Checklist Item | Description |
---|---|
Altered level of consciousnessa | Â |
   A | No response |
   B | Response to intense and repeated stimulation |
   C | Response to mild or moderate stimulation |
   D | Normal wakefulness |
   E | Exaggerated response to normal stimulation |
Inattentiveness | Difficulty following instructions or easily distracted |
Disorientation | To time, place, or person |
Hallucination-delusion-psychosis | Clinical manifestation or suggestive behavior |
Psychomotor agitation or retardation | Agitation requiring use of drugs or restraints, or slowing |
Inappropriate speech or mood | Related to events or situation, or incoherent speech |
Sleep/wake cycle disturbance | Sleeping <4 hours/day, waking at night, sleeping all day |
Symptom fluctuation | Symptoms above occurring intermittently |
Total score | 0 to 8 |