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Intensive Care Delirium Screening Checklist


The scale is completed based on information collected from each entire 8-h shift or from the previous 24 h. Score of 4 or higher sensitive but not specific indicator of delirium

Level of consciousness. Specific features of delirium. Patient scores 1 for each category if features are present and 0 if features are absent
A. No response Inattention


Hallucination, delusion or psychosis

Psychomotor agitation or retardation

Inappropriate speech or mood

Sleep/wake cycle disturbance

Symptom fluctuation from one shift to another

B. Vigorous stimulation required to obtain response. If patient is rated A or B most of the time period no further evaluation is carried out during that time period
C. Drowsy or requires mild to moderate stimulation to obtain response. Scores 1 point
D. Awake or easily roused. 0 points
E. Hypervigilance. 1 point



Any of:

  • Difficulty in following a conversation or instructions
  • Easily distracted by external stimuli
  • Difficulty in shifting focus


  • unequivocal clinical manifestation of hallucination or of behavior probably due to hallucination (e.g., trying to catch a nonexistent object)

Psychomotor agitation or retardation

Any of:

  • hyperactivity requiring the use of additional sedative drugs or restraints in order to control potential danger to oneself or others (e.g., pulling out intravenous lines, hitting staff)
  • hypoactivity
  • clinically noticeable psychomotor slowing

Sleep-wake cycle disturbance

  • sleeping less than 4h or waking frequently at night (do not consider wakefulness initiated by medical staff or loud environment) OR
  • sleeping during most of the day

©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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