Review articleDelirium: Guidelines for 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.
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- 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).