Symptoms Symptoms rating
1 Disorientation
0

1

2
Verbal or behavioural manifestation of not being oriented to time or place or misperceiving persons in the environment
2 Inappropriate behaviour
0

1

2
Behaviour inappropriate to place, for the person, or both; e.g. pulling at tubes or dressings, attempting to get out of bed when that is contraindicated, and the like
3 Inappropriate communication
0

1

2
Communication inappropriate to place, for the person, or both; e.g. incoherence, non-communicativeness, nonsensical or unintelligible speech
4 Illusions/
hallucinations

0

1

2
Seeing or hearing things that are not there; distortions of visual objects
5 Psychomotor retardation
0

1

2
Delayed responsiveness, few or no spontaneous actions/words; e.g. when the patient is prodded, reaction is deferred, the patient is unarousable, or both
Total score
Delirium ≥2 □ yes <2 □ no
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