1. Delirium elderly At-Risk Instrument
Nora McPherson, APRN, CNS, Geriatrics
Jill Tusing MS, RN, BC Service Line: Behavioral Health

2. SBAR: Delirium Identifying high risk patients
Situation: Delirium (acute confusion) a common, under recognized, post-operative complication in elective orthopaedic patients (10%-40%); manifests as acute impairment in cognition and attention.
Background: Post-operative delirium is associated with poor outcomes, greater costs, longer lengths of stays, poor recovery, institutionalization, and mortality.

3. Assessment: Currently, HE does not have process to screen patient pre-op for risk Screening pts. may allow for early interventions to reduce severity
Recommendation: Trial delirium risk assessment tool (DEAR) with elective total joint population age 65 and older to identify high risk for delirium. Phase 2 (future plans): On care units, patient screening every shift with use of Confusion Assessment Method (CAM)

4. Delirium Elderly At-Risk (DEAR) instrument is used to assess risk for developing post-operative delirium. 5 scoring domains are listed below:
Yes No
Patient age
Age > 80
Sensory Impairment
Patient uses hearing aid
and/or
has very low vision
Functional Dependence
Patient requires assistance with any of the following:
Bathing, dressing toileting, grooming, or feeding
Substance Use
Patient consumes >3 drinks of alcohol per week
Patient takes benzodiazepine >3 times/week
Cognition
Previous post-op delirium/confusion or
Failed Clock-drawing Score
A DEAR score of Yes > 1 places the patient at higher risk of developing post operative delirium.
The Target population for the screening is elective total joints age 65 and over. Patient age of = to or > 80 is a specific risk factor for delirium

5. DEAR Instrument Instructions
The circle is a clock face. Ask your patient to place numbers and hands (small and large) on the face so the time reads 10 minutes after three o’clock. The instructions:
May be repeated as often as requested
No other directions or assistance should be given
Do not cover up or conceal any time pieces in the room
After your patient has completed this task, you may score their efforts as pass or fail. Please review the following examples displaying pass and fail clocks.

6. Scoring Guidelines : Pass or Fail
Hands and numbers are all present in correct positions. Patient corrects without prompting are acceptable.
There are slight errors
in placement of hands OR
One missing number
without number spacing
errors.
Moderate errors in placement of hands, confusion with small and large hands OR
Number spacing errors alone.

7. Scoring Passed
Guidelines: Placement of hands is significantly off course OR Number spacing is inappropriate. Example: Even though there is bunching, distortion not grossly inappropriate. Typically seen in those who are cued to spatial mistakes once they get to the 6 (because they know it is supposed to be at the bottom), and make correction only to commit same error in subsequent numbers.

8. Score Fail
Guidelines:
Clock hands are used inappropriately OR
There is use of a digital display
Circling of numbers OR
Perseveration in writing of numbers
Example:
The clock hands are clearly pointing inward. This is scored 6, even though the 2 and 3 are correctly indicated, because there is clear evidence that problem solving how to correctly draw in the hands is lacking.

9. Score Fail
Example: Here is perseveration of numbers (3's and 8's). Only one example of perseverated numbers is needed for a score of 6. The hands are not included in this sample to focus on illustrating number perseveration.

10. Score Fail
Example: A digital representation of 3:10 is drawn. This is often drawn in the middle of the clock face, or even well outside of it.

11. Example: The numbers are circled to indicate 3:10.
Score Fail
Example: The numbers are circled to indicate 3:10.

12. Score Fail
Example: This is an inappropriate use of clock hands, where a straight line is drawn from the 3 to the 2, without use of the center of the clock.

13. Score Fail
Guidelines: Numbers are crowded to one end of the clock. Reversed in order or absent. Example: Numbers are reversed.

14. Score Fail
Example: All of the numbers are crowded into to one end of the clock face.

15. Score Fail
Guidelines: There is significant distortion in number sequences. Counterclockwise order many missing numbers OR Number placed outside of clock face border. Example: There are many added numbers. This tends to occur when the patient loses track of the task at hand (drawing the numbers for the clock) and continues to add numbers until they run out of space.

16. Example: Some numbers fall outside of the border
Score Fail
Example: Some numbers fall outside of the border

17. Score Fail
Example: Numbers placed outside of the clock face. Even if all other criteria are met.

18. Score Fail
Example: Prompting needed. This is a fairly common presentation of "drawing in the numbers". When this is seen, prompt the patient to put in numbers instead of dashes, allowing them to erase. This should not be scored unless the patient is unable to place the numbers at all, or is significantly confused by the directions.

19. Numbers and clock face are no longer connected in the drawing.
Score Fail
Only vague representation of a clock or irrelevant spatial representation exist.
Numbers and clock face are no longer connected in the drawing.

20. Result cannot be interpreted OR No attempt is made to draw a clock
Score Fail
Result cannot be interpreted OR
No attempt is made to draw a clock

21. DEAR scores >1 indicate patient is at higher risk for developing delirium.:
Yes No
Patient age
Age > 80 X
Sensory Impairment
Patient uses hearing aid
and/or
has very low vision
Functional Dependence
Patient requires assistance with any of the following:
Bathing, dressing toileting, grooming, or feeding
Substance Use
Patient consumes >3 drinks of alcohol per week
Patient takes benzodiazepine >3 times/week
Cognition
Previous post-op delirium/confusion or
Failed Clock-drawing Score
A DEAR score of Yes > 1 places the patient at higher risk of developing post operative delirium. 2
Be sure and total and score the YES answers on the bottom of the document. A score of over 1 means the patient is at risk for delirium.

22. Scores of over 1 are considered high risk.
Scoring DEAR Tool
Add up all of the yes scores on the left side of the tool and place score on bottom.
Scores of over 1 are considered high risk.
If a patient is scored to be at high risk for delirium, communicate this risk with the medical team.
Place High risk for delirium sticker on patient Care Plan (or write it yourself).

23. References
Feter, S., Dunbar, M., MacLeod, H., Morrison, M., MacKnight, C., et al. (2005) Predicting post- operative delirium in elective orthopaedic patients: the Delirium Elderly At-Risk (DEAR) instrument. Age and Ageing, 34(2),
HealthEast A3 team: Joe Clubb, Director Behavior Health, Dr. David Frenz; Dr. Alvin Holm, Jill Tusing RN Education, Nora McPherson, APRN, CNS.