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Printed on 7/21/2026
For informational purposes only. This is not medical advice.
The Ultra-Brief 2-Item delirium screen (UB-2) is designed for very rapid delirium triage in busy clinical settings. It uses two simple cognitive prompts; failing either item is typically considered a positive screen and prompts more comprehensive delirium assessment.
Formula: UB-2 result is based on number of failed items (0-2); any failure is positive.
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The UB-2 consists of two cognitive items designed to detect attention impairment and disorientation — the core features of delirium. Item 1 (Months Backwards): Ask the patient to recite the months of the year in reverse order starting from December (or the current month). The patient must correctly recite at least 4-5 months without significant error to pass. Inability to perform this task indicates impaired attention and/or executive function. Item 2 (Orientation): Ask the patient what year it is, or use an alternative orientation question such as 'Can you tell me where you are?' A clearly incorrect response indicates disorientation. Both items should be administered in under 60 seconds.
Score each item as pass (0) or fail (1). A patient who correctly recites months backward with minor hesitation but no substantive errors passes item 1. A patient who cannot begin the task, makes multiple errors, or gives up passes as 1 (failed). For orientation, use clinical judgment to determine whether the response reflects genuine confusion or simply cultural/educational factors. For patients with known sensory impairment (hearing loss, severe dysarthria), adjust the administration method to ensure the task is comprehensible before scoring.
Any failed item (score 1 or 2) is considered a positive UB-2 screen indicating possible delirium. Published data report sensitivity of approximately 93% and specificity of approximately 64% for detecting DSM-defined delirium in hospitalized older adults. The high sensitivity makes UB-2 excellent for ruling out delirium (a patient who passes both items is unlikely to have clinically significant delirium), while the lower specificity means that positive screens require confirmatory assessment. A positive UB-2 should trigger formal delirium evaluation using the [CAM](/tools/cam-delirium), [4AT](/tools/4at-delirium), or [DOSS](/tools/doss-delirium) and physician notification.
Emergency physicians, triage nurses, ED advanced practice providers
The emergency department sees disproportionately high rates of delirium in older adults, yet time pressure, high patient volumes, and competing priorities make comprehensive cognitive assessment challenging. The UB-2's sub-minute administration makes it practical for ED triage alongside vital signs and chief complaint intake. A positive UB-2 at triage flags the patient for formal delirium work-up and appropriate environmental precautions (bed position, family presence, frequent reorientation) that can begin immediately rather than waiting for physician assessment.
Admissions nurses, bed management nurses
The UB-2 serves as a rapid delirium screen at hospital admission, identifying patients who require formal cognitive assessment before a full nursing evaluation is completed. Positive UB-2 screens at admission document pre-existing cognitive impairment or delirium and establish a baseline for detecting new confusion during hospitalization. In high-volume admissions areas, its brevity makes it feasible to apply universally to all patients 65 and older without significantly extending admission workflow.
Pre-anesthesia clinics, surgical admissions nurses, anesthesiologists
Pre-operative cognitive assessment identifies patients at risk for post-operative delirium, allowing proactive prevention planning. The UB-2 provides a rapid first-pass cognitive screen in pre-operative clinics where comprehensive cognitive testing is impractical. A positive UB-2 pre-operatively indicates elevated post-operative delirium risk and should prompt anesthesiologists to consider regional anesthesia alternatives, minimize anticholinergic and benzodiazepine premedication, plan for early post-operative mobility, and ensure the team is prepared for delirium management protocols.
Medical ward nurses, hospitalists, geriatric liaison teams
For admitted patients 70 and older, daily UB-2 screening supplements longer nursing observation tools such as DOSS. The UB-2's speed allows it to be incorporated into every clinician-patient interaction — morning rounds, medication administration, or meals — without formal assessment sessions. A change from negative to positive UB-2 during hospitalization signals acute cognitive deterioration requiring urgent medical review for new infection, metabolic disturbance, medication change, or other precipitating factors.
Primary care physicians, geriatricians, outpatient NPs
In busy outpatient clinics, the UB-2 provides a rapid cognitive flag for patients who present appearing confused, disoriented, or acutely altered from their baseline. Unlike longer screening tools, the UB-2 can be completed while the clinician is gathering history or during the physical examination. A positive screen in an outpatient context should prompt a family history of baseline function, determination of whether the change is acute (suggesting delirium or acute illness) versus chronic (suggesting dementia progression), and appropriate urgent or emergent workup.
With reported sensitivity around 93%, the UB-2 is most valuable when negative — a patient who passes both items is very unlikely to have delirium. Use this rule-out property when clinical suspicion is low and rapid reassurance is needed. However, a positive UB-2 has lower specificity (~64%), meaning many positive screens will not represent true delirium — these patients may have chronic cognitive impairment, educational limitations, severe hearing loss, or extreme fatigue. Always confirm positive screens with a formal assessment tool before acting on the result clinically.
The months-backward task is a validated attentional probe that is highly specific for attention impairment — the defining cognitive feature of delirium. Normal individuals, including those with mild dementia, can typically recite months backward with effort. Significant impairment on this task strongly suggests either acute attentional disruption (delirium) or moderate-to-severe cognitive decline. When only one item can be administered due to time or patient constraints, months backward provides the highest diagnostic yield.
Uncorrected hearing loss is the most common cause of false-positive UB-2 results. A patient who cannot hear the months-backward instruction clearly may appear to fail due to sensory impairment rather than cognitive dysfunction. Always ensure hearing aids are in place and functioning, face the patient and speak clearly, and confirm the patient understood the task before scoring. Similarly, patients with severe dysphasia after stroke may fail the verbal response component due to language impairment rather than cognitive confusion. Document any sensory or communication factors that may have affected scoring.
The UB-2 is explicitly a screening tool and should never be used as a standalone diagnostic test for delirium. A positive UB-2 indicates the need for formal assessment; it does not confirm delirium. The clinical consequences of delirium diagnosis — formal medical review for precipitating causes, potential antipsychotic consideration, family notification, goals of care discussion — should always be based on confirmatory assessment, not screening results alone. This distinction protects patients from over-treatment of false-positive screens.
The UB-2 results are most informative when compared to a documented baseline. A patient who scored 0 on admission but now scores 2 has an acute change — delirium is probable. A patient who scored 2 on admission may have chronic dementia rather than acute delirium. Admission UB-2 scoring as a routine practice for all patients 65 and older establishes the baseline needed to detect acute-on-chronic cognitive changes during hospitalization. Document the admission UB-2 score prominently in the problem list or nursing flowsheet.
The UB-2 cognitive items work best when paired with a brief behavioral observation: Is the patient's attention wandering during the interaction? Are responses appropriate to context? Is the patient sleeping when awoken or pulling at lines? This 30-second behavioral observation effectively supplements the 2 cognitive items and increases overall sensitivity for hypoactive delirium presentations that may pass the verbal items due to their preserved language but still show behaviorally observable features. The combination mirrors the approach used in more comprehensive tools like the CAM.
Inexperienced examiners often fail to administer months backward correctly — they may give too many hints, accept incorrect responses, or fail to recognize partial errors. Administer the task as follows: 'I am going to ask you to tell me the months of the year in backwards order, starting with the last month of the year. What would that be?' If the patient says December correctly, continue. Allow maximum 30 seconds. Score as failed if they cannot begin, stop before reaching July, or make more than 1-2 errors in the 7 months from December to June.
In the emergency department, months backward may be difficult for patients with severe pain, dyspnea, or intoxication even without delirium. In these scenarios, consider alternative attentional probes: counting backward from 20, the days of the week backward, or serial 7 subtractions. While these are not the standardized UB-2 items, they assess the same attentional construct and may be more contextually appropriate in severely ill or medicated patients. Document that a non-standard administration was used.
UB-2 has reported utility as a rapid first-pass delirium screen in hospitalized older adults.
A positive UB-2 screen indicates possible delirium and need for further diagnostic assessment.
Use for quick front-line delirium triage when time constraints limit longer screening tools.
As an ultra-brief screen, UB-2 prioritizes speed and should not be used as a standalone diagnostic test.
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.
April 21, 2026 · trust-baseline
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A nursing observation-based delirium screen scored 0-13, with >=3 commonly treated as positive.
OpenGeriatricsA brief 5-item nursing delirium screen (0-10) commonly using >=2 as a positive threshold.
OpenGeriatricsScreen for delirium using the CAM (Confusion Assessment Method). Gold standard with ~94% sensitivity and ~89% specificity. Requires acute onset + inattention, plus disorganized thinking or altered consciousness.
OpenGeriatricsRapid delirium screening tool scored 0-12; scores of 4 or more suggest possible delirium.
Open