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Quality of clinical practice guidelines in delirium: a systematic appraisal
  1. Shirley H Bush1,2,
  2. Katie L Marchington3,
  3. Meera Agar4,
  4. Daniel H J Davis5,
  5. Lindsey Sikora6,
  6. Tammy W Y Tsang2
  1. 1Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  2. 2Bruyère Research Institute, Ottawa, Ontario, Canada
  3. 3Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  4. 4Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
  5. 5MRC Unit for Lifelong Health and Ageing, University College London, London, UK
  6. 6Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
  1. Correspondence to Dr Shirley H Bush; sbush{at}


Objective To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality.


  1. Systematic literature search for formal guidelines (in English or French) with focus on delirium assessment and/or management in adults (≥18 years), guideline summary papers and evaluation studies.

  2. Full appraisal of delirium guidelines published between 2008 and 2013 and obtaining a ‘Rigour of Development’ domain screening score cut-off of >40% using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

Data sources Multiple bibliographic databases, guideline organisation databases, complemented by a grey literature search.

Results 3327 database citations and 83 grey literature links were identified. A total of 118 retrieved delirium guidelines and related documents underwent full-text screening. A final 21 delirium guidelines (with 10 being >5 years old), 12 guideline summary papers and 3 evaluation studies were included. For 11 delirium guidelines published between 2008 and 2013, the screening AGREE II ‘Rigour’ scores ranged from 3% to 91%, with seven meeting the cut-off score of >40%. Overall, the highest rating AGREE II domains were ‘Scope and Purpose’ (mean 80.1%, range 64–100%) and ‘Clarity and Presentation’ (mean 76.7%, range 38–97%). The lowest rating domains were ‘Applicability’ (mean 48.7%, range 8–81%) and ‘Editorial Independence’ (mean 53%, range 2–90%). The three highest rating guidelines in the ‘Applicability’ domain incorporated monitoring criteria or audit and costing templates, and/or implementation strategies.

Conclusions Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice.

  • Clinical practice guidelines
  • delirium
  • Appraisal of Guideline Research and Evaluation (AGREE II) instrument
  • quality

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  • Contributors SB conceived and designed the study, and drafted and revised the manuscript. She is the guarantor. LS developed the database literature search strategy. SB and KM performed the initial abstract and full-text screening. SB, KM, MA and DD appraised the guidelines with the full AGREE II instrument. TT conducted the grey literature search and coordinated the online AGREE appraisal system. SB led the collection, analysis and interpretation of the data. All researchers had access to the data. All authors made substantial contributions to the study concept and the interpretation of the data, critically revised the article for important intellectual content and approved the final version of the manuscript to be published. The guarantor (SB) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported and that no important aspects of the study have been omitted.

  • Funding This study was supported in part by funding from a Bruyère Academic Medical Organization 2014 Incentive grant (SB), entitled ‘The development, implementation and evaluation of a delirium clinical practice guideline on the palliative care unit’.

  • Disclaimer The funders played no role in the study design, collection, analysis, interpretation of data, writing of the report or in the decision to submit the article for publication.

  • Competing interests All authors have completed the ICMJE uniform disclosure at and declare that SB has received a research grant from the Bruyère Academic Medical Organization, and a research award from the Department of Medicine, University of Ottawa; SB was an external reviewer for four sections of the Canadian Coalition for Seniors’ Mental Health (CCSMH) guideline for older adults at the end of life.

  • Ethics approval Review by a Human Ethics Review Committee was not required as this research involved only review of published work and did not involve any data collection from humans.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.