Frequently Asked Questions (FAQs) About Delirium Screening

My patient has a MASS of 2. Can I screen this patient for delirium?

If a patient has a MASS of 2, they are able to obey commands, but have some reduction in their level of alertness. If a patient has a MASS of 2, attempt to screen them using the ICDSC.

Some patients may achieve a MASS score of 2 by opening their eyes to voice only, but have no other meaningful reaction. When you begin to screen them with the ICDSC, you may discover that the patient does not have a sufficient level of consciousness to screen for delirium. If this is the case, record the ICDSC score as "U/A *".  Write a DAR note to explain why you are unable to screen the patient despite an ICDSC of 2.

My patient has a MASS of 1. Can I screen this patient for delirium?

A patient with a MASS of 0 or 1 has a level of consciousness that is insufficient for screening for delirium. A MASS of 1 is a patient who only responds only to a noxious stimulus (localizing is a response to noxious stimulus). At times, the level of consciousness in a patient with an ICDSC of 2 is too low to assess for delirium.

Why do we screen in the second half of the shift?

One of the hallmarks of delirium is the fluctuation in symptoms. In order to determine if a patient has fluctuating symptoms, you need to observe the patient's behaviour over several hours. 

When scoring each of the 8 criteria on the ICDSC, you are reflecting upon whether the patient displayed the criteria at any point in the past 24 hours (and the criteria was not due to another obvious cause such as sedation administration).

My patient became drowsy after a prn dose of sedation. Should I score my patient as positive for item #5 (psychomotor retardation)?

Do not screen the patient as positive for criteria that are clearly due to another cause (e.g., temporary agitation that is due to pain, or pschomotor retardation that is due to the administration of sedatives).

 

Why do I need to screen for pain before screening for delirium?

Unresolved pain can be a potential trigger for delirium. Pain can cause agitation, inattention and sleep disturbances. The symptoms are part of the ICDSC delirium screening tool.  To reduce the chance for a false positive delirium screen, pain should be treated (or attempts should be made to see if analgesia alleviates the symptoms) before the patient is screened for delirium. 

Too much analgesia can reduce the patient's level of consciousness, making delirium screening impossible.

If your patient is free of pain and receiving continuous or regular dose narcotics, consider decreasing the dose of medication unless contraindicated (e.g., neuromuscular blockers in use, pain control has just been established after repeated medication trials). 

Why do I need to assess sedation level (VAMASS) before screening for delirium?

A sedation assessment needs to be performed prior to delirium screening to evaluate the patient's level of consciousness and determine whether the patient is awake enough to be assessed for delirium.  It is also needed to ensure that the patient's level of sedation is within the desired range if sedatives are in use.

The MASS portion of the VAMASS score is used to determine whether the patient has criteria 1 of the ICDSC present. The patient has an altered level of consciousness if the MASS is not equal to 3.

If the patient has a MASS of 0 or 1, the patient's level of consciousness is too low to perform a delirium assessment. For some patient's a MASS score of 2 may also be too low.

If a patient has a MASS of 0, 1 or 2, we need to reassess the patient's sedation and attempt to wean any sedating medications, unless contraindicated.  Rescreening should be reattempted if the patient's level of consciousness improves after sedation withdrawal, or on the next shift (whichever comes first).

Benzodiapines should be used sparingly and withdrawn as soon as they are no longer needed, as there is some evidence to suggest that these are potential triggers for delirium.

Exception:
Benzodiapine use is indicated for the prophylaxis and treatment of alcohol withdrawal. They should be withdrawn slowly in patients with preadmission or prolonged ICU use of benzodiazipines as rapid termination can cause withdrawal. Seizures can be induced by rapid benzodiazipine withdrawal in patients at risk for seizures.

Do I need to reassess pain and sedation when I conduct a delirium screen?

Yes. There are 3 steps to a delirium screen including: pain assessment (first), sedation assessment (second) and delirium screening (third). When you conduct your delirium assessment, begin by rescreening for pain and sedation.

If my patient is sleeping at the end of my night shift, should I wake the patient to screen for delirium?

Never wake a sleeping patient at night unless absolutely necessary! If the patient is asleep, assume that the patient is not in pain or screen using CPOT without awakening the patient. Do not awaken for a VAMASS. Screen using the ICDSC based on your observations from the earlier part of the shift when the patient was awake.

Remember that a delirium screen is a reflection of whether the patient has any of the 8 criteria present during the preceding 24 hour period, not at the moment when the assessment is done.

 

My patient has a mental health condition or dementia. When I screen, I am not sure how to score the patient.

When screening a patient with other potential causes for behavioural findings such as dementia or another pscyhiatric disorder, identify criteria as present or absent. Don't try to determine whether the cause is their dementia or other disorders.  Once screening is done, identify them as "screen positive" or "screen negative".  A positive screen does not necessarily mean a patient has delirium. The diagnosis of delirium is a medical diagnosis that is made after the patient the patient is assessed.

No tool is perfect. All screening tools have fault positives and false negatives.

My patient nods yes and no when asked if they are in London or in the ICU. How do I know if their comprehension is normal?

Asking patients to nod if they agree with a statement can make it difficult to know whether their affirmation reflects true comprehension. Intubated patients who are awake and appear calm, can be challenging to assess. They may nod yes to questions without truly understanding.

The two key features that must be present to diagnose delirium are waxing and waning confusion and inattention. You can utilized items from the CAM ICU if you remain uncertain after screening a patient with the ICDSC.

Inattention:

Tell the patient you are going to spell out a word. Ask them to squeeze your hand every time they hear a specific letter. Spell the word slowly. If they squeeze on the appropriate letter, they are able to follow instructions and maintain attention. You can use any word you are able to recall. The CAM ICU uses the word "SAVEAHAART" and asks the patient to squeeze upon the letter "A".

Disorganized Thought

Instead of asking the patient to simply nod if they agree with you, choose questions that require the patient to make a clear choice between a simple right and wrong scenario.

The CAM ICU includes 4 simple questions. You can ask other straight forward questions that necessitate a choice on the part of the patient to provide a clear cut right or wrong answer.If the patient gets all 4 correct, simple comprehension and organization appears to be intact.

Examples from CAM ICU

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?

 

LHSCHealth Professionals

Last Updated December 9, 2012 | © 2007, LHSC, London Ontario Canada