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HELP Score (Postoperative Delirium Risk)
HELP Score: Predicts delirium risk before it happens. Score 1 point for every risk factor present at admission.
Assess 4 Risk Factors
1. Vision Impairment
Visual acuity < 20/70 (binocular) on Snellen chart.
2. Severe Illness
High severity of illness (e.g., APACHE II > 16).
3. Cognitive Impairment
MMSE score < 24 or known baseline dementia.
4. High BUN/Cr Ratio
BUN/Cr > 18 (indicative of dehydration or renal stress).
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Preoperative assessment for adults ≥ 70 years old undergoing major surgery.
Medical admissions for older adults to predict delirium risk during hospitalization.
Triage tool for enrollment into the Hospital Elder Life Program (HELP).
Proactive vs Reactive
Unlike the CAM or 4AT which diagnose delirium *after* it has occurred, the HELP predictive model identifies patients at risk *before* the surgery, allowing for aggressive preventative measures.
Section 2
Formula & Logic
Scoring
4 baseline risk factors. Score 1 point for each.
Total score: 0–4.
Score 0: Low Risk (9% incidence).
Score 1-2: Intermediate Risk (23% incidence).
Score 3-4: High Risk (83% incidence).
The 4 Risk Factors
Vision Impairment
Visual acuity < 20/70 (binocular) on Snellen chart.
Severe Illness
BUN/Cr ratio ≥ 18 (surrogate for dehydration/severe illness).
BUN/Cr > 18 was historically used; modern adaptations often use clinical dehydration or acute illness severity.
Section 3
Pearls/Pitfalls
Modifiable Risk
Three of the four risk factors (Vision, Severe Illness, Dehydration) are highly modifiable. Ensuring the patient has their glasses in the recovery room and optimizing preoperative IV hydration can dramatically reduce postoperative delirium incidence.
Section 4
Next Steps
Management (The HELP Protocol)
Section 5
Evidence Appraisal
Primary Reference
A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics.
Inouye SK et al. • Ann Intern Med.. 1993;119(6):474-81. The original derivation of the 4-factor predictive model.
A multicomponent intervention to prevent delirium in hospitalized older patients.
Inouye SK et al. • N Engl J Med.. 1999;340(9):669-76. The landmark trial proving that the HELP protocol reduced delirium incidence by one-third.
Section 6
Origins
Sharon Inouye
Developed by Dr. Sharon Inouye at Yale. She recognized that delirium was treated as an inevitable consequence of hospitalization, and proved that a targeted, multi-component nursing intervention could prevent it.
