on the flow sheet
A score of ≥ 4 on the ICU-DSC is considered positive for delirium
Patients with a psychiatric diagnosis (depression, schizophrenia, dementia, polysubstance abuse, etc.), structural neurologic
abnormalities, or hepatic encephalopathy may test falsely positive on the ICU-DSC, use with caution in these patients
All positive screenings should be brought to the providers attention to rule out other causes for the change in mental status
and for possible treatment
Refer to treatment algorithm for both pharmacologic and non-pharmacologic therapy
Intensive Care Unit-Delirium Screening Checklist (ICU-DSC)
PATIENT EVALUATION (see descriptions below)
1. Altered level of consciousness* (A-E)
SCORE
If A or B patient evaluation stops here
2. Inattention
3. Disorientation
4. Hallucination-delusion-psychosis
5. Psychomotor agitation or retardation
6. Inappropriate speech or mood
7. Sleep/wake cycle disturbance
8. Symptom fluctuation
TOTAL SCORE (0-8)
SCORING SYSTEM:
The scale is completed based on information collected from each shift or from the previous 24 hours.
Obvious manifestation of an item = 1 point. No manifestation of an item or no assessment possible = 0 point.
The score of each item is entered in the corresponding empty box and is 0 or 1.
1. Altered level of consciousness*:
A) No response or B) the need for vigorous stimulation in order to obtain any response signified a severe alteration in the level of
consciousness precluding evaluation. If there is coma (A) or stupor (B) most of the time period then a dash (-) is entered and there
is no further evaluation during that period.
C) Drowsiness or requirement of a mild to moderate stimulation for a response implies an altered level of consciousness
and scores 1 point.
D) Wakefulness or sleeping state that could easily be aroused is considered normal and scores no point.
E) Hypervigilance is rated as an abnormal level of consciousness and scores 1 point
Altered level of consciousness*:
A: no response
B: response to intense and repeated stimulation (loud voice and pain)
C: response to mild or moderate stimulation
D: normal wakefulness
E: exaggerated response to normal stimulation
Score
(-)
(-)
1
0
1
2.
Inattention: Difficulty in following a conversation or instructions. Easily distracted by external stimuli. Difficulty in shifting focuses.
Any of these scores 1 point.
3. Disorientation: Any obvious mistake in time, place, or person scores 1 point.
4. Hallucination, delusion, or psychosis: The unequivocal clinical manifestation of hallucinations or of behavior probably due to
hallucination (e.g. trying to catch a non-existent object) or delusion. Gross impairment in reality testing. Any of these scores 1 point.
5. Psychomotor agitation or retardation: Hyperactivity requiring the use of additional sedative drugs or restraints in order to control
potential dangerousness (e.g. pulling out IV lines, hitting staff). Hypoactivity or clinically noticeable psychomotor slowing. Any of
these scores 1 point.
6. Inappropriate speech or mood: Inappropriate, disorganized or incoherent speech. Inappropriate display of emotion related to events or
situation. Any of these scores 1 point.
7. Sleep/wake cycle disturbance: Sleeping less than 4 hours or waking frequently at night (do not consider wakefulness initiated by
medical staff or loud environment). Sleeping during most of the day. Any of these scores 1 point.
8. Symptom fluctuation: Fluctuation of the manifestations of any item or symptom over 24 hours (e.g. from one shift to another) scores 1
point.
-Intensive Care Delirium Screening Checklist modified
Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is
an understanding that, depending on the patient, the setting, the circumstances, or other factors, guidelines can and should be tailored to fit individual needs.
TREATMENT ALGORITHM
Is the Patient Delirious (ICU-DSC positive (Score ≥4))?
(See Delirium Assessment)
NO
Reassess for delirium every shift
Treat pain and anxiety
YES
Consider differential diagnosis to r/o other causes
for change in mental status
e.g. Sepsis, CHF, metabolic disturbances
Remove deliriogenic drugs1
Non-pharmacological therapy2
SAS of 6 to 7
SAS of 4 to 5
Is the patient in pain?
YES
Give analgesic
(See pain guideline)
Assure adequate pain control
Reassess target sedation goal
(See pain guideline)
(See sedation guidelines)
NO
Consider antipsychotic3
Give adequate sedative for
safety then minimize and/or
Consider treatment for
*Acute Delirium*3
1. DELIRIOGENIC MEDICATIONS
Consider stopping or substituting for:
-Benzodiazepines
-Corticosteroids
-Metoclopramide
-H2 Antagonists
-Anticholinergics
-Promethazine
-Diphenhydramine
3. ANTIPSYCHOTIC THERAPY
While tapering or discontinuing sedatives, consider:
-Haloperidol 5 mg IV/PO q6h, increase dose by 5 mg to max of
20 mg q6h (consider lower starting dose in elderly patients)
-Quetiapine 50-400 mg/day PO divided twice daily
-Olanzapine 2.5-20 mg/day PO divided once or twice daily
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Haloperidol 1-10mg IV q2h prn can be used for breakthrough symptoms
*Acute Delirium* Haloperidol 3-5 mg IV x1 for acute delirium
(ICU-DSC positive and SAS of 6 to 7)
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SAS of 2 to 3
Double previous Haloperidol dose every 20 minutes until patient
controlled or maximum dose of 40 mg is reached
Haloperidol maintenance dose is 25% of total dose given to control
agitation every six hours
 Monitor QTc daily if on a scheduled antipsychotic regimen
-Hold if QTc is > 0.5 msec
 Discontinue antipsychotics if high fever, QTC prolongation, or drug-
2. NON-PHARMACOLOGIC THERAPY
Orientation
 Provide visual and hearing aids
 Encourage communication and
reorient patients
 Have familiar objects in the room
 Attempt consistency in nursing staff
 Allow television during day with daily
news
 Non-verbal music
Environment
 Sleep hygiene: Lights off at night, on
during day
 Control excess noise at night
 Ambulate and mobilize early and
often
Clinical Parameters
 Maintain systolic blood pressure >90
mmHg
 Maintain oxygen saturations >90%
 Treat underlying metabolic
derangements and infections
induced rigidity occurs
Prepared by C. Groth, Adapted from ICUdelirium.org
Last updated 10/2010
Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is
an understanding that, depending on the patient, the setting, the circumstances, or other factors, guidelines can and should be tailored to fit individual needs.