AWOL Score for Delirium
Predicts risk of delirium during hospitalization.
Result:
Why did you develop the AWOL Score for Delirium? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
As a medicine and neurology resident, I always thought there should be an easy way to predict the likelihood a patient admitted to the hospital would develop delirium. It is well known that underlying cognitive dysfunction is the most important risk factor for delirium, and it should therefore be the basis of any delirium prediction tool. However, many patients’ early dementia or mild cognitive impairment is unrecognized when they present to the hospital; most tools for assessing cognitive impairment were too time consuming to perform routinely for every patient admission. In designing the AWOL Score, we tried to address both of these problems.
What pearls, pitfalls and/or tips do you have for users of the AWOL Score for Delirium? Do you know of cases when it has been applied, interpreted, or used inappropriately?
A limitation to AWOL is the fact it has only been validated in English speakers since it relies on the patient being able to spell "world" backwards. In some languages, the backwards spelling task can be directly translated; in others, especially in languages that use characters to represent words, the task has to be modified to, for example, serial 7s.
What recommendations do you have for doctors once they have applied the AWOL Score for Delirium? Are there any adjustments or updates you would make to the score based on new data or practice changes?
Fortunately, non-pharmacological interventions can prevent delirium in roughly a third of cases. However, it is difficult to implement these interventions in every hospitalized patient. The AWOL Score can be used to target delirium prevention: patients with AWOL scores of 2 or higher have a high chance of developing delirium, and delirium prevention measures can be particularly focused on them.
How do you use the AWOL Score for Delirium in your own clinical practice? Can you give an example of a scenario in which you use it?
Our nurses routinely administer AWOL to every patient upon hospital admission. Delirium prevention measures are targeted to patients who score 2 or higher on AWOL. These prevention measures include but are not limited to: mobilization with occupational and physical therapy, careful avoidance of medications known to cause delirium, maintenance of normal sleep-wake cycles in the hospital and minimization of night-time wake-ups, avoidance of unnecessary tethers such as urinary catheters, and cognitive stimulation and frequent reorientation during daylight hours.
Vanja C. Douglas, MD, is a neurohospitalist and associate professor of clinical neurology at the University of California, San Francisco. He holds the Sara & Evan Williams Foundation Endowed Neurohospitalist Chair and is the director of the neurohospitalist division at UCSF. Dr. Douglas’ primary research interests are delirium and models of inpatient neurological care.