Note: Should be assessed separately from level of consciousness. A subject who is lethargic or stuporous may have intact attentions during periods of arousal.

Definition: Reduced ability to maintain attention to external stimuli and to appropriately shift attention to new external stimuli. Respondent seems unaware or out-of-touch with environment (e.g. dazed, fixated, or darting attention). Did the patient have difficulty focusing attention, for example being easily distractible, or having difficulty keeping track of what was being said?


  • Questions must be frequently repeated because attention wanders, NOT because of decreased hearing
  • Unable to gain respondent's attention or to make any prolonged eye contact. Respondent's focus seems to be darting about room
  • Respondents keep repeating answer to the previous question
  • Respondent is dazedly staring at the TV. When you ask a question, he looks at you momentarily but does not answer. He then continues to stare at the TV.

If unsure of attention formal attention can be assessed by getting respondent to do either of the following:

  • Spell WORLD backwards
  • Recite months of the year of days of the week backwards
  • Count backwards from 20 to 1

A patient's attention deficit will be apparent if errors occur or they are unable to complete the tasks. The respondent can usually state the first few items correctly then goes forwards instead of backwards and/or fails to complete the task. This may also help at baseline when patients have no delirium but have dementia as they can perform simple attention tests (counting backwards from 20 to 1), unless the dementia is advanced.

Reference: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide, Copyright 2003, Sharon K. Inouye, M.D., MPH. Not to be reproduced without permission. Instructions for correct usage available at the Hospital Elder Life Program (HELP) website Linked to another web site, or on request from Dr. Sharon Inouye.