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The Delirium Rating Scale

Its Use In Consultation-Liaison Research


PAULA T. TRZEPACZ , M.D.

In addition to diagnostic criteria, delirium research requires standardized instruments to measure


symptoms. This article reviews the literature about the Delirium Rating Scale (DRS), the most
widely used scale to assess delirium that has been translated into at least seven other languages.
The DRS has 10 items and is clinician-rated, but 7- or 8-item subscale adaptations have been
used for repeated measurements. It has high scale characteristics, including internal consistency,
validity, specificity, sensitivity and interrater reliability. The DRS distinguishes delirious from demented, schizophrenic, and depressed patients and is more accurate than cognitive tests in identifying delirium. Scores are sensitive to treatment of delirium. Principal components analyses find
one underlying dimension that can be subdivided into two or three components. The DRS has
been used in studies of phenomenology, physiology, treatment, outcome, and at-risk populations.
Tables summarize details from various studies. The DRS is used clinically and in research. It is
currently being revised to enhance its use in phenomenologic and treatment research.
(Psychosomatics 1999; 40:193204)

ASSESSMENT OF DELIRIUM
Delirium is a neuropsychiatric syndrome that involves a
number of symptoms, including diffuse cognitive impairment, psychosis, sleep-wake cycle disturbance, perceptual
disturbances, thought disorder, language impairment, and
mood lability. Symptoms of delirium typically have an
acute onset and tend to fluctuate in intensity throughout a
24-hour period. Its incidence averages about 18% to 20%
of patients admitted to general hospitals, though this figure
varies somewhat depending on the patient population and
methodology of the research.1 Despite its prevalence and
associated morbidity and mortality,1 delirium is understudied compared with dementias and other psychiatric
disorders. One of the methodological difficulties in studying delirium had been a dearth of appropriate symptomrating scales and lack of diagnostic criteria. DSM-III,
DSM-III-R, and DSM-IV diagnostic criteria have been
published as various revisions by the American Psychiatric
Association since 1980 and have been beneficial in that
Psychosomatics 40:3, May-June 1999

they list specific inclusion and exclusion criteria for diagnosing cases of delirium.2,3
Several instruments have been devised for health care
professionals or laypersons to screen for the presence of
symptoms of delirium, such as the Confusion Assessment
Method (CAM)4 and the Delirium Symptom Interview
(DSI),5 respectively. The CAM and DSI are reviewed in
more detail elsewhere.6,7 The CAM has four items that represent cardinal symptoms, three of which are required to
be present for a diagnosis of delirium. The CAM was originally reported to have sensitivity ranging from 94% to
100% and specificity ranging from 90% to 95%, compared
with diagnoses made by using DSM-III-R criteria. HowReceived August 26, 1998; revised November 24, 1998; accepted December 4, 1998. From the University of Mississippi Medical School,
Jackson, Mississippi. Previously published in similar form in Japanese in
Neuro-Psychiatric Review, Vol. 26, 1998, pp. 1631. Address correspondence and reprint requests to Dr. Trzepacz, Department of Psychiatry and
Human Behavior, University of Mississippi Medical Center, 2500 North
State St., Jackson, MS 39216; e-mail: ptrzepacz@psychiatry.umsmed.edu.
Copyright q 1999 The Academy of Psychosomatic Medicine.

193

The Delirium Rating Scale


ever, a subsequent study8 reported CAM sensitivity to be
68% when rated by nurses, compared with diagnoses made
by research physicians who used DSM-III-R criteria (and
the Delirium Rating Scale) to assess medically ill elderly
patients.
There are a few instruments that include a broad range
of delirium symptoms to detect and rate the severity of
those symptoms. Three scalesthe Saskatoon Delirium
Checklist,9 the Organic Brain Syndrome Scale,10 and the
Delirium Assessment Scale11are checklists that operationalize DSM-III criteria, with items rated on a mild-tomoderate severe continuum. In contrast, three other scales
rate symptoms by using descriptive choices for each item.
These are the Delirium Rating Scale,12 the Nurses Delirium
Rating Scale,13 and the Memorial Delirium Assessment
Scale (MDAS).14 The MDAS is intended for rapid serial
ratings of delirium severity but does not include items for
diagnosis. When compared with the DRS in 51 delirious
patients with AIDS or cancer, the MDAS showed a high
correlation to DRS total scores (r40.88, P,0.0001), while
its individual item correlations with DRS total scores
ranged from 0.50 to 0.78.14
The Delirium Rating Scale (DRS) is the most widely
used instrument for rating the severity of delirium with
validity, high interrater reliability, and substantial sensitivity and specificity. It is used for clinical and research purposes not only in the United States, but also in Canada,
Europe, South America, and Asia. The DRS has been translated into seven languages other than English. It was translated into French by Darius Razavi in Brussels, Mandarin
Chinese by Chia-Yih Liu in Taipei, Dutch by Herman Sno
in Amsterdam, Spanish by A. Bulbena in Barcelona, Italian
by Augusto Caraceni in Milan, Swedish by Walter Osika
in Karlskoga, and Japanese by Kunihiro Isse in Tokyo. The
DRS also may become available in Portugese and a language of India (being translated by Mahesh Tilwani in Gujarat).
This article reviews the literature involving the DRS,
including scale characteristics, analyses of scale items, and
studies on treatment, phenomenology, physiology, and outcome of delirium.
DELIRIUM RATING SCALE
Scale Description
The DRS is a 10-item rating scale (see Table 1) intended to be completed by a clinician with psychiatric
training to more sensitively detect the range of psychiatric
194

symptoms assessed by the scale. Thus, it most often has


been used by psychiatrists and research-trained psychiatric
or geriatric clinicians. Each item has specific descriptors
that can be scored from 0 to a maximum either of 2, 3, or
4 points, depending on the item. The sum of all item scores
comprises the total DRS score; the maximum possible
score is 32 points.
It is suggested that symptoms be rated over a 24-hour
period because of the fluctuating nature of delirium symptom severity and to better detect the disruption of the sleepwake cycle. With some adaptation, the DRS can be rated
for partial days. However, because the inherent waxing and
waning of symptom severity might falsely lead the rater to
conclude clinical improvement or worsening, smaller time
intervals for repeated ratings must be chosen carefully. In
addition, certain items are difficult to rate during repeated
administrations. This includes Item #1, temporal onset of
symptoms, because a judgment is required to determine
at what point during an episode to no longer take into account the characteristics of the initial symptom onset. For
example, when the episode no longer meets DSM criteria
for delirium, the rater might decide to rate Item #1 as 0
at that time. Though this possibility poses a rating dilemma, Item #1 does capture an important phenomenologic
characteristic of delirium, which contributes to the validity
of the scale and helps to differentiate delirium from other
psychiatric disorders, including dementia. The same issue
applies to the rating of Item #7, which requires a decision
about when the underlying medical cause of delirium is no
longer relevant. (A revised form of the DRS that is currently under study will address this problem for repeated
ratings.) In addition, some researchers have used partial
scale ratings when the DRS is used serially. For repeated
measures in a treatment study, Uchiyama et al.15 used a
subscale of 7 items (excluding temporal onset, physical
disorder, and fluctuation of symptoms) that was used after
the initial ratings. Nakamura et al.16 used an 8-item scale
(excluding temporal onset and physical disorder) for reTABLE 1.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Items on the Delirium Rating Scale

Temporal onset
Perceptual disturbances
Hallucinations
Delusions
Psychomotor behavior
Cognitive status
Physical disorder
Sleep-wake cycle disturbance
Lability of mood
Variability of symptoms

Psychosomatics 40:3, May-June 1999

Trzepacz
peated measurements in a drug treatment study of delirium.
Koolhoven et al.17 used a 7-item modified scale as a symptom checklist in an observational study by excluding two
items (temporal onset and physical disorder) and compressing perceptual disturbances and hallucinations into one
item.
The DRS was devised intentionally to reflect a broader
range of symptoms of delirium than was assessable by using only cognitive tests such as the Mini-Mental State
Exam (MMSE). Bedside cognitive tests alone cannot distinguish between different disorders that involve cognitive
impairment, for example, delirium and dementia. Instead,
assessment of a broad range of symptoms is necessary to
distinguish delirium from other cognitive disorders. This
includes assessing the severity and type of cognitive deficits, because different dementias affect different cognitive
functions at different stages of the illness (e.g., frontal lobe
dementias vs. Alzheimers dementia). One type of dementia Lewy body dementia has significant overlap with
delirium in its presentation, as does Alzheimers dementia
at its end-stage.
It was originally intended that the DRS be supplemented by whatever cognitive tests that the rater chooses.
The DRS has only one cognitive status item (Item #6) and
does not rate separate items for different components of
cognition (e.g., attention, memory, orientation). Though
this allows relatively more emphasis of noncognitive
symptoms, it may make the DRS less useful for phenomenological studies or repeated measurements.
Scale Attributes
The DRS has been studied in different settings and
found to have very good construct validity based on multiple lines of evidence, which are detailed in Table 2 and
Table 3 and in later sections of this article. These include
comparisons to expert diagnoses by using DSM criteria,
differences in DRS scores compared with other patient
groups, differences in DRS scores following standard delirium treatment when patients no longer meet DSM criteria for delirium, and correlations with ratings on other
scales (e.g., Brief Psychiatric Rating Scale [BPRS], cognitive tests, and global ratings) that assess some delirium
symptoms.
The DRS has excellent internal consistency, with a
Cronbachs alpha score of 0.90 in a study of elderly patients.18 In addition, principal components analysis of DRS
scores has shown that it has one major underlying dimension,19,20 supporting that it is measuring one overall conPsychosomatics 40:3, May-June 1999

struct. Moekken analysis performed by van der Mast21 in


postcardiotomy patients revealed a coefficient of reliability
Rho P4 0.81, HI item coefficients that were each .0.40,
and the H coefficient of scalability40.61, indicating a
strong hierarchical nature of the items of the scale. These
authors felt that the results of their Moekken analysis implicated that each DRS item was related to the severity of
delirium and, therefore, that the DRS can function as a
symptom severity scale.
Correlations of DRS items to other items have been
done in two studies. In 20 general medically ill delirious
patients, the cognitive item correlated highly with hallucinations (r40.44, P40.027); delusions (r40.63,
P40.001); psychomotor behavior (r40.48, P40.017);
sleep-wake cycle disturbance (r40.56, P40.0005); and
lability of mood (r40.60, P40.003) in one study.12 The
cognitive item correlated highly with psychomotor behavior (r40.41, P40.014), sleep-wake cycle disturbance
(r40.39, P40.02) and variability of symptoms (r40.38,
P40.023) in a study of 36 delirious postcardiotomy patients.21 In both studies, temporal onset of symptoms correlated significantly with perceptual disturbances (r40.44,
P40.028 in the former and r40.53, P40.001 in the latter).
There are a few studies about DRS items. One study
found individual DRS item scores to be significantly higher
in delirious than in moderately demented patients for all
items, except cognitive status, which was similar
(P40.022 for hallucinations and P,0.001 for other
items).19 In a comparison between elderly patients with
delirium and those with both delirium and dementia,20 only
the cognitive status item differentiated the groups, with
more impairment in the dual diagnosis group. Wada and
Yamaguchi22 reported that the presence of certain DRS
items predicted the duration of delirium episodes. Meagher
et al.23 subgrouped DRS items into subscales for core disturbances representing either cognitive impairment or behavioral management problems in a study of environmental manipulation as a delirium treatment.
Because the DRS does not rely on only cognitive
items, it is has been found to be superior to cognitive tests
alone in distinguishing delirium from other disorders. The
DRS, unlike the MMSE, distinguished delirium from dementia patients, and the DRS also distinguished delirium
from schizophrenia patients, unlike the Trailmaking
Tests.12 Receiver operating characteristic curve analyses
comparing the DRS with the MMSE in a study of 104
elderly delirious patients found the DRS to be significantly
more accurate than the MMSE in classifying delirium (area
195

196

Consecutive C-L patients in


general hospital in Ireland,
n446, mean age460

Geriatric psychiatry consults


Attending physicians plus
(n434) and geriatric medicine
independently rated DRS
inpatients (n470) in general
by a resident physician in
hospital in Nova Scotia
psychiatry or geriatric
medicine

Consecutive geriatric psychiatry


inpatients (n4791),
Mean5SD age47359, 3
groups studied: delirium
(n470), organic mental
disorder without delirium
(n4291), nonorganic
diagnosis (n4430)

General and psychiatric hospital


patients; delirious (n420),
demented (n49),
schizophrenic (n49), other
medically ill (n49);
mean5SD age of delirious:
59517 and of demented:
7854

Consecutive elderly in general


hospital geriatric psychiatry
unit (n462), mean age480.7
years, 50 had hyperactive
delirium and 12 had
hypoactive delirium; 25 had
preexisting dementia

Meagher et al.
(1996).

Rockwood et al.
(1996).

Rosen et al.
(1994)

Trzepacz et al.
(1988)

Uchiyama et al.
(1996)

Attending psychiatrists and


psychiatric residents

Trained research clinicians


(nonphyscians) who were
blind to final diagnosis

Clinicians

5 trained research assistants


(nonphysicians) who were
blind to diagnoses

Geriatric psychiatry inpatients,


n461, from 843 consecutive
admissions, mean age5SD:
7458

Trzepacz et al.
(1998).

DRS Raters

Sample

Delirium Rating Scale (DRS) characteristics in studies

Study

TABLE 2.

DSM-III criteria; boxplots


showed no overlap in DRS
scores between groups; DRS
not correlated with age; DRS
correlated with MMSE (r4
10.43, P40.033) and
Trailmaking Test part B
(r40.66, P40.007) in
delirium
Used DSM-IV criteria and a 7item DRS for repeated
measurements in a treatment
study after the initial rating;
baseline DRS scores did not
predict treatment
responsiveness

ICC 40.97

DSM-III-R criteria; compared


delirium to dementia, other
psychiatric, and a cognitively
unimpaired group; ROC curve
analysis showed DRS
significance higher than for
MMSE as a test for delirium;
Cronbachs alpha40.90 as a
test of internal consistency

ICD-10 delirium criteria; DRS


broken down into two
subscales: behavioral and
cognitive disturbances

DSM-III-R criteria; 45/56


patients had abnormal EEGs;
compared delirium with
delirious-demented patients

Other

DSM-III-R criteria; psychosis


and cognitive impairment
symptoms falsely elevated
DRS scores in organic mental
disorder group; only 4/70
delirious were false negatives;
32% were false positives in
organic mental disorder group
but these cases were more
likely to have abnormal EEG
and lower MMSE scores

Cutoff score410:
Sensitivity40.82
Specificity40.94
Cutoff score47.5:
Sensitivity40.90
Specificity40.82

Sensitivity and Specificity

ICC40.69 to 0.99 (range over


At cutoff $ 10:
study period) on DRS, BPRS,
Sensitivity40.94
and MMSE
Specificity40.82,
Predictive positives433%,
predictive negatives499%

ICC40.91

Intraclass correlation coefficient


(ICC) range during study
period was 0.59 to 0.75

Interrater Reliability

The Delirium Rating Scale

Psychosomatics 40:3, May-June 1999

Psychosomatics 40:3, May-June 1999

Goldstein and Fo- Postop elderly tested at Day 3,


Research assistants (trained
gel (1993)
n482; excluded demented panurses and psychologists)
tients and those with MMSE,23
preoperatively; mean5SD age:
6757

4 psychiatrists
General hospital psychiatric referrals (n476); alcohol withdrawal excluded; mean5SD
age: 69.5512.4
Nakamura et al.
(1994)

IR40.90

Clinical diagnosis of delirium;


modified DRS used (without 2
items) for repeated measures
over 7 days for drug treatment
study

DSM-III-R and DSM-III criteria


Consecutive acute geriatric admissions (n4168) to medical
wards in Nova Scotia, delirium
(n448), though half also demented; mean5SD age: 7958
Rockwood et al.
(1993)

Attending physicians and in half Interrater Reliability (IR)40.86


of cases a research physician did
an independent second DRS

Consecutive post-cardiotomy pa- One of two research psychiatrists


tients (n4296) in general hospital in the Netherlands; delirious
(n436) and non-delirious
(n4256); mean5SD age:
63511 (range: 2083)
Van der Mast
(1994)

DSM-III-R criteria; DRS on day


3 and on maximum day; high
discriminant ability; Moekken
analysis showed heirarchical
structure of DRS

Trzepacz
under the curve40.87 for the DRS, area test411.93,
P40.03).18
Though the DRS measures more than just cognition,
DRS scores have correlated with cognitive test scores in
general hospital samples. The DRS correlated with the
MMSE scores (r410.43, P40.033) and with Trailmaking Test part B scores (r40.66, P40.007) in 20 delirious
patients and with the MMSE scores (r410.78, P,0.01)
in 104 elderly delirious patients.18 In contrast, in a study
of 61 elderly delirious patients who were admitted to a
psychiatric hospital instead of a general hospital, there was
no correlation between the DRS and the MMSE
(r40.16).20 However, in that same study, the DRS was
significantly correlated with the BPRS in delirious
(r40.57, P40.017) and delirious-demented patients
(r40.35, P4 0.04). This finding suggests possible differences in the presentation of patients whose identified medical morbidity is lower and who are admitted to a psychiatric hospital instead of a general hospital.
Two studies have compared delirious, demented,
schizophrenic, and noncognitively impaired medically ill
patients and found little or no overlap in total DRS scores
among these groups when graphing scores on boxplots.18,20
Similarly, a study of postcardiotomy patients found very
little overlap in DRS scores graphed on boxplots between
the delirious and nondelirious patients;21 overlap was attributed to a methodological issue in the timing of the ratings. By using ROC analysis, Rockwood18 found the DRS
to be more accurate than the MMSE in classifying delirium
among groups of elderly patients with either delirium, dementia, or other psychiatric disorders.
Rosen et al.24 studied 791 consecutive geriatric psychiatry inpatients who were divided into three study
groups: delirium, dementia/organic mental disorder not
otherwise specified, and noncognitively impaired patients.
Rosen et al. reported that the DRS had a high predictive
negative value of 99%, but its predictive positive value was
only 33%, largely related to its difficulty differentiating the
other organic mental group from the delirium group due to
overlapping symptoms of psychosis and cognitive impairment. There were only 4 out of 70 false-negatives among
the delirium group, but 94 out of 291 other organic mental
disorder patients were rated as false-positives when using
a DRS cutoff of $10 points. However, these false-positives
in the other organic group were more likely to have significant electroencephalogram (EEG) abnormalities, with
Grades II and III dysrhythmias, higher BPRS psychosis
scores, and lower MMSE scores than the true-negatives in
that group. Abnormal EEGs of that severity are usually
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The Delirium Rating Scale


common in delirium and uncommon in dementia until very
late stages, which opens the possibility of misassignment
of patients who may have really been delirium cases and
were not truly false-positive cases. Their DRS ratings
were in the high 8-point range. In addition, differential diagnosis of organic mental disorders is especially difficult
in the elderly. This study used nonphysician DRS raters
whose interrater reliabilities were lower than in other studies that used physicians (for example, in Rockwood et al.,18
1996).
The DRS generally has high values for sensitivity and
specificity and high interrater reliability (see Table 2). Interrater reliabilities vary according to who does the ratings.
Highest ratings are for psychiatric and geriatric medical
physicians and range from 0.86 to 0.97. For nonphysicians
who are trained to use the DRS for research purposes, interrater reliability ranges from 0.59 to 0.99. Sensitivity and
specificity depends on the cutoff value used for the DRS.
In usage of a cutoff score of 10 points, sensitivity has been
reported at 0.94 and 0.82, and specificity at 0.94 and 0.82.
In usage of a cutoff score of 7.5 points, sensitivity has been
reported at 0.90 and specificity at 0.82.
Mean DRS scores for delirious patients are considerably higher than for demented or other diagnostic groups
of patients in many studies (see Table 3) across a broad
range of ages of adults who have a wide variety of delirium
etiologies, medical and surgical. Mean scores decrease
with treatment of delirium.15,16,2527 Mean DRS scores also
do not change when treatment is ineffective.15,26 DRS
scores can distinguish different motoric presentations of
delirium, that is, hyperactive and hypoactive subtypes, with
mixed presentations having intermediate scores between
them.23 Total DRS scores differentiated patients whose delirium episodes lasted more or less than 1 week,22 suggesting the score has predictive value as an outcome measure.
Factor Analysis of DRS Items
There are three studies of DRS items using principal
components analyses to better understand the relationship
between items of the scale and whether they reflect one or
more groupings.1921 In two studies, there seems to be a
single underlying dimension consistent with the DRS measuring a single construct, that is, the syndrome of delirium.
Trzepacz and Dew19 found one strong underlying dimension that could be further subdivided into two components
after Varimax rotation, in a study of 20 delirious adults seen
in a general hospital. One component was composed of
198

delusions, psychomotor behavior, cognition, sleep-wake


cycle disturbance, and mood lability; the other composed
of temporal onset of symptoms, perceptual disturbances,
hallucinations, and fluctuation of symptoms. Van der
Mast21 studied 40 postcardiotomy delirious patients and
found three underlying factors after Varimax rotation:
1) temporal onset of symptoms, perceptual disturbances,
delusions, and psychomotor behavior; 2) psychomotor behavior, cognitive dysfunction, sleep-wake cycle disturbance, and fluctuation of symptoms; and 3) physical disorder and absence of lability of mood. Van der Mast,
however, felt the third was an artifact because the most
severely physically ill patients were not ratable on the
mood lability item. Trzepacz et al.20 studied a psychogeriatric population, comparing delirious with deliriousdemented patients, and identified two core factors on the
DRS after Varimax rotation. A total of seven DRS items
were common to both groups, while three items did not
cluster similarly (hallucinations, cognition, and fluctuation
of symptoms). In addition, these delirious-only patients
factor structure was remarkably similar to that from a general hospital delirium sample from a general hospital sample.19 In both of these delirium samples, Factor 1 loaded
sleep-wake cycle disturbance, psychomotor behavior, and
mood lability, while Factor 2 loaded temporal onset, symptom variability, and perceptual disturbances.20 The three
items that loaded onto Factor 2 have been considered by
several experts to be highly associated with delirium, suggesting that the DRS analyses were detecting information
applicable to delirium phenomenology.
STUDIES USING THE DRS
In addition to reports about scale characteristics or DRS
item analyses, the DRS has been used in research studies
and as an assessment instrument in at-risk populations.
These include studies about phenomenology, physiology,
outcome, and treatment.
Phenomenology Studies
Platt et al.27 studied motoric subtypes of 24 hospitalized delirious AIDS patients by using DSM-III-R criteria
and repeated DRS measurements. All had DRS scores .12
points prior to treatment with either haloperidol or chlorpromazine. Nine were considered hyperactive and 11 hypoactive in presentation based on clinical judgment and a
score of at least .1 point on the DRS psychomotor item.
Both the hyperactive and hypoactive groups responded
Psychosomatics 40:3, May-June 1999

Trzepacz
within hours of treatment with either antipsychotic drug
(even before the underlying medical problems were corrected), as evidenced by significant declines in their DRS
scores (P,0.001 for each subtype). Platt et al. suggested
that both motoric subtypes respond equally well to dopamine blockade.
Rockwood28 studied the occurrence and duration of
symptoms in 173 elderly medical inpatients in Camp Hill
Hospital, Nova Scotia. Many had concurrent dementia.
DSM-III and DSM-III-R criteria and DRS ratings were applied on admission. Delirious patients mean5standard deviation (SD) age was 8258 years and mean5SD DRS
score was 1754 points; nondelirious patients mean5SD
age was 7958. Rockwood28 found that DSM-III-R had
better sensitivity and DSM-III had better specificity in delirium diagnosis, compared with a clinical gold standard.
In addition, some delirium symptoms were found to persist
at discharge after the episode had ended.
Uchiyama et al.15 used the DRS to compare drug response between hyperactive and hypoactive presentations
of delirium in their study of 62 delirious elderly. The researchers found that 80.6% were hyperactive and 19.4%
were hypoactive on the basis of clinical observation. The
hyperactive patients responded better to mianserin than did
the hypoactive patients (P,0.05). Medication response
was defined as improvement on item scores for $4 DRS
items with worsening on #2 items. DRS scores for each
motoric subtype were not reported.
Meagher et al.23 studied hypoactive, mixed, and hyperactive subtypes in 46 delirious inpatients. By using International Classification of Diseases (ICD)-10 criteria and
Liptzin and Levkoffs definition of motoric subtypes, the
researchers found significantly higher (P,0.01) DRS
scores in hyperactive and lower (P,0.01) scores in hypoactive than in mixed subtypes (see Table 3). In addition,
the hyperactive group required significantly more nursing
management interventions (P,0.05) and hypoactive less
(P,0.01) than the mixed group. The hyperactive group
(93%) also received more psychotropic drugs prior to consultation.
Physiology Studies
In a drug treatment study of delirious patients, Nakamura et al.16 measured plasma-free 4-methoxy-3-hydroxyphenylethylene glycol (MHPG) and homovanillic acid levels. The researchers found a significant reduction in plasma
free-MHPG over time in all delirious patients, regardless
of drug treatment using mianserin, oxypertine, or haloperPsychosomatics 40:3, May-June 1999

idol. This reduction paralleled a decrease in DRS scores,


indicating that reducation in delirium severity was associated with decreased plasma-free MHPG.
Tanaka et al.29 used the DRS in a study of the role of
cerebrospinal fluid (CSF) prostaglandin D2 and E2 levels
in the sleep-wake mechanism of delirium. Seven inpatients
at Tokyo Metropolitan Tama General Hospital (mean age:
78.4) who had delirium were compared with 7 agematched controls (mean age: 74.9) without neurologic or
psychiatric problems. DSM-III-R criteria were used for diagnosis, and the DRS was used serially. Mean DRS
score424 points. The researchers found that CSF prostaglandin D2 was significantly higher in the delirious patients
than in the control subjects.
At-Risk Population Studies
The DRS has been used to assess the presence of delirium symptoms in at-risk medical populations. DiMartini
and colleagues30 used the DRS in studies of liver transplant
patients at the University of Pittsburgh Medical Center. In
a comparison of two immunosuppressant drugs, cyclosporine A and FK506 (tacrolimus), DRS scores were in the
nondelirious range (see Table 3), despite the presence of
neuropsychiatric symptoms known to be associated with
toxicity of these drugs.30 Some patients scored below 24
points on the MMSE and above 80 seconds on Trailmaking
Test part B. This finding suggests some specificity for the
DRS regarding the symptoms it detects. In a randomized
comparison study of FK506 and cyclosporine A, DiMartini
et al.31 described 31 orthotopic liver transplant patients
cross-sectionally 1 week postop (mean5SD age: 4059).
DRS scores were in the nondelirious range in both drug
groups, with only 2 patients scoring above 12 points (19
and 22 points), both in the FK506 group. MMSE scores
were also in the unimpaired range, though some patients
had impairment on the Trailmaking tests.
Goldstein and Fogel32 used the DRS to assess 82 elderly patients (mean5SD age: 6757) undergoing elective
surgery at State University of New York, Buffalo, School
of Medicine, as part of a longitudinal study. Patients whose
MMSE score was ,23 points preoperatively were excluded from the study. Mean5SD DRS score at Day 3
postop was 2.1752.73 (range: 016) and only one patients DRS score was in the delirium range. The researchers found that a combination of preop MMSE scores and
an MMSE change score (between preop and postop) accounted for most of the variance in MMSE scores that were
measured at a 10-month follow-up. This finding suggests
199

The Delirium Rating Scale

TABLE 3.

Delirium Rating Scale (DRS) scores reported in different patient populations

Authors

Diagnosis (n)

Trzepacz et al. (1988)

Delirious (20)
Demented (9)
Schizophrenic (9)
Other medical (9)

DRS scores (mean5SD)


2354.8
4.652.1
3.351.6
0.6750.5

Trzepacz et al. (1998)

Delirious (18)
Delirious-demented (43)

13.655.2
14.254.0

Rockwood et al. (1996)

Delirious (36)
Demented (16)
Other psychiatric (18)
Cognitively normal (27)

17.157.6
6.454.5
3.451.5
2.252.6

Rockwood et al. (1993)

Delirious (48)
Nondelirious controls (125)

Goldstein and Fogel (1993)

DRS Scores Range


1230
17
27
01

17.054.0
Not reported

1027

Mild postoperative cognitive impaired,


nondemented elderly (82)

2.1752.73

016

Rosen et al. (1994)

Delirious (70)
Other organic mental disorders (291)
Nonorganic psychiatric (430)

14.553.8
8.853.6
5.652.8

726

Tanaka et al. (1993)

Delirium (7)

Wada and Yamaguchi (1993)

Delirium (28):
Duration .1 week (16)
Duration #1 week (12)

DiMartini et al. (1991)

Post-operative liver transplant:


On FK506 (14)
On cyclosporine (10)

Nakamura et al. (1994)a

Meagher et al. (1996)

DiMartini et al. (1997)

Breitbart et al. (1996)

200

Delirium (76):
Mianserin (46)
Baseline
Day 5
Oxypertine (17)
Baseline
Day 1
Haloperidol (13)
Baseline
Day 5
Delirium (46):
Hyperactive (14)
Hypoactive (11)
Mixed (21)
Postoperative liver transplant:
On FK506 (17)
On cyclosporine (14)
Delirium (30):
Baseline
Day 2
End of treatment
Baseline haloperidol (11)
Day 2 haloperidol
End day haloperidol
Baseline chlorpromazine (13)
Day 2 chlorpromazine
End day chlorpromazine
Baseline lorazepam (6)
Day 2 lorazepam
End day lorazepam

24
16.553.3
18.452.71
14.051.86

12-25

756
552

21.251.0
8.050.9
20.150.8
12.351.3
22.051.3
9.551.4
20.255
24.153.9
15.052.3
20.154.2
6.255.5
4.651.5
20.153.5
13.356.1
12.856.4
20.553.5
12.555.9
11.656.1
20.653.9
12.156.5
11.956.7
18.352.6
17.354.2
17.055.0

Only two cases in delirious range


(19 and 22 points)

1428
326
326

Psychosomatics 40:3, May-June 1999

Trzepacz

TABLE 3.

Delirium Rating Scale (DRS) scores reported in different patient populations (continued)

Authors

Diagnosis (n)

Uchiyama et al. (1996)a

Delirium (62):
Mianserin responders
Mianserin nonresponders
Delirium (64):
Single day (43)
First day (20)

22.654.4
25.453.6

Delirium (43):
Admission
Discharge

14.5
6.6

Masand and Sipahimalani


(1998)

Delirious (22):
Baseline haloperidol (11)
Post haloperidol
Baseline olanzapine (11)
Post olanzapine

20.155.0
11.157.1
17.954.4
10.354.8

Van der Mast (1994)

Delirious (36):
Postop day 3
Maximum
Nondelirious (256):
Postop day 3
Maximum

Rudberg et al. (1997)

Albronda et al. (1996)

DRS scores (mean5SD)

DRS Scores Range

21.953.2
22.253.3
1431
18-32

729
13.857.2
19.055.7
111
4.151.7
4.451.9

Notes that a modified DRS was used.

that the decline in cognitive function following surgery in


these nondemented elderly was not related to delirium, but
rather to some other vulnerability for the later decline.
Outcome Studies
Albronda et al.25 studied 43 elderly patients (mean
age: 78.5) hospitalized on a geriatric unit at Ziekenhuis
Rijnstate in Arnhem, Netherlands, who had a recent change
in mental status. By using DSM-III-R criteria for diagnosis,
28 had delirium, 23 dementia, 6 depression, and 21 multiple problems. The mean DRS was 14.5 points within 3
days of admission and 6.6 at discharge (P,0.001 for this
difference in scores). Despite improvement in most patients conditions they found that those admitted for recent
mental status changes were at increased risk for nursing
home placement after discharge 53%, compared with
13%, for geriatric admissions in general. The researchers
did not report any predictive data for the DRS, however.
Wada and Yamaguchi22 studied 28 elderly patients
who met DSM-III-R criteria for delirium (mean5SD age:
67.759.1, range: 5083 years) who were referred to the
Neuropsychiatric Unit of Kanazawa University Hospital.
The DRS was administered the first day of admission. The
patients were followed throughout their hospitalization and
divided into groups according to a clinical assessment of
duration of the delirium episode. In 16 patients, delirium
Psychosomatics 40:3, May-June 1999

lasted more than 1 week. There was no difference in age


or gender for the patients whose delirium lasted #1 week
or .1 week, but DRS scores differentiated these groups
(14.0 vs. 18.27, respectively; P,0.001). In addition, the
group with shorter episodes had significantly lower scores
for three DRS items: cognitive status (P,0.05), sleepwake cycle disturbance (P,0.005), and mood lability
(P,0.005). No comment was made about treatment for
delirium, though usual care was implied. These authors
suggested that the DRS may predict one dimension of delirium outcome (i.e., episode duration).
Rockwood et al.8 studied the outcome of educational
interventions to recognition of delirium by housestaff at
Victoria General Hospital in Dalhousie, Nova Scotia.
Medical records were reviewed to compare 187 elderly
control patients consecutively admitted before the educational intervention with 247 patients admitted thereafter.
Housestaff were educated about delirium and in how to use
the CAM. Recognition of delirium or acute confusion, as
documented in the record, was the outcome measure. An
independent assessment was done by research nurses who
used the CAM and by research physicians who completed
both the CAM and the DRS. The CAM had a low sensitivity (0.68), compared with research physicians diagnosis
of delirium using DSM-III-R. The educational intervention
had a significant impact on housestaff recognition of delirium. However, when compared with diagnosis by research
201

The Delirium Rating Scale


physicians, housestaff recognition had a sensitivity of 0.64
and specificity of 0.93. DRS scores were not reported.
Rudberg et al.33 studied 432 elderly consecutively admitted to medical and surgical wards of the University of
Chicago Hospitals to assess characteristics of presentation,
course, and duration of delirium. After using the CAM and
attention tests to screen cases daily to identify possible delirium, research clinicians independently used DSM-III-R
criteria for definitive diagnosis. Those identified as being
delirious (about 15%) were rated daily by using the DRS
to describe attributes of the delirium. The researchers found
that 69% had delirium only for 1 day and that DRS scores
were significantly higher for the first day (mean5SD:
25.453.6) if the delirium lasted multiple days than if it
lasted only 1 day (mean5SD: 22.654.4), suggesting that
more severe delirium episodes last longer. The researchers
found no patterns of change among mean scores for individual DRS items over the multiple days, instead finding
much interindividual variation for symptoms that was attributed to physiological differences from multiple medical
diagnoses (mean5SD: 6.352.3 per patient) and multiple
medications (mean5SD: 6.952.6 per patient). Effects on
DRS items related to whether and how delirium was treated
were not discussed.
Treatment Studies
Nakamura et al.16 studied 53 delirious patients referred
for psychiatric consultation at Kurume University Hospital.
Alcohol withdrawal patients were excluded. Their
mean5SD age was 69.5512.4 years. The patients were
rated serially using a modified DRS (without items #1 and
7) and treated with either mianserin (n446), oxypertine (a
phenylpiperazine antipsychotic) (n417), or haloperidol
(n413). Mean5SD DRS scores (see Table 3) decreased
in each drug group over time, though no statistical comparisons were made between treatment groups nor were
survival analyses performed. It was not mentioned whether
patients were randomized to drug treatments or if the DRS
was rated blind to treatment status. Each evening throughout the study period, a single dose of drug was given. DRS
scores correlated with plasma mianserin levels (r40.67,
P,0.01) on Day 3 of treatment. The calculated difference
between baseline DRS scores and Day 3 scores was inversely correlated with mianserin plasma levels
(r410.67, P,0.01), suggesting that mianserin was related to delirium reduction.
Uchiyama et al.15 did an open trial of mianserin (10
60 mg) treatment of delirium in 62 elderly patients hospi202

talized on a psychogeriatric unit of a general hospital,


whose mean age was 80.7 years. DSM-IV categories for
delirium etiology were used. Twenty-five of these patients
(40.3%) also had a preexisting dementia, and 8 were continued on benzodiazepine hypnotics or morphine. Of the
31 patients who had not responded to psychotropic treatment of their delirium episode, only 25 had received an
antipsychotic (drug or dose was not reported). A 7-item
DRS was used for repeated measurements, with clinical
improvement determined by improvement on at least four
items and worsening on two or fewer items. Baseline5SD
DRS scores did not predict response to mianserin
(21.953.2 and 22.253.3). Rate of improvement on DRS
items included psychomotor behavior (85.5%), hallucinations (80.6%), sleep-wake cycle disturbance (82.3%), lability of mood (81.4%), delusions (79.6%), perceptual disturbances (67.7%), and cognitive status (48.4%). It was
hypothesized that mianserins H1 and 5-HT2 blocker activity might differentially affect certain delirium symptoms.
Breitbart et al.26 did a double-blind, randomized comparison of haloperidol, chlorpromazine, and lorazepam for
delirium in hospitalized AIDS patients at Memorial-Sloan
Kettering Cancer Center in New York City. DSM-III-R criteria and a score of $13 on the DRS were used to diagnose
delirium in a prospectively assessed cohort of 244 patients,
30 of whom (12%) became delirious. MMSE scores were
used to guide the rating of the DRS cognitive status item.
The patients were rated hourly on the DRS during drug
treatment and, when scores exceeded 13 points, the next
drug dosage was administered. The randomization to lorazepam was stopped halfway through the study because all
those patients developed treatment-limiting adverse effects
(e.g., increased confusion, sedation). They also showed no
clinical improvement over the study period. DRS scores
(see Table 3) significantly improved in each of the haloperidol and chlorpromazine groups between baseline and
Day 2, producing DRS scores below the delirium cutoff
value within the first 24 hours of treatment. The mean dose
of drugs given during the first 24 hours was 2.8 mg for
haloperidol, 50 mg for chlorpromazine, and 3.0 mg for
lorazepam.
Masand et al.34 retrospectively completed the DRS
based on chart reviews in a nonrandomized naturalistic
comparison of delirious psychiatric patients treated with
either haloperidol (n411, mean5SD age: 63.5518.3)
or olanzapine (n411, mean5SD age: 63.5523.2).
Mean5SD pretreatment DRS scores were 20.155 for
haloperidol and 17.954.4 for olanzapine. Mean5SD
Psychosomatics 40:3, May-June 1999

Trzepacz
posttreatment DRS scores were 11.157.1 for haloperidol
and 10.354.8 for olanzapine. Clinical improvement was
similar in each group, though there were methodological
issues, including nonrandomization, simultaneous use of
other neuroleptics in the olanzapine group, and delirium
being comorbid with other Axis I diagnoses that share
some of its symptoms.
Meagher et al.23 examined the pattern and frequency
of use of environmental interventions and psychotropic
drug use in delirium management. Consecutive referrals to
a consultation-liaison (C-L) psychiatry service in a large
general hospital in Dublin were prospectively assessed for
delirium by using ICD-10 criteria for diagnosis and the
DRS for symptom severity. Mean5SD age of the sample
was 60.1519.5 years, and mean5SD DRS was
20.1754.98. The patients received a mean5SD of
4.0451.87 nursing interventions. When separated into
high and low intervention groups (using cutoff of four interventions), the high group was found to have greater delirium severity (P,0.01), though the DRS score was not
reported. The DRS was also divided into two core subscales: cognitive, which included cognitive status, delusions, and hallucinations, and behavioral management,
which included psychomotor behavior, sleep-wake cycle
disturbance, and mood lability. Nursing intervention scores
were significantly associated (P,0.01) with the DRS behavioral management core scores but not with cognitive
core scores.
REVISION OF THE DRS
The DRS is very useful clinically, and its routine use can
enhance the detection of delirium symptoms as well as assist trainees to appreciate the breadth of the delirium syndrome. Use of the DRS for research purposes has highlighted some of its shortcomings. To be more useful as a
research tool, the DRS needs to be revised by separating
items more relevant for diagnosis from items more related
to symptom severity, which will allow its use during re-

peated serial ratings in intervention studies. To be used to


advance phenomenologic research of delirium, the DRS
needs to be more comprehensive in its ability to detect
abnormalities of cognitive, behavioral, thinking, and language functions that have been described in the clinical
literature.
Thus, the revised DRS will include separate items for
each cognitive function (disorientation, attention, memory,
etc.), irrespective of whether formal, standardized cognitive tests are administered as an adjunct. The revised DRS
will separate psychomotor items into one for hyperactive
and one for hypoactive states. It will add items that each
rate the severity of thought process and language abnormalities, to address what constitutes the problems that are
traditionally represented by the terms confusion or
clouding of consciousness.
The revised DRS is now being validated against the
original DRS and will become available for translation and
international crossvalidation during 1999.
CONCLUSIONS
C-L research requires standardized rating instruments to
measure symptoms and improve methodological quality.35
Delirium is still an understudied disorder and is of major
clinical importance to C-L psychiatrists. The DRS is the
most widely used and best studied of instruments designed
specifically for use in delirium. It has been shown to have
excellent scale characteristics and reliability, to serve as a
symptom severity scale, and to be responsive to change in
delirium status during treatment. Recommended cutoff
score for the DRS is about 12 points, though choosing a
cutoff score also depends on the study design, in which
sensitivity or specificity may be affected by context or
comparison groups.
Though the revised DRS will be better suited for phenomenological and treatment studies of delirium, the original DRS will still be useful and valid for clinical and research purposes in C-L psychiatry.

References

1. Trzepacz PT: Delirium: Advances in diagnosis, pathophysiology,


and treatment. Psychiatr Clin North Am 1996;19:429448
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC,
American Psychiatric Association, 1987
3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American
Psychiatric Association, 1994

Psychosomatics 40:3, May-June 1999

4. Inouye SK, van Dyke CH, Alessi C, et al: Clarifying confusion:


the confusion assessment method. Ann Intern Med 1990; 113:941
948
5. Albert MS, Levkoff SE, Reilly C, et al: The Delirium Symptom
Interview: an interview for the detection of delirium symptoms in
hospitalized patients. J Geriatr Psychiatry Neurol 1992; 5:1421
6. Musselman DL, Hawthorne CN, Stoudemire A: Screening for delirium: a means to improved outcome in hospitalized elderly pa-

203

The Delirium Rating Scale


tients. Reviews in Clinical Gerontology 1997; 7:23556
7. Trzepacz PT: A review of delirium assessment instruments. Gen
Hosp Psychiatry 1994; 16:397405
8. Rockwood K, Cosway S, Stolee P, Kydd D, et al: Increasing the
recognition of delirium in elderly patients. J Am Geriatr Soc 1994;
42:252256
9. Miller PS, Richardson JS, Jyu CA, et al: Association of low serum
anticholinergic levels and cognitive impairment in elderly presurgical patients. Am J Psychiatry 1988; 145:3425
10. Berrgren D, Gustafson Y, Eriksson B, et al: Postoperative confusion
following anesthesia in elderly patients treated for femoral neck
fractures. Anesth Analg 1987; 1394:497504
11. OKeeffe ST: Rating the severity of delirium: the Delirium Assessment Scale. Int J Geriatr Psychiatry 1994; 9:551956
12. Trzepacz PT, Baker RW, Greenhouse J: A symptom rating scale for
delirium. Psychiatr Res 1988; 23:8997
13. Rutherford L, Sessler CN, Levenson JL, et al: Prospective evaluation of delirium and agitation in a medical intensive care unit. Crit
Care Med 1991; 19(suppl):S81
14. Breitbart W, Rosenfeld B, Roth A, et al: The Memorial Delirium
Assessment Scale. J Pain Symptom Manage 1997; 13:128137
15. Uchiyama M, Tanaka K, Isse K, et al: Efficacy of mianserin on
symptoms of delirium in the aged: an open trial study. Progress in
Neuro-Psychopharmacology & Biological Psychiatry 1996;
20:651656
16. Nakamura J, Uchimura N, Yamada S, et al: Effects of mianserin
hydrochloride on delirium: comparison with effects of oxypertine
and haloperidol. Japanese J Psychopharmacology 14:269
277;1994
17. Koolhoven I, Tjon-A-Tsien MRS, van der Mast PC: Early diagnosis
of delirium after cardiac surgery. Gen Hosp Psychiatry 1996;
18:448451
18. Rockwood K, Goodman J, Flynn M, et al: Cross-validation of the
Delirium Rating Scale in older patients. J Am Geriatr Soc 1996;
44:839842
19. Trzepacz PT, Dew MA: Further analyses of the Delirium Rating
Scale. Gen Hosp Psychiatry 1995; 17:7579
20. Trzepacz PT, Mulsant BH, Dew MA, et al: Is delirium different
when it occurs in dementia: A study using the Delirium Rating
Scale. J Neurospsychiatry Clin Neurosci 1998; 10:199204
21. van der Mast RC: Detecting and measuring the severity of delirium

204

with the symptom rating scale for delirium, in Delirium After Cardiac Surgery. Amsterdam, The Netherlands, Benecke Consultants,
1994, pp 7889
22. Wada Y, Yamaguchi N: Delirium in the elderly: relationship of
clinical symptoms to outcome. Dementia 1993; 4:113116
23. Meagher D, OHanlon D, OMahony E, et al: The use of environmental strategies and psychotropic medication in the management
of delirium. Br J Psychiatry 1996; 168:512515
24. Rosen J, Sweet RA, Mulsant BH, et al: The DRS in a psychogeriatric inpatient setting. J Neuropsychiatry Clin Neurosci 1994;
6:3035
25. Albronda T, Bruijns E, Willekens FL: Diagnosis and discharge destination of patients admitted for mental dysfunctioning in a geriatric
department. Nederlands Tijdschrift voor Geneeskunde 1996;
140:19931996
26. Breitbart W, Marotta R, Platt MM, et al: A double-blind trial of
haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996;
153:231237
27. Platt MM, Breitbart W, Smith M, et al: Efficacy of neuroleptics for
hypoactive delirium. J Neuropsychiatry Clin Neurosci 1994; 6:66
28. Rockwood K: The occurrence and duration of symptoms in elderly
patients with delirium. J Gerontol Med Sci 1993; 48:162166
29. Tanaka K, Mitsushio H, Isse K, et al: A clinical study of prostaglandin D2 in cerebrospinal fluid of elderly patients with delirium.
Ann Rep Pharmacopsychiat Res Found 1993; 24:1421
30. DiMartini AF, Pajer K, Trzepacz PT, et al: Psychiatric morbidity
in liver transplant patients. Transplant Proc 1991; 23:31793180
31. DiMartini AF, Trzepacz PT, Pajer KA, et al: Neuropsychiatric side
effects of FK506 vs. cyclosporine A: first week postoperative findings. Psychosomatics 1997; 38:565569
32. Goldstein MZ, Fogel BS: Cognitive change after elective surgery
in nondemented older adults. Am J Geriatric Psychiatry 1993;
1:118125
33. Rudberg MA, Pompei P, Foreman MD, et al: The natural history
of delirium in older hospitalized patients: a syndrome of heterogeneity. Age Aging 1997; 26:169174
34. Masand P, Sipahimalani A: Olanzapine in the treatment of delirium.
Psychosomatics 1998; 39:422429
35. Trzepacz PT: Neuropathophysiology of delirium: a need to focus
our research. Psychosomatics 1994; 35:374391

Psychosomatics 40:3, May-June 1999