Review article
Delirium: Guidelines for general hospitals

https://doi.org/10.1016/j.jpsychores.2006.10.004Get rights and content

Abstract

Objective

Delirium is highly prevalent in general hospitals but remains underrecognized and undertreated despite its association with increased morbidity, mortality, and health services utilization. To enhance its management, we developed guidelines covering all aspects, from risk factor identification to preventive, diagnostic, and therapeutic interventions in adult patients.

Methods

Guidelines, systematic reviews, randomized controlled trials (RCT), and cohort studies were systematically searched and evaluated. Based on a synthesis of retrieved high-quality documents, recommendation items were submitted to a multidisciplinary expert panel. Experts scored the appropriateness of recommendation items, using an evidence-based, explicit, multidisciplinary panel approach. Each recommendation was graded according to this process' results.

Results

Rated recommendations were mostly supported by a low level of evidence (1.3% RCT and systematic reviews, 14.3% nonrandomized trials vs. 84.4% observational studies or expert opinions). Nevertheless, 71.1% of recommendations were considered appropriate by the experts. Prevention of delirium and its nonpharmacological management should be fostered. Haloperidol remains the first-choice drug, whereas the role of atypical antipsychotics is still uncertain.

Conclusions

While many topics addressed in these guidelines have not yet been adequately studied, an explicit panel and evidence-based approach allowed the proposal of comprehensive recommendations for the prevention and management of delirium in general hospitals.

Introduction

Delirium is an acute change in cognition with altered consciousness and impaired attention that fluctuates over time [1]. It is a frequent condition seen in general hospitals. Its prevalence ranges from 11% to 33% on admission [2], [3], [4], and its incidence during hospital stay ranges between 3% and 56% [2], [3], [5], [6]. Delirium is associated with adverse outcomes, including increased morbidity, increased mortality, and increased health services utilization [7], [8], [9], [10], [11], [12], [13], [14], [15]. Despite these observations, delirium recognition rates are low (12–43%) [4], [16], [17], [18], and its management remains inadequate in up to 80% of patients [16]. This suggests lack of preventive and screening activities, missed diagnoses, and inappropriate management of diagnosed delirium. Beneficial changes following guidelines implementation have been demonstrated in several domains [19]. Following the adaptation [20] and implementation [21] of guidelines for depression in general hospitals, we undertook the development of new specific guidelines covering all relevant aspects of the management of delirium among adult patients in general hospitals.

Section snippets

Methods

We chose to start with a strategy of adapting published guidelines, where available, in order not to perform anew valid high-quality work that had been previously conducted [22]. Thus, we first searched to identify high-quality clinical practice guidelines and completed our sources of information with systematic reviews and, in the absence of such documents, clinical trials and cohort studies, when appropriate. The main steps of guidelines development were: (a) a systematic literature search;

Results

The 392 recommendation items on delirium that were submitted to the expert panel resulted in about 5500 ratings (response rate=94%). Most recommendation items had a low level of evidence (Level I, 1.3%; Level II, 6.1%; Level III, 8.2%; Level IV, 6.6%; Level V, 77.8%). However, of the recommendation items, 71.1% were considered by the experts as appropriate, 21.7% were considered uncertain, and 7.2% were considered inappropriate. A permanent disagreement remained among the experts in only 3.8%

Discussion

The development and implementation of guidelines is an important preliminary step to improve delirium management, given its high occurrence in patients hospitalized in general hospitals and highly variable care practices. A recent survey showed that only two countries in Europe possess a guideline for the diagnosis and treatment of delirium [140]. The present guidelines thus constitute a significant contribution from several perspectives. First, from a methodological standpoint, these

Acknowledgments

We thank Anne Gerber, RN (Intensive Care Department, University Hospital, Lausanne, Switzerland), for participating in the delirium guidelines group. We also thank Dr. M. Cole (McGill University, Montreal, Canada) and Dr. R. Gonthier (University of Saint-Etienne, France) for reviewing the full document; Patrick Taffé for statistical advice; and Valérie Pittet for logistic and informatics support.

References (148)

  • E McNicol et al.

    Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review 1

    J Pain

    (2003)
  • M Wheeler et al.

    Adverse events associated with postoperative opioid analgesia: a systematic review

    J Pain

    (2002)
  • D Litaker et al.

    Preoperative risk factors for postoperative delirium

    Gen Hosp Psychiatry

    (2001)
  • ER Marcantonio et al.

    The association of intraoperative factors with the development of postoperative delirium

    Am J Med

    (1998)
  • Y Sasajima et al.

    Postoperative delirium in patients with chronic lower limb ischaemia: what are the specific markers?

    Eur J Vasc Endovasc Surg

    (2000)
  • F Schneider et al.

    Risk factors for postoperative delirium in vascular surgery

    Gen Hosp Psychiatry

    (2002)
  • B Yildizeli et al.

    Factors associated with postoperative delirium after thoracic surgery

    Ann Thorac Surg

    (2005)
  • JD Gaudreau et al.

    Impact on delirium detection of using a sensitive instrument integrated into clinical practice

    Gen Hosp Psychiatry

    (2005)
  • MF Folstein et al.

    “Mini-Mental State.” A practical method for grading the cognitive state of patients for the clinician

    J Psychiatr Res

    (1975)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorder, text revision

    (2000)
  • G Bucht et al.

    Epidemiology of delirium

    Dement Geriatr Cogn Disord

    (1999)
  • J Lindesay et al.

    The epidemiology of delirium

  • M Elie et al.

    Prevalence and detection of delirium in elderly emergency department patients

    CMAJ

    (2000)
  • SK Inouye et al.

    A multicomponent intervention to prevent delirium in hospitalized older patients

    N Engl J Med

    (1999)
  • SK Inouye

    Delirium in older persons

    N Engl J Med

    (2006)
  • MG Cole et al.

    Delirium: prevention, treatment, and outcome studies

    J Geriatr Psychiatry Neurol

    (1998)
  • ER Marcantonio et al.

    Delirium is independently associated with poor functional recovery after hip fracture

    J Am Geriatr Soc

    (2000)
  • J McCusker et al.

    Delirium predicts 12-month mortality

    Arch Intern Med

    (2002)
  • J McCusker et al.

    Does delirium increase hospital stay?

    J Am Geriatr Soc

    (2003)
  • SK Inouye et al.

    Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study

    J Gen Intern Med

    (1998)
  • J McCusker et al.

    Predictors of functional decline in hospitalized elderly patients: a systematic review

    J Gerontol A Biol Sci Med Sci

    (2002)
  • DL Leslie et al.

    Premature death associated with delirium at 1-year follow-up

    Arch Intern Med

    (2005)
  • ER Marcantonio et al.

    Outcomes of older people admitted to postacute facilities with delirium

    J Am Geriatr Soc

    (2005)
  • RS Morrison et al.

    Relationship between pain and opioid analgesics on the development of delirium following hip fracture

    J Gerontol A Biol Sci Med Sci

    (2003)
  • KR Farrell et al.

    Misdiagnosing delirium as depression in medically ill elderly patients

    Arch Intern Med

    (1995)
  • JM Grimshaw et al.

    Effectiveness and efficiency of guideline dissemination and implementation strategies

    Health Technol Assess

    (2004)
  • B Fervers et al.

    Adaptation of clinical guidelines: literature review and proposition for a framework and procedure

    Int J Qual Health Care

    (2006)
  • K Fitch et al.

    The RAND/UCLA appropriateness method user's manual

    (2001)
  • J Jacobi et al.

    Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult

    Crit Care Med

    (2002)
  • CG Rapp et al.

    Acute confusion/delirium protocol

    J Gerontol Nurs

    (2001)
  • American Psychiatric Association

    Practice guideline for the treatment of patients with delirium

    Am J Psychiatry

    (1999)
  • Delirium guidelines

  • GS Alexopoulos et al.

    Treatment of agitation in older persons with dementia

    Postgraduate medicine special report

    (1998)
  • M Elie et al.

    Delirium risk factors in elderly hospitalized patients

    J Gen Intern Med

    (1998)
  • MG Cole et al.

    Effectiveness of interventions to prevent delirium in hospitalized patients: a systematic review

    CMAJ

    (1996)
  • MG Cole et al.

    Prognosis of delirium in elderly hospital patients

    CMAJ

    (1993)
  • DM Fick et al.

    Delirium superimposed on dementia: a systematic review

    J Am Geriatr Soc

    (2002)
  • A Yildiz et al.

    Pharmacological management of agitation in emergency settings

    Emerg Med J

    (1920)
  • B Draper

    The effectiveness of old age psychiatry services

    Int J Geriatr Psychiatry

    (2000)
  • RS Morrison et al.

    The medical consultant's role in caring for patients with hip fracture

    Ann Intern Med

    (1998)
  • Cited by (119)

    • Psychiatric aspects of care in the cancer patient

      2022, Neurological Complications of Systemic Cancer and Antineoplastic Therapy
    • ACR Appropriateness Criteria <sup>®</sup> Acute Mental Status Change, Delirium, and New Onset Psychosis

      2019, Journal of the American College of Radiology
      Citation Excerpt :

      Acute pathology that resulted in a change of management was detected in a small proportion of patients on head CT, including ischemic and hemorrhagic stroke, subdural hematoma, SAH, encephalitis or meningitis, and cerebral tumors. Therefore, the low diagnostic yield of CT in this setting must be weighed against the risk of possible, preventable morbidity [8,11], acknowledging that patients may not have clinical signs on examination that predict a focal pathology [41]. There is no relevant literature regarding the use of contrast-enhanced head CT in the evaluation of delirium.

    View all citing articles on Scopus
    1

    The members of the Delirium Guidelines Development Group are as follows: Laurent Michaud, MD (Clinical Epidemiology Center, Institute of Social and Preventive Medicine, University Hospital, Lausanne, Switzerland; Psychiatry Service, University Hospital, Lausanne, Switzerland); Alexandre Berney, MD (Psychiatry Service, University Hospital, Lausanne, Switzerland); Christophe Büla, MD (Service of Geriatric Medicine, CHUV and CUTR Sylvana, Epalinges, Switzerland); Vincent Camus, MD (Service of Old Age Psychiatry, University Hospital, Lausanne, Switzerland; Clinique Psychiatrique Universitaire, Centre Hospitalier Régional Universitaire and Faculté de Médecine, Université François-Rabelais, Tours, France); Rachel Voellinger MD (Clinical Epidemiology Center, Institute of Social and Preventive Medicine, University Hospital, Lausanne, Switzerland; Psychiatry Service, University Hospital, Lausanne, Switzerland); Friedrich Stiefel, MD (Psychiatry Service, University Hospital, Lausanne, Switzerland); Bernard Burnand MD, MPH (Clinical Epidemiology Center, Institute of Social and Preventive Medicine, University Hospital, Lausanne, Switzerland); Thierry Buclin, MD (Division of Clinical Pharmacology, University Hospital, Lausanne, Switzerland); François Chevalley, MPH (Orthopedic Department, University Hospital, Lausanne, Switzerland); Olivier Lamy, MD (Service of Internal Medicine, University Hospital, Lausanne, Switzerland); Yves Dorogi, RN (Psychiatry Service, University Hospital, Lausanne, Switzerland); Mauro Oddo, MD (Intensive Care Department, University Hospital, Lausanne, Switzerland); Patrick Schoettker, MD (Department of Anesthesiology and Prehospital Emergency Medicine University Hospital, Lausanne, Switzerland); Joseph Ghika, MD (Service of Neurology, University Hospital, Lausanne, Switzerland); Armin von Gunten, MPhil, MD (Service of Old Age Psychiatry, University Hospital, Lausanne, Switzerland).

    View full text