Table 3. The Intensive Care Delirium Screening Checklist

 If A or B do not complete patient evaluation for the period)

  A: No response

0

  B: Response to intense and repeated stimulation (loud voice and pain)

0

  C: Response to mild or moderate stimulation

1

  D: Normal wakefulness

0

  E: Exaggerated response to normal stimulation

1

 Difficulty in following a conversation or instructions.

0 or 1

 Easily distracted by external stimuli.

 Difficulty in shifting focuses.

 Any of these scores 1 point.

 Any obvious mistake in time, place, or person scores 1 point.

0 or 1

 The unequivocal clinical manifestation of hallucination or of behavior probably due to hallucination or delusion.

0 or 1

 Gross impairment in reality testing.

 Any of these scores 1 point.

 Hyperactivity requiring the use of additional sedative drugs or restraints in order to contral potential danger to oneself or others.

0 or 1

 Hypoactivity or clinically noticeable psychomotor slowing.

 Any of these scores 1 point.

 Inappropriate, disorganized, or incoherent speech.

0 or 1

 Inappropriate display of emotion related to events or situation.

 Any of these scores 1 point.

 Sleeping less than 4h or waking frequently at night (do not consider wakefulness initiated by medical staff or loud environment).

0 or 1

 Sleeping during most of the day.

 Any of these scores 1 point.

 Fluctuation of the manifestation of any item or symptom over 24h scores 1 point.

0 or 1