How is DEAR interpreted?

A score of 0–1 indicates lower delirium vulnerability (standard precautions recommended); a score of 2 or above indicates elevated delirium risk warranting enhanced prevention measures; scores of 3–4 identify very high-risk patients requiring intensive delirium prevention protocols and proactive monitoring.

What should follow a positive DEAR screen?

Positive screens should trigger enhanced delirium prevention bundles (orientation, early mobilization, sensory correction, sleep optimization, medication review), twice-daily CAM monitoring, notification of the care team, and consideration of geriatric medicine involvement.

Does DEAR diagnose delirium?

No. DEAR estimates pre-existing vulnerability risk and should be paired with active delirium detection tools such as the Confusion Assessment Method (CAM). DEAR is applied before delirium occurs; CAM is used to detect it when it develops.

Who can administer the DEAR score?

DEAR can be administered by nurses, physicians, pharmacists, or any trained clinician involved in the pre-operative or admission assessment of older adults. Training involves familiarity with the four risk factor definitions.

How does pre-existing cognitive impairment increase delirium risk?

Cognitive impairment reflects reduced cerebral reserve — the brain's capacity to maintain normal function under physiologic stress. Patients with dementia or MCI have 2–5 times the delirium incidence of cognitively intact patients under similar stressors, because their brains are already operating near the threshold of disruption.

Is delirium preventable?

Evidence-based non-pharmacological prevention programs (like HELP) reduce delirium incidence by 30–40% in high-risk patients. While not all delirium is preventable, identifying high-risk patients with tools like DEAR and implementing targeted prevention significantly reduces incidence and severity.

What is the difference between delirium prevention and delirium detection?

Prevention uses tools like DEAR to identify vulnerable patients before delirium develops and implements protective interventions. Detection uses tools like CAM or 4AT to identify delirium when it occurs so it can be managed promptly. Both are essential — prevention is always preferable, but reliable detection ensures prompt recognition when delirium does develop.

Should sensory aids be brought to the hospital for DEAR-positive patients?

Yes, this is an important practical action. Patients should be instructed to bring glasses and hearing aids to the hospital and these should be documented and placed at the bedside. Loss or absence of sensory aids during hospitalization is a modifiable delirium precipitant that nursing staff should actively monitor and address.

Online Medical Tools — DEAR Score

Printed on 9/3/2026

For informational purposes only. This is not medical advice.

Geriatrics

DEAR Score

The DEAR (Delirium Elderly At Risk) score is a short delirium-risk screen commonly used around surgery and acute-care admission in older adults. It typically combines baseline cognitive vulnerability, sensory impairment, functional dependence, and substance-use-related vulnerability. Higher totals suggest increased delirium risk and support targeted prevention bundles.

Formula: DEAR total = sum of 4 binary risk items (0-4). Common elevated-risk threshold is >=2.

Cognitive impairment present

Sensory impairment (vision/hearing)

Dependence in activities of daily living

Alcohol/substance use risk

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How It Works

Assess the Four Pre-Delirium Risk Factors

The DEAR (Delirium Elderly At Risk) score evaluates four baseline vulnerability factors that are established predictors of delirium in hospitalized older adults: (1) Cognitive impairment — the presence of pre-existing dementia, mild cognitive impairment, or documented cognitive decline; (2) Sensory impairment — clinically significant vision or hearing impairment that affects the patient's ability to perceive and interpret their environment; (3) ADL dependence — dependence in one or more basic activities of daily living prior to the acute admission, reflecting reduced functional reserve; and (4) Alcohol or substance use risk — history of significant alcohol use (typically defined as regular heavy use) or other substance use that may indicate neurological vulnerability and alcohol withdrawal risk. Each item is scored 1 if present, 0 if absent.

Sum the Score and Apply the Risk Threshold

Sum the four binary items to obtain a DEAR total ranging from 0 to 4. A score of 0 or 1 indicates lower delirium vulnerability, though any hospitalized older adult carries some baseline delirium risk and should receive standard age-appropriate preventive measures. A score of 2 or higher is the commonly used elevated risk threshold, indicating significant pre-existing vulnerability that substantially increases the probability of developing delirium during hospitalization or in the postoperative period. A score of 3 or 4 identifies patients at very high delirium risk who require intensive prevention and should be flagged immediately for proactive delirium management protocols.

Implement Risk-Stratified Delirium Prevention Bundles

The DEAR score guides which patients receive enhanced delirium prevention interventions during hospitalization or surgery. All hospitalized older adults should receive standard universal precautions: reorientation, early mobilization, sensory aids (glasses, hearing aids), sleep hygiene, adequate hydration, and avoiding unnecessary sedating medications. DEAR-positive patients (score ≥2) warrant additional targeted interventions: more frequent orientation assessments, delirium monitoring with [CAM](/tools/cam-delirium) at least twice daily, physiotherapy for early mobilization, pharmacist review for high-risk medications, proactive sensory correction, and family engagement to provide familiar faces and orienting information. Patients scoring 3–4 may warrant additional safeguards including geriatric medicine consultation, alcohol withdrawal prophylaxis (if relevant), and lowest-possible sedation in surgical settings.

Who Uses the DEAR Score

Pre-Operative Delirium Risk Stratification

Surgeons, anesthesiologists, pre-operative assessment nurses

The DEAR score is used during pre-operative assessment to identify older adults at high risk of developing post-operative delirium — one of the most common and serious complications of surgery in older patients, associated with prolonged hospital stays, functional decline, accelerated cognitive deterioration, and increased mortality. Pre-operative identification of DEAR-positive patients allows proactive planning: informing the patient and family, adjusting anesthetic technique (regional where possible), avoiding long-acting sedatives, planning post-operative cognitive monitoring, and ensuring sensory aids are present in recovery. Families of high-DEAR patients should be encouraged to stay at the bedside in the early post-operative period.

Acute Medical Admission Triage

Hospitalists, acute medicine physicians, ward nurses

On acute medical admissions, DEAR provides a rapid vulnerability screen that identifies patients who need enhanced delirium prevention from the moment of admission. High-DEAR patients admitted for acute illness (pneumonia, UTI, sepsis, fracture) are at significantly elevated risk of developing delirium superimposed on their acute illness, which worsens outcomes and prolongs recovery. Implementing HEAR-positive pathways at admission — flagging the risk in the care plan, prescribing sensory aids, scheduling mobility assessments, and initiating daily CAM monitoring — is most effective when started on admission day 1 rather than reactively when delirium has already developed.

ICU Delirium Prevention in Older Patients

Intensivists, ICU nurses, critical care pharmacists

In the ICU, delirium is extremely common in older adults and associated with prolonged ventilation, longer ICU stays, and lasting cognitive impairment. DEAR-positive patients admitted to ICU for any reason require an enhanced delirium prevention protocol including ABCDEF bundle implementation, optimization of the sleep-wake cycle, minimization of benzodiazepines and anticholinergics, early sedation protocols, and daily delirium monitoring using [CAM-ICU](/tools/cam-delirium). DEAR score documents baseline vulnerability that ICU teams can reference when encountering delirium or interpreting behavioral changes during the ICU stay.

Geriatric Liaison Service Triage

Geriatric medicine liaison nurses, geriatric consultation teams

In hospitals with proactive geriatric liaison services, DEAR scores help prioritize limited consultation capacity toward the highest-risk patients. DEAR-positive patients — particularly those with cognitive impairment and ADL dependence — benefit most from early geriatric medicine involvement, including comprehensive medication review, environment optimization, early mobilization protocols, and coordinated discharge planning. Services may use DEAR as an automatic trigger for same-day geriatric liaison assessment in surgical and acute medicine settings.

Pharmacist-Led Medication Risk Reduction

Clinical pharmacists, medication safety leads

Patients with high DEAR scores require priority medication safety review to minimize pharmacological contributors to delirium risk. The ADL dependence and cognitive impairment items on DEAR identify patients with the greatest vulnerability to delirium-precipitating medications including anticholinergics, benzodiazepines, opioids (high doses), sedating antihistamines, and certain antiemetics. Pharmacists can use DEAR-positive status as a trigger for structured medication review targeting the [Anticholinergic Burden Score](/tools/acb-score), Beers Criteria medications, and unnecessary psychoactive drugs before and during hospitalization.

Pro Tips

Cognitive Impairment Is the Strongest DEAR Predictor of Delirium

Among the four DEAR criteria, pre-existing cognitive impairment is the single strongest predictor of delirium development. Patients with dementia have 2–5 times the delirium incidence of cognitively intact patients of the same age and illness severity. The cognitive impairment item should be scored positive if there is any documented history of dementia, mild cognitive impairment, or if the patient or a reliable caregiver reports memory or thinking problems — do not rely solely on absence of a formal diagnosis, as many patients with significant cognitive impairment have never been formally assessed.

Sensory Impairment Item Includes Both Vision and Hearing

Score the sensory impairment item positive if there is significant vision or hearing impairment, or both. The mechanism is clear: sensory impairment impairs the patient's ability to correctly perceive and interpret the hospital environment, increasing disorientation and delusional misperception. Correcting sensory impairment during hospitalization — ensuring glasses are present and worn, hearing aids are in place and functioning, and communication is optimized — is one of the highest-yield non-pharmacological delirium prevention interventions. Ask explicitly about glasses and hearing aids on admission and ensure they are in the patient's possession at the bedside.

ADL Dependence Reflects Physiologic Reserve Depletion

Pre-existing ADL dependence — needing help with bathing, dressing, transferring, or other basic self-care — reflects an already-depleted physiologic reserve that makes the patient more vulnerable to additional stressors. Assess ADL dependence relative to the patient's pre-illness baseline (not performance during acute illness). A patient who was independent before admission but is currently dependent due to acute illness should not have the ADL item scored positive based on their current impaired state — ask about their typical abilities 2 weeks before admission.

Alcohol History Requires Direct and Non-Judgmental Questioning

Alcohol-related vulnerability is frequently underreported when patients are asked judgmentally about 'alcohol problems.' Use standardized screening questions such as AUDIT-C or the brief CAGE questionnaire, framed non-judgmentally as routine assessment. Document any significant alcohol use history regardless of patient minimization, as withdrawal delirium (delirium tremens) can be catastrophic and requires specific pharmacological prophylaxis (benzodiazepines, thiamine) that should be initiated at admission for at-risk patients.

DEAR Is a Pre-Admission Tool; CAM Is the Post-Admission Detection Tool

DEAR identifies pre-existing vulnerability before delirium occurs; it is not a diagnostic tool for active delirium. Active delirium detection requires a different instrument — the [Confusion Assessment Method (CAM)](/tools/cam-delirium) for non-ICU settings or CAM-ICU for ventilated patients. Use DEAR to implement preventive strategies at or before admission, and use CAM systematically (at least twice daily in high-DEAR patients) to detect delirium early when it does develop, enabling prompt identification and management.

Non-Pharmacological Bundle Components Are Evidence-Based

The HELP (Hospital Elder Life Program) and similar non-pharmacological delirium prevention bundles have Level I evidence for reducing delirium incidence in high-risk patients, with 30–40% relative risk reduction in randomized trials. Components include cognitive stimulation (daily orientation activities, stimulating reading or conversation), early mobilization (getting out of bed by day 2 for most patients), vision and hearing correction, sleep protocol (avoiding sleep disruption, minimizing nocturnal vital signs and procedures), and dehydration prevention. These bundle components should be implemented for all DEAR-positive patients.

Document DEAR Score Prominently in the Care Plan

A DEAR score documented at admission is only useful if it is visible and acted upon by the entire care team. Document the score and its implications prominently in the medical record care plan, on medication charts (to flag high-risk drug avoidance), and in nursing handover communication. High-DEAR patients should be identifiable in ward rounds so that team members default to delirium-conscious care practices without needing to re-assess each time.

High DEAR Score Should Prompt Advance Care Planning Discussion

Patients with high DEAR scores — particularly those with cognitive impairment and functional dependence — often have not completed advance care planning documentation. Delirium itself significantly impairs capacity, and a patient who develops severe delirium may be unable to participate in treatment decisions for days to weeks. Use the pre-admission window when a DEAR-positive patient is cognitively intact (or most intact) to initiate or update advance care plans, health proxy designation, and goals-of-care documentation.

Common Questions About Your Results

The DEAR score identifies elevated pre-existing vulnerability but cannot predict every case of delirium. Delirium has both vulnerability factors (what DEAR measures) and precipitating factors — the acute triggers that tip a patient into delirium. A patient with a DEAR score of 1 can still develop delirium if exposed to sufficient precipitating stressors: severe infection, major surgery, pain, urinary retention, medication changes, or immobility. Delirium risk is always multiplicative between vulnerability and precipitants. A low DEAR score reduces but does not eliminate risk, and universal standard delirium precautions remain appropriate for all hospitalized older adults.

DEAR, DRAT, and PRE-DELIRIC are all pre-admission or admission delirium risk tools, but they differ in scope and setting. DEAR is brief (4 items, 1 minute) and focused on pre-existing vulnerability, making it suitable for rapid pre-operative or acute admission screening. PRE-DELIRIC uses 10 clinical variables at ICU admission and was specifically validated for ICU patients. DRAT (Delirium Risk Assessment Tool) uses a slightly broader variable set. The optimal tool depends on clinical setting: DEAR for rapid pre-operative and acute admission screening; PRE-DELIRIC or E-PRE-DELIRIC for ICU settings where more comprehensive prediction is needed.

The evidence for pharmacological delirium prophylaxis (antipsychotics, melatonin, dexmedetomidine) remains mixed, and current guidelines generally do not recommend routine prophylactic antipsychotics or melatonin based solely on delirium risk score. Non-pharmacological prevention bundles have stronger evidence. However, specific pharmacological interventions are indicated for particular risk items: thiamine and benzodiazepine prophylaxis for patients with significant alcohol use risk; pain management optimization to prevent pain-precipitated delirium; careful sedation protocols in the peri-operative period; and avoidance of high-risk medications (anticholinergics, benzodiazepines, high-dose opioids) in all DEAR-positive patients.

Yes. The four DEAR items can be reliably completed by trained nursing staff during admissions assessment without physician involvement. The assessor needs to determine the presence or absence of cognitive impairment, sensory impairment, ADL dependence, and alcohol risk — information typically obtained through standard nursing admission assessment and brief history taking. Nursing-led DEAR completion improves screening uptake and ensures delirium prevention pathways are initiated promptly without waiting for physician review. Nurses should be trained in the assessment approach for each item and in when to escalate borderline findings to physician review.

Evidence-Based Methodology

Delirium predictors underlying DEAR items validated in landmark studies: Inouye SK et al. (Ann Intern Med 1993) — cognitive impairment, dehydration, immobility, vision impairment each independently predict delirium with 2–5x odds ratios. HELP delirium prevention trial (Inouye NEJM 1999) — non-pharmacological prevention bundle targeting these factors reduced delirium incidence 34%. Sensory correction for delirium prevention: Litaker D et al. (Arch Intern Med 2001).

Clinical Content Trust

Last reviewed:: April 21, 2026
Guideline version:: General evidence framework v2026.04
Source set version:: Primary-source set v1

How to Interpret Your Result

Higher DEAR scores indicate greater delirium vulnerability and support early prevention-oriented care pathways.

When to Use This Tool

Use in older adults before surgery or during acute-care intake to identify patients needing enhanced delirium prevention and surveillance.

Limitations

Cutoffs and variable definitions may vary by local protocol; DEAR should complement, not replace, direct delirium monitoring.

Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.

Changelog

April 21, 2026 · trust-baseline
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