Delirium Assessment in the ICU

Begin each assessment by documenting level of arousal with the Richmond Agitation-Sedation Scale (RASS). CAM-ICU and ICDSC results are difficult to interpret in deep sedation or coma; patients at RASS -3 are commonly classified as unable to assess in delirium studies, whereas assessment data are more established from RASS 0 through -2. Wolters Kluwer+1Wolters KluwerClinical Practice Guidelines for the Prevention... : Critical Care ...Wolters KluwerA Novel Computerized Test for Detecting and... : Critical Care Medicine

When the patient is sufficiently arousable, perform CAM-ICU or ICDSC rather than substituting routine orientation questions or a general impression of confusion. Both tools are validated for ICU use, including in mechanically ventilated nonverbal patients, and can be completed in 2–5 minutes. Wolters Kluwer+1Wolters KluwerClinical Practice Guidelines for the Prevention... : Critical Care ...Wolters KluwerEvaluation of delirium in critically ill... : Critical Care Medicine

Record the paired result as arousal status plus delirium status—for example, “RASS -4, delirium unassessable” or “RASS -1, CAM-ICU positive.” This distinguishes coma/deep sedation from a negative screen and makes serial change interpretable during sedation adjustment and recovery. Wolters Kluwer+1Wolters KluwerClinical Practice Guidelines for the Prevention... : Critical Care ...Wolters KluwerA Novel Computerized Test for Detecting and... : Critical Care Medicine

CAM-ICU is a practical choice when a brief, repeated bedside determination is needed in verbal or nonverbal ICU patients. In its original ICU validation cohort, CAM-ICU showed high interrater reliability and sensitivity of 95% to 100% and specificity of 89% to 93% against a reference delirium assessment. Wolters KluwerWolters KluwerEvaluation of delirium in critically ill... : Critical Care Medicine

ICDSC is also guideline-endorsed for ICU screening. Tool performance and reproducibility vary by ICU population, particularly in patients with neurologic injury, communication impairment, aphasia, sensory deficits, or neuroprotective sedation; in these settings, interpret an instrument result alongside the neurologic examination and the expected trajectory of the primary brain injury. Wolters Kluwer+1Wolters KluwerClinical Practice Guidelines for the Prevention... : Critical Care ...Wolters KluwerAbstracts From the 51st Annual Meeting of the... : Journal of Neurosurgical Anesthesiology

Avoid switching instruments merely because a result is unexpected. A change from CAM-ICU to ICDSC changes the measurement method, not necessarily the patient’s mental state. Maintain the same tool for serial bedside monitoring when feasible, and escalate discordant or clinically implausible results to direct clinical evaluation rather than assuming either a false-positive or false-negative screen. Wolters Kluwer+1Wolters KluwerClinical Practice Guidelines for the Prevention... : Critical Care ...Wolters KluwerAbstracts From the 51st Annual Meeting of the... : Journal of Neurosurgical Anesthesiology

For a new positive CAM-ICU or ICDSC, first compare the result with the contemporaneous RASS and recent sedative changes. Benzodiazepines are an independent delirium risk factor in ICU patients; evaluate whether ongoing benzodiazepine exposure is necessary and whether the sedation target can be safely lightened. PubMedPubMedPrevention and management of delirium in critically ill adult patients in the intensive care unit: a review based on the 2018 PADIS guidelines - PMC

Review potentially modifiable ICU precipitants at the bedside: immobilization, physical restraints, isolation or absent visitation, lack of visible daylight, excessive noise or light, and disrupted sleep. Also reassess pain and analgesic strategy, because pain control and reduction of avoidable distress are integrated components of PADIS-based ICU care. PubMed+1PubMedPrevention and management of delirium in critically ill adult patients in the intensive care unit: a review based on the 2018 PADIS guidelines - PMCWolters KluwerImpact of the 2018 Society of Critical Care Medicine Pain,... : Critical Care Explorations

Use the examination to decide whether delirium may instead reflect a neurologic emergency or a primary neurologic disorder. New focal deficits, unexplained depressed consciousness, or concern for seizure should prompt a neurologic assessment; EEG can be useful when evaluating metabolic encephalopathy or infectious encephalitis with characteristic EEG patterns. PubMedPubMedPrevention and management of delirium in critically ill adult patients in the intensive care unit: a review based on the 2018 PADIS guidelines - PMC

Repeat a validated assessment whenever the patient becomes newly arousable, after a meaningful change in sedation or neurologic status, and as part of the unit’s routine delirium-monitoring workflow. Delirium is dynamic, and screening studies and ICU protocols rely on serial rather than one-time assessments. Wolters Kluwer+2Wolters KluwerPoststroke delirium incidence and outcomes : Critical Care MedicineWolters KluwerClinical Practice Guidelines for the Prevention... : Critical Care ...Wolters KluwerEvaluation of delirium in critically ill... : Critical Care Medicine

In acute stroke, early serial testing is particularly important: delirium began on the first day in 67.3% of affected patients and within 5 days in all affected patients in one prospective cohort. CAM-ICU demonstrated 76% sensitivity and 98% specificity against DSM assessment in that poststroke population, but aphasia and stroke-related deficits still require clinical interpretation. Wolters KluwerWolters KluwerPoststroke delirium incidence and outcomes : Critical Care Medicine

Trend delirium status with RASS and exposure changes rather than treating either measure as isolated. A patient transitioning from RASS -4 to -1 has become assessable; a new positive CAM-ICU at that point may represent emerging delirium, sedation-related cognitive effects, or both, and should trigger reassessment of the full clinical context. Wolters KluwerWolters KluwerClinical Practice Guidelines for the Prevention... : Critical Care ...

Use each positive assessment to activate a multicomponent nonpharmacologic plan: optimize orientation and cognition, mobilize early when feasible, assess and control pain, reduce avoidable environmental sleep disruption, and involve family when possible. Comparative evidence identifies multicomponent strategies as the most effective nonpharmacologic approach for reducing ICU delirium incidence; SCCM also conditionally recommends enhanced mobilization/rehabilitation over usual mobilization/rehabilitation. Nature+2NatureEffectiveness of non-pharmacological intervention protocol for prevention of postoperative delirium in the surgical intensive care unit | Scientific ReportsWolters KluwerSCCM Guidelines : Critical Care MedicineScienceDirectComparative effectiveness of non-pharmacological interventions for preventing delirium in critically ill adults: A systematic review and network meta-analysis

Do not prescribe an antipsychotic solely because CAM-ICU or ICDSC is positive. SCCM’s focused update was unable to recommend antipsychotics for treatment of delirium in critically ill adults, and SCCM guidance for older critically ill adults suggests against antipsychotics for delirium prevention. Wolters Kluwer+1Wolters KluwerSCCM Guidelines : Critical Care MedicineWolters KluwerSociety of Critical Care Medicine Guidelines on... : Critical Care Medicine

For patients who require sedation, choice of sedative should be considered as part of the delirium-assessment response rather than separately. SCCM conditionally recommends dexmedetomidine over propofol for sedation in critically ill adults; this does not convert a positive delirium screen into an indication for drug treatment, but it can inform sedation strategy when sedation remains necessary. Wolters KluwerWolters KluwerSCCM Guidelines : Critical Care Medicine