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Assisting Detection of Hospital Acquired Delirium by Informal Caregivers – The Sour Seven

In the March 2018 edition of Reader’s Digest, I came across an article called “State of Confusion”[i] about hospital acquired delirium and the negative consequences that can arise from it. (The author’s original article can be found online.)[ii] The editor’s letter “Decoding Delirium”[iii] in the same issue recounts her mother’s experience with hospital acquired delirium and her frustration with the delay in coming up with the diagnosis. My fellow blogger, Audrey Miller, also recently wrote about hospital acquired delirium.

Delirium in hospitalized seniors is a state of confusion with an acute onset that develops over a few hours to days. It is characterized by inattentiveness and disturbances in consciousness, orientation, memory, thought, perception, and behaviour.[iv] Prevalence of delirium in seniors on admission to a hospital is estimated at 14 to 24%, and incidences of delirium arising during hospitalization ranges from 6 to 56%.[v] Delirium is associated with substantial morbidity, increased average length of stay, functional decline, persistent cognitive impairment, loss of independence, higher Long Term Care (LTC) institutionalization rates, worse rehabilitation outcomes and death with an in-hospital mortality of up to 33%.[vi] [vii]

Despite being a medical emergency, the presence of delirium often goes unrecognized by health care providers during routine care in a hospital setting; non-detection rates of delirium in hospitalized seniors is reported to range from 33% to as high as 66%.[viii] Reasons for lack of delirium detection include: lack of routine formal screening, high prevalence of pre-morbid dementia in hospitalized seniors confounding mental status assessments, language barriers, lack of prior knowledge of the patient by medical staff, lack of nursing training in mental status assessment, nursing discomfort with cognitive assessments, fluctuation of symptoms during the day, and different clinical presentations of delirium (hypoactive and hyperactive).[ix]

However, if given the right tools, informal caregivers and untrained nurses can occupy a helpful role to assist in delirium detection in hospitalized seniors. Results of our pilot study support the validity of the Sour Seven Delirium Questionnaire to assist in delirium detection in hospitalized seniors by any informal or untrained formal caregiver.[x] The Sour Seven Delirium Questionnaire is designed for caregivers to screen for delirium in hospitalized seniors, including those with dementia, that requires no training, no prior knowledge of the person, no questions posed to the person, is independent of language and is based on seven simple observations of the person during caregiving. A total score of 4 provides an 89% predictive value for possible delirium, suggesting a need to evaluate for potential medical causes and medications/substances that may lead to delirium. A total score of 9 provides a 100% predictive value for delirium, suggesting immediate medical evaluation is required.

The Sour Seven Delirium Questionnaire is available for open access distribution and can be downloaded to be used freely among researchers, clinicians, allied health staff, and all informal caregivers.[xi]

[i] Loney, S. “State of Confusion.” Reader’s Digest, March 2018.

[ii] Loney, S. “Why Is No One Talking About Hospital-Acquired Delirium?”

[iii] Ritter, D. “Decoding Delirium – Editor’s Letter.” Reader’s Digest, March 2018.

[iv] Cole, M. G. “Delirium in Elderly Patients.” American Journal of Geriatric Psychiatry. 2004;12:7–21.

[v] Inouye, S. K. “Delirium in older persons.” N England Journal of Medicine. 2006;354(11):1157–65.

[vi] Saxena, S and D. Lawley. “Delirium in the elderly: a clinical review.” Postgraduate Medicine Journal. 2009;85(1006):405–13.

[vii] Popeo, D. M. “Delirium in older adults.” Mt Sinai Journal of Medicine. 2011;78(4):571–82.

[viii] Inouye, S. K. “The dilemma of delirium. Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients.” American Journal of Medicine. 1994;97:278.

[ix] Martins, S and L. Fernandes. “Delirium in elderly people: a review.” Frontiers in Neurology. 2012;3:101.

[x] Shulman, R. W. et al. “Validation of the Sour Seven Questionnaire for screening delirium in hospitalized seniors by informal caregivers and untrained nurses.” BMC Geriatrics (2016) 16:44 DOI 10.1186/s12877-016-0217-Available at

[xi] The Sour Seven: Delirium Detection Questionnaire for Caregivers available for free download at:


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About Dr. Richard Shulman
Dr. Shulman is a geriatric psychiatrist at Trillium Health Partners and is an assistant professor at the University of Toronto. He is medical director of the Capacity Clinic and available for independent medical-legal capacity assessments.

1 Comment

  1. Audrey Miller

    March 28, 2018 - 8:51 pm

    Richard, thanks so much for sharing your great tool , the Sour Seven. Love the catchy name!

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