For patients in ICU who are unable to talk because of artificial ventilation the ICU-CAM has been developed to assess for the presence of delirium. This assessment of delirium in ICU patients involves a 2 Step approach:

Step One: Sedation Assessment

The Richmond Agitation and Sedation Scale (RASS)*
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s) aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
+1 Restless Anxious but movements not aggressive, vigorous
0 Alert and calm  
-1 Drowsy Not fully alert, but has sustained wakening (eye-opening/eye contact) to voice (>10 seconds)
-2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)
-3 Moderate sedation Movement or eye opening to vice (but no eye contact)
-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation
-5 Unrousable No response to voice or physical stimulation

If RASS is -4 or -5, then Stop and Reassess patient at later time
If RASS is above - 4 (-3 through +4) then Proceed to Step 2

*Sessler, et al. AJRCCM 2002; 166:1338-1344.
*Ely, et al. JAMA 2003; 289:2983-2991.

Step Two: Delirium Assessment

To screen for delirium use the Confusion Assessment Method following the CAM-ICU (PDF file)Linked to another web site specific adapted guidelines.