TRZEPACZ et al.

DELIRIUM RATING SCALE-R-98 (DRS-R-98)

This is a revision of the Delirium Rating Scale (Trzepacz et al. 1988). It is used for initial assessment and repeated measurements of delirium
symptom severity. The sum of the 13 item scores provides a severity score. All available sources of information are used to rate the items
(nurses, family, chart) in addition to examination of the patient. For serial repeated ratings of delirium severity, reasonable time frames
should be chosen between ratings to document meaningful changes because delirium symptom severity can fluctuate without interven-
tions.

DRS-R-98 SEVERITY SCALE

1. Sleep-wake cycle disturbance

Rate sleep-wake pattern using all sources of information, including from family, caregivers, nurses’ reports, and patient. Try to distinguish
sleep from resting with eyes closed.
0. Not present
1. Mild sleep continuity disturbance at night or occasional drowsiness during the day
2. Moderate disorganization of sleep-wake cycle (e.g., falling asleep during conversations, napping during the day or several brief
awakenings during the night with confusion/behavioral changes or very little nighttime sleep)
3. Severe disruption of sleep-wake cycle (e.g., day-night reversal of sleep-wake cycle or severe circadian fragmentation with multiple
periods of sleep and wakefulness or severe sleeplessness.)

2. Perceptual disturbances and hallucinations

Illusions and hallucinations can be of any sensory modality. Misperceptions are “simple” if they are uncomplicated, such as a sound,
noise, color, spot, or flashes and ‘‘complex’’ if they are multidimensional, such as voices, music, people, animals, or scenes. Rate if reported
by patient or caregiver, or inferred by observation.
0. Not present
1. Mild perceptual disturbances (e.g., feelings of derealization or depersonalization; or patient may not be able to discriminate dreams
from reality)
2. Illusions present
3. Hallucinations present

3. Delusions
Delusions can be of any type, but are most often persecutory. Rate if reported by patient, family or caregiver. Rate as delusional if ideas
are unlikely to be true yet are believed by the patient who cannot be dissuaded by logic. Delusional ideas cannot be explained otherwise
by the patient’s usual cultural or religious background.
0. Not present
1. Mildly suspicious, hypervigilant, or preoccupied
2. Unusual or overvalued ideation that does not reach delusional proportions or could be plausible
3. Delusional

4. Lability of affect
Rate the patient’s affect as the outward presentation of emotions and not as a description of what the patient feels.
0. Not present
1. Affect somewhat altered or incongruent to situation; changes over the course of hours; emotions are mostly under self-control
2. Affect is often inappropriate to the situation and intermittently changes over the course of minutes; emotions are not consistently
under self-control, though they respond to redirection by others
3. Severe and consistent disinhibition of emotions; affect changes rapidly, is inappropriate to context, and does not respond to redi-
rection by others

5. Language
Rate abnormalities of spoken, written or sign language that cannot be otherwise attributed to dialect or stuttering. Assess fluency, grammar,
comprehension, semantic content and naming. Test comprehension and naming nonverbally if necessary by having patient follow com-
mands or point.
0. Normal language
1. Mild impairment including word-finding difficulty or problems with naming or fluency
2. Moderate impairment including comprehension difficulties or deficits in meaningful communication (semantic content)
3. Severe impairment including nonsensical semantic content, word salad, muteness, or severely reduced comprehension

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6. Thought process abnormalities

Rate abnormalities of thinking processes based on verbal or written output. If a patient does not speak or write, do not rate this item.
0. Normal thought processes
1. Tangential or circumstantial
2. Associations loosely connected occasionally, but largely comprehensible
3. Associations loosely connected most of the time

7. Motor agitation
Rate by observation, including from other sources of observation such as by visitors, family and clinical staff. Do not include dyskinesia,
tics, or chorea.
0. No restlessness or agitation
1. Mild restlessness of gross motor movements or mild fidgetiness
2. Moderate motor agitation including dramatic movements of the extremities, pacing, fidgeting, removing intravenous lines, etc.
3. Severe motor agitation, such as combativeness or a need for restraints or seclusion

8. Motor retardation
Rate movements by direct observation or from other sources of observation such as family, visitors, or clinical staff. Do not rate components
of retardation that are caused by parkinsonian symptoms. Do not rate drowsiness or sleep.
0. No slowness of voluntary movements
1. Mildly reduced frequency, spontaneity or speed of motor movements, to the degree that may interfere somewhat with the
assessment.
2. Moderately reduced frequency, spontaneity or speed of motor movements to the degree that it interferes with participation in
activities or self-care
3. Severe motor retardation with few spontaneous movements.

9. Orientation
Patients who cannot speak can be given a visual or auditory presentation of multiple choice answers. Allow patient to be wrong by up
to 7 days instead of 2 days for patients hospitalized more than 3 weeks. Disorientation to person means not recognizing familiar persons
and may be intact even if the person has naming difficulty but recognizes the person. Disorientation to person is most severe when one
doesn’t know one’s own identity and is rare. Disorientation to person usually occurs after disorientation to time and/or place.
0. Oriented to person, place and time
1. Disoriented to time (e.g., by more than 2 days or wrong month or wrong year) or to place (e.g., name of building, city, state), but
not both
2. Disoriented to time and place
3. Disoriented to person

10. Attention
Patients with sensory deficits or who are intubated or whose hand movements are constrained should be tested using an alternate modality
besides writing. Attention can be assessed during the interview (e.g., verbal perseverations, distractibility, and difficulty with set shifting)
and/or through use of specific tests, e.g., digit span.
0. Alert and attentive
1. Mildly distractible or mild difficulty sustaining attention, but able to refocus with cueing. On formal testing makes only minor
errors and is not significantly slow in responses
2. Moderate inattention with difficulty focusing and sustaining attention. On formal testing, makes numerous errors and either requires
prodding to focus or finish the task
3. Severe difficulty focusing and/or sustaining attention, with many incorrect or incomplete responses or inability to follow instruc-
tions. Distractible by other noises or events in the environment

11. Short-term memory

Defined as recall of information (e.g., 3 items presented either verbally or visually) after a delay of about 2 to 3 minutes. When formally
tested, information must be registered adequately before recall is tested. The number of trials to register as well as effect of cueing can be
noted on scoresheet. Patient should not be allowed to rehearse during the delay period and should be distracted during that time. Patient
may speak or nonverbally communicate to the examiner the identity of the correct items. Short-term deficits noticed during the course of
the interview can be used also.
0. Short-term memory intact
1. Recalls 2/3 items; may be able to recall third item after category cueing
2. Recalls 1/3 items; may be able to recall other items after category cueing
3. Recalls 0/3 items

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 TRZEPACZ et al.

12. Long-term memory

Can be assessed formally or through interviewing for recall of past personal (e.g., past medical history or information or experiences that
can be corroborated from another source) or general information that is culturally relevant. When formally tested, use a verbal and/or
visual modality for 3 items that are adequately registered and recalled after at least 5 minutes. The patient should not be allowed to
rehearse during the delay period during formal testing. Make allowances for patients with less than 8 years of education or who are
mentally retarded regarding general information questions. Rating of the severity of deficits may involve a judgment about all the ways
long-term memory is assessed, including recent and/or remote long-term memory ability informally tested during the interview as well
as any formal testing of recent long-term memory using 3 items.
0. No significant long-term memory deficits
1. Recalls 2/3 items and/or has minor difficulty recalling details of other long-term information
2. Recalls 1/3 items and/or has moderate difficulty recalling other long-term information
3. Recalls 0/3 items and/or has severe difficulty recalling other long-term information

13. Visuospatial ability

Assess informally and formally. Consider patient’s difficulty navigating one’s way around living areas or environment (e.g., getting lost).
Test formally by drawing or copying a design, by arranging puzzle pieces, or by drawing a map and identifying major cities, etc. Take
into account any visual impairments that may affect performance.
0. No impairment
1. Mild impairment such that overall design and most details or pieces are correct; and/or little difficulty navigating in his/her
surroundings
2. Moderate impairment with distorted appreciation of overall design and/or several errors of details or pieces; and/or needing
repeated redirection to keep from getting lost in a newer environment despite, trouble locating familiar objects in immediate
environment
3. Severe impairment on formal testing; and/or repeated wandering or getting lost in environment

䉷 Trzepacz 1998

DRS-R-98 OPTIONAL DIAGNOSTIC ITEMS

These three items can be used to assist in the differentiation of delirium from other disorders for diagnostic and research purposes. They
are added to the severity score for the total scale score, but are NOT included in the severity score.

14. Temporal onset of symptoms

Rate the acuteness of onset of the initial symptoms of the disorder or episode being currently assessed, not their total duration. Distinguish
the onset of symptoms attributable to delirium when it occurs concurrently with a different preexisting psychiatric disorder. For example,
if a patient with major depression is rated during a delirium episode due to an overdose, then rate the onset of the delirium symptoms.
0. No significant change from usual or longstanding baseline behavior
1. Gradual onset of symptoms, occurring over a period of several weeks to a month
2. Acute change in behavior or personality occurring over days to a week
3. Abrupt change in behavior occurring over a period of several hours to a day

15. Fluctuation of symptom severity

Rate the waxing and waning of an individual or cluster of symptom(s) over the time frame being rated. Usually applies to cognition,
affect, intensity of hallucinations, thought disorder, language disturbance. Take into consideration that perceptual disturbances usually
occur intermittently, but might cluster in period of greater intensity when other symptoms fluctuate in severity.
0. No symptom fluctuation
1. Symptom intensity fluctuates in severity over hours
2. Symptom intensity fluctuates in severity over minutes

16. Physical disorder

Rate the degree to which a physiological, medical or pharmacological problem can be specifically attributed to have caused the symptoms
being assessed. Many patients have such problems but they may or may not have causal relationship to the symptoms being rated.
0. None present or active
1. Presence of any physical disorder that might affect mental state
2. Drug, infection, metabolic disorder, CNS lesion or other medical problem that specifically can be implicated in causing the altered
behavior or mental state

䉷 Trzepacz 1998

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DELIRIUM RATING SCALE-REVISED-98

DRS-R-98 SCORESHEET

Name of patient: Date: / / Time:

Name of Rater:

SEVERITY SCORE: TOTAL SCORE:

Severity Item Item Score Optional Information

Sleep-wake cycle 0 1 2 3 Naps Nocturnal disturbance only
Day-night reversal
Perceptual disturbances 0 1 2 3 Sensory type of illusion or hallucination:
auditory visual olfactory tactile
Format of illusion or hallucination:
simple complex
Delusions 0 1 2 3 Type of delusion:
persecutory
Nature: poorly formed systematized
Lability of affect 0 1 2 3 Type: angry anxious dysphoric
elated irritable
Language 0 1 2 3 Check here if intubated, mute, etc.
Thought process 0 1 2 3 Check here if intubated, mute, etc.

Motor agitation 0 1 2 3 Check here if restrained

Type of restraints:
Motor retardation 0 1 2 3 Check here if restrained
Type of restraints:

Orientation 0 1 2 3 Date:
Place:
Person:
Attention 0 1 2 3
Short-term memory 0 1 2 3 Record # of trials for registration of items:
Check here if category cueing helped
Long-term memory 0 1 2 3 Check here if category cueing helped
Visuospatial ability 0 1 2 3 Check here if unable to use hands
Diagnostic Item Item Score Optional Information

Temporal onset of symptoms 0 1 2 3 Check here if symptoms appeared on a background of other

psychopathology
Fluctuation of symptom 0 1 2 Check here if symptoms only appear during the night
severity

242 J Neuropsychiatry Clin Neurosci 13:2, Spring 2001