Vol. - No.

- - 2014 Journal of Pain and Symptom Management 1

Special Article

Clinical Practice Guidelines for Delirium

Management: Potential Application in
Palliative Care
Shirley H. Bush, MBBS, MRCGP, FAChPM, Eduardo Bruera, MD,
Peter G. Lawlor, MB, FRCPI, MMedSc, Salmaan Kanji, BSc Pharm, PharmD,
Daniel H.J. Davis, MB ChB, MRCP, Meera Agar, MBBS, FRACP,
David Wright, RN, PhD, CHPCN(C), Michael Hartwick, MD, FRCPC,
David C. Currow, BMed, MPH, FRACP, Bruno Gagnon, MD, MSc,
Jessica Simon, MD, FRCPC, and Jos
e L. Pereira, MBChB, CCFP, MSc
Division of Palliative Care (S.H.B., P.G.L., M.H., J.L.P.) and Division of Critical Care (M.H.),
Department of Medicine, Department of Epidemiology and Community Medicine (P.G.L.), University
of Ottawa; Bruye re Research Institute (S.H.B., P.G.L., J.L.P.), Bruye re Continuing Care, Ottawa,
Ontario, Canada; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas,
USA; Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community
Medicine, University of Ottawa; The Ottawa Hospital Research Institute (P.G.L., S.K.); The Ottawa
Hospital (S.K., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of
Cambridge, Cambridge, United Kingdom; Discipline, Palliative & Supportive Services (M.A.,
D.C.C.), Flinders University, Adelaide, South Australia; South West Sydney Clinical School (M.A.)
University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital,
HammondCare, Sydney, New South Wales, Australia; McGill University (D.W.), Montreal, Que bec;
De partement de me decine familiale et de me decine d’urgence, Universite Laval (B.G.); Centre de
recherche du CHU de Que bec (B.G.), Que bec City, Que bec; Division of Palliative Medicine (J.S.),
Department of Oncology; and Department of Internal Medicine (J.S.), University of Calgary, Calgary,
Alberta, Canada

Abstract
Context. Delirium occurs in patients across a wide array of health care settings.
The extent to which formal management guidelines exist or are adaptable to
palliative care is unclear.
Objectives. This review aims to 1) source published delirium management
guidelines with potential relevance to palliative care settings, 2) discuss the
process of guideline development, 3) appraise their clinical utility, and 4) outline
the processes of their implementation and evaluation and make
recommendations for future guideline development.
Methods. We searched PubMed (1990e2013), Scopus, U.S. National Guideline
Clearinghouse, Google, and relevant reference lists to identify published
guidelines for the management of delirium. This was supplemented with

Address correspondence to: Shirley H. Bush, MBBS, Accepted for publication: September 10, 2013.
MRCGP, FAChPM, Bruyere Continuing Care, 43
Bruyere Street, Ottawa, Ontario K1N 5C8, Canada.
E-mail: sbush@bruyere.org

Ó 2014 U.S. Cancer Pain Relief Committee. 0885-3924/$ - see front matter
Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpainsymman.2013.09.023
2 Bush et al. Vol. - No. - - 2014

multidisciplinary input from delirium researchers and other relevant stakeholders

at an international delirium study planning meeting.
Results. There is a paucity of high-level evidence for pharmacological and non-
pharmacological interventions in the management of delirium in palliative care.
However, multiple delirium guidelines for clinical practice have been developed,
with recommendations derived from ‘‘expert opinion’’ for areas where research
evidence is lacking. In addition to their potential benefits, limitations of clinical
guidelines warrant consideration. Guidelines should be appraised and then
adapted for use in a particular setting before implementation. Further research is
needed on the evaluation of guidelines, as disseminated and implemented in a
clinical setting, focusing on measurable outcomes in addition to their impact on
quality of care.
Conclusion. Delirium clinical guidelines are available but the level of evidence
is limited. More robust evidence is required for future guideline
development. J Pain Symptom Manage 2014;-:-e-. Ó 2014 U.S. Cancer Pain
Relief Committee. Published by Elsevier Inc. All rights reserved.

Key Words
Delirium, palliative care, practice guidelines

Introduction
The evidence base for the management of
delirium in palliative care patients is limited
by the lack of good quality randomized
controlled trials,1 with practice often guided
by expert opinion and consensus-based clinical
guidelines. Clinical practice guidelines have
been defined as ‘‘systematically developed
statements to assist practitioner and patient de-
cisions about appropriate health care for spe-
cific clinical circumstances.’’2 From the
Canadian Medical Association’s Handbook on
Clinical Practice Guidelines, guidelines aim to
‘‘summarize research findings and make clin-
ical decisions more transparent’’ and ‘‘identify
gaps in knowledge and prioritize research activ-
ities.’’3 Considering delirium, these aims are
especially advantageous, given the multifaceted
approach required for delirium assessment and
management. The development of guidelines
requires a broad evidence-based approach to
evaluate research findings4 but good quality
studies are still lacking.
This review aims to 1) source published
delirium management guidelines with poten-
tial relevance to palliative care settings, 2)
discuss the process of guideline development,
3) appraise their clinical utility, and 4) outline
the processes of their implementation and
evaluation and make recommendations for
future guideline development.
Methods
Various formal delirium clinical guidelines
have been developed by consensus. Before an
international delirium study meeting, a non-
systematic search for formal guidelines was con-
ducted. We searched PubMed (1990e2013),
Scopus, U.S. National Guideline Clearinghouse,
GoogleÔ, and relevant reference lists to identify
published guidelines for the management of
delirium. ‘‘Relevance’’ was determined by the
primary author’s (S. H. B.) review of titles and ab-
stract or content, where available. The Scopus
database was used because of its broader journal
range.5 In June 2012, Scopus was searched using
the search term ‘‘delirium guideline.’’ The Na-
tional Guideline Clearinghouse, hosted by the
U.S.-based Agency for Healthcare Research and
Quality,6 was searched according to ‘‘guidelines
by topic’’ and ‘‘delirium.’’ GoogleÔ was searched
using the search term ‘‘delirium guideline’’ and
reviewing the first 15 Web pages of results. A
PubMed search of ‘‘delirium,’’ using ‘‘guideline’’
and ‘‘English’’ as filters, was subsequently con-
ducted in March 2013. This literature search
was supplemented with multidisciplinary input
from delirium researchers and other relevant
stakeholders (primary care and specialist-level
clinicians, palliative care experts, and clinical ad-
ministrators) at a two-day international delirium
study planning meeting (SUNDIPS) in June
2012 in Ottawa.
Vol. - No. - - 2014 Delirium Guidelines in Palliative Care 3

Results Sixteen listings were found on the National

Guideline Clearinghouse Web site.6 From
Scope of Identified Delirium Guidelines
these, only a summary of the NICE guideline
The Scopus database search resulted in 17
(with an electronic link to obtain a PDF version
citations, of which four were relevant: two arti-
of the guideline), an ‘‘acute confusion/
cles summarized delirium guidelines,7,8 one
delirium’’ guideline summary,20 and an
reported a European survey of delirium guide-
evidence-based geriatric nursing protocol21
lines,9 and one presented delirium guidelines
specifically referred to delirium. Additionally,
for general hospitals.10 A follow-up Scopus
the summary for an updated version of nursing
search, conducted in March 2013, retrieved
guidelines for caregiving strategies for older
another article describing a controlled trial
adults with delirium, dementia, and depression
evaluation of implemented delirium guide-
also was sourced on this repository.22
lines on a medical ward in Australia.11
From the GoogleÔ search, it was possible to
The PubMed search retrieved 153 articles, of
find the repositories and retrieve a larger num-
which 11 were relevant to the topic of delirium
ber of actual guidelines including those from
guidelines on abstract review. These included
the APA,23 Royal College of Physicians with
six published articles providing ‘‘executive sum-
the British Geriatric Society,24 Royal College
maries’’ of published guidelines7,12e16 and the
of Psychiatrists (a fact sheet for patients and ju-
same European survey of delirium guidelines.9
nior doctor’s practical guide),25 NICE,26 and
Only four distinct delirium guidelines were
Australian and Canadian (2006) delirium
retrieved from the PubMed search: American
guidelines in the elderly.27,28 Excluding dupli-
Psychiatric Association (APA),17 the U.K. Na-
cates, the overall literature search sourced
tional Institute for Health and Clinical Excel-
nine actual delirium guidelines; a summary
lence (NICE),18 guidelines for general
of these results is shown in Fig. 1.
hospitals,10 and the recently updated clinical
Review of the titles and tables of contents
practice guidelines for the intensive care
where appropriate (S. H. B.) of the sourced
setting.19

Fig. 1. Summary of results of non-systemic literature search for delirium guidelines. CPG ¼ Clinical Practice Guide-
line. a‘‘Relevance’’ determined by S. H. B.’s review of titles, abstract, and/or content. bNote: Reference 18 and 26 are
different sources/citations for the National Institute for Health and Clinical Excellence (NICE) CPG.
4 Bush et al. Vol. - No. - - 2014

guidelines and executive summaries identified delirium. Locally developed institutional

four published guidelines focusing on the
management of delirium at the end of life,
or in older adults.29e32 In addition, another
earlier delirium guideline with a focus on pa-
tients near the end of life was sourced through
separate hand searching (S. H. B.)33 (Table 1).
The APA Practice Guideline for the treatment
of patients with delirium was the earliest pub-
lished guideline found.17 It was originally pub-
lished in May 1999 but has not been formally
updated since then.
In 2006, Leentjens and Diefenbacher re-
ported a survey of national liaison psychiatric
associations to ascertain the existence and
content of European delirium guidelines.9 At
that time, only the associations for The
Netherlands and Germany reported having na-
tional delirium guidelines, with the German
guideline being focused on alcohol withdrawal
guidelines also were reported, and beyond
consultation-liaison psychiatric associations,
the British Geriatric Society guideline was
highlighted. The following year, Michaud
et al. reported the development of delirium
guidelines for general hospitals in Lausanne,
Switzerland. An expert multidisciplinary panel
used a consultative process to supplement the
areas of low evidence found on evaluation of
the literature and gain consensus on compre-
hensive recommendations.10 More recently,
the U.S. Department of Veterans Affairs pub-
lished a systematic review of the evidence for
the screening, prevention, and diagnosis of
delirium.34
The degree of dissemination of delirium
guidelines published by guideline develop-
ment groups, colleges, specialist professional
societies, and government organizations into

Table 1
Examples of Published Guidelines on the Management of Delirium at the End of Life and in Older Adults
Guideline Title Source Country, Year Domains Included

Diagnosis and Management of
Delirium near the End of
Life33
Guideline on the Assessment Canadian Coalition for Seniors’
and Treatment of Delirium in
Older Adults at the End of
29
Life
Prevention, Diagnosis, and
Management of Delirium in
Older People: National
Guidelines30
Clinical Practice Guidelines for
the Management of Delirium
in Older People31
National Guidelines for Senior
Mental Health: The
Assessment and Treatment of
Delirium32
American College of Physicians- United States, 2001 Detection, assessment,
American Society of Internal prevention and non-
Medicine End-of-Life Care pharmacological
Consensus Panel management,
pharmacological management
Canada, 2010 Prevention, detection,
Mental Health assessment, monitoring, non-
pharmacological
management,
pharmacological
management, education,
legal, and ethical issues
British Geriatric Society and United Kingdom, 2006 Prevention, detection,
Royal College of Physicians assessment, non-
pharmacological
management,
pharmacological
management, education,
implementation
Clinical Epidemiology and Australia, 2006 Detection, assessment of risk
Health Service Evaluation factors, prevention, non-
Unit, Melbourne and pharmacological
Delirium Clinical Guidelines management,
Expert Working Group pharmacological
management, education,
implications for research,
implementation
Canadian Coalition for Seniors’ Canada, 2006 Prevention, detection,
Mental Health assessment, monitoring, non-
pharmacological
management,
pharmacological
management, education, legal
and ethical issues, systems of
care, challenges and
opportunities for research on
delirium
Vol. - No. - - 2014 Delirium Guidelines in Palliative Care
the peer-reviewed literature from our litera-
ture search appeared to vary.7,8,12e15 NICE
created a brief downloadable slide set for
implementing its clinical guideline on
delirium.35 An interactive case-based tutorial
was developed for the 2006 Canadian Coali-
tion for Seniors’ Mental Health National
Guidelines.36
Discussion
The Process of Delirium Guideline
Development
The development of clinical guidelines takes
significant time and money.9,10 Guideline
development panels should include various
members of the interprofessional care team
including nursing, as well as other clinical dis-
ciplines (e.g., psychiatry, geriatrics, pharma-
cists), nonclinical stakeholders (such as
health economists and methodological ex-
perts), and carers/family members.9,37
There remains a lack of evidence for many
interventions, so many delirium guideline rec-
ommendations may only be supported by weak
or inconclusive evidence or derived from
‘‘expert opinion’’ within the guideline devel-
opment group. Further studies with higher
quality design and placebo-controlled trials
are needed to strengthen recommendat-
ions related to specific interventions within
guidelines, including pharmacological and
non-pharmacological modalities and ap-
proaches.1,38 Defined methods for incorpo-
rating qualitative studies and other types of
knowledge, such as clinical audits and quality
improvement projects, into clinical guidelines
need to be developed.39
The validity and quality of clinical practice
guidelines should be critically assessed.40
Guideline quality is impacted by many factors,
including lack of adherence to methodological
standards for development, composition of the
writing panel, potential conflicts of interest,
limited external review,37,41 and not solely on
the quality of currently available published
studies. The Appraisal of Guidelines for
Research and Evaluation (AGREE) instru-
ment, now updated to AGREE II, is an
example of an appraisal instrument to assess
the quality of clinical practice guidelines and
evaluates the development process.42,43
5
Clinical guidelines need to be kept up to
date, the so called ‘‘living guideline.’’3 To avoid
guidelines going beyond an ‘‘expiry date,’’ it
has been recommended that guideline validity
is reassessed every three years.44 However, the
National Guideline Clearinghouse Web site re-
quires annual verification,6 and in April 2012,
a summary of new evidence for the 2010
NICE clinical guideline was produced.45
Potential Benefits of Clinical Guidelines
Several potential benefits of guidelines have
been noted, including benefits to patients
through improved health outcomes on an in-
dividual level, along with shaping public policy
at a macro level.46 For health care profes-
sionals, guidelines can assist with clinical care
and decision making.46 By providing a stan-
dard of care and guidance to non-experts,
guidelines ensure continuity of patient care
and also reduce unnecessary variation in care
delivery. Another potential benefit of guide-
lines is the ability to carry out benchmarking
exercises for inter-institutional comparison
and maintenance of predefined standards.
However, guidelines lose their flexibility if
automatically used as performance mea-
sures.47 By providing a critical appraisal of cur-
rent research evidence, the process of
guideline development will highlight the areas
where more evidence and higher quality
studies are needed.
Potential Limitations of Clinical Guidelines
Guidelines are not without limitations and
these should be recognized. The recommen-
dations may be influenced by the individual
biases of members of the guideline develop-
ment group, especially when research evi-
dence is lacking. A flawed clinical guideline
may compromise patient care by providing
inaccurate or out-of-context information to cli-
nicians.46 By standardizing clinical practice,
guidelines may reduce individualized patient
care if they are applied without inbuilt flexi-
bility, as there may be individual patient situa-
tions that warrant deviation from practice
guidelines. Guidelines may not be applicable
across diverse populations. General delirium
guidelines may not address specific issues
relating to particular patient populations,
such as palliative care. Poor accessibility, dupli-
cation, and suboptimal implementation of
6 Bush et al.
clinical guidelines may lead to guideline
confusion or ‘‘fatigue’’ and lead to poor up-
take and adoption by health care profes-
sionals. There may be legal implications for
cases where health care professionals have
deviated from clinical practice guidelines that
have been accepted into routine practice if
the guideline is considered to be a standard
of care.48,49
Implementation of Clinical Guidelines
Shaneyfelt stresses that the goal of guide-
lines is to enhance health care quality and out-
comes.37 However, circulation of guidelines
alone may not achieve this, even when supple-
mented with teaching sessions.50 Potential bar-
riers to change should be determined to assist
with the planning of a site implementation
initiative.51 These include barriers relating to
the current level of knowledge, existing cul-
ture, and practices of health care profes-
sionals, in addition to organizational and
economic barriers.3,52 The implementation of
guidelines requires ongoing education, orga-
nizational change, management ‘‘buy in,’’
and budgetary support.9,38,53 Long-term orga-
nizational support is also critical to ensure sus-
tainability.8,11 Appraised guidelines need to be
adapted for use in a particular setting, taking
into account current institutional culture and
resource availability, by a multidisciplinary
clinical practice guideline working group
before commencing the implementation
strategy.52 Several approaches have been
described to adapt or adopt existing guidelin-
es and improve utilization. These include
the ADAPTE and CAN-IMPLEMENT meth-
odologies.54e56 The guideline recommenda-
tions may need to be reconceived as
measurable criteria and quality improvement
goals.52 This will enable outcomes to be quan-
tified post-implementation. The full version of
a lengthy, but comprehensive, guideline is
often impractical to implement in busy clinical
settings, so it may need to be reformatted as a
practical user-friendly summary sheet that is
easy to follow. Adapted guidelines need to sup-
port staff, rather than add additional
burden.57 A variety of dissemination tech-
niques and implementation strategies that
actively engage health care professionals
should be considered.58 However, single inter-
ventions (such as dissemination of educational
Vol. - No. - - 2014
materials) may be as effective as multifaceted
interventions59 but more evidence is re-
quired.60 Visible reminders such as posted
flyers and also clinical prompts or algorithms
will assist health professionals to use the guide-
line in their clinical practice.
Evaluation of Implemented Clinical
Guidelines
A formal evaluation plan is vital to assessing
the impact of clinical guidelines on the quality
of patient care and other desired outcomes, as
well as unintended consequences and undesir-
able outcomes. The support of guideline eval-
uation experts for this stage is recommended.3
Measurable evaluation outcomes should be
determined by the clinical practice guideline
working group. This will inform the necessary
data collection strategy and the most appro-
priate study design.3
An Australian medical record audit of
elderly hospitalized patients with delirium,
before the implementation of new guidelines,
showed a wide variation in prescribing of anti-
psychotics and associated documentation.61 A
lack of physician prescribing consistency can
be very confusing, especially for nursing staff
and medical learners, and affect quality of
care. Guidelines should help clinicians follow
a more integrated approach to manage
delirium, thus reducing unnecessary variation
in care delivery.12 The impact of guidelines
on standardizing an institution’s pharmacolog-
ical management of delirium in palliative care
patients (choice of drugs and dosing) and
improving documentation is an area deserving
further study. This in turn will stimulate a
search for further evidence regarding the
appropriate drug dosing of antipsychotics in
delirium management in this patient popula-
tion. Leentjens and Diefenbacher pointed out
that for a guideline to be truly ‘‘evidence
based,’’ and not just developed from evidence-
based studies, then it should be first tested
against usual treatment.9
The efficacy of guidelines in the implemen-
tation of non-pharmacological interventions
by nursing and other clinical staff for patients
at risk or experiencing delirium is another
area for further research in palliative care pop-
ulations.62 The evidence used to make individ-
ual recommendations within a guideline are
often based on the potential benefit or harm
Vol. - No. - - 2014 Delirium Guidelines in Palliative Care
of a particular intervention, whereas the evalu-
ation of an implemented guideline appraises
the potential additive, synergistic, or antago-
nistic effects of a multifaceted approach to a
disease or syndrome, such as delirium.
Other examples for future research evalu-
ating guideline implementation may include
local, single center initiatives that include the
measurement of outcomes pre- and post-
guideline implementation as a quality improve-
ment project. The systematic assessment of the
impact of implemented guidelines on clinical
outcomes using standardized non-burdensome
tools that are part of clinical practice could be
a useful approach.63 Larger, multicentered
research programs might evaluate adherence
to implemented guideline recommendations
and also clinical outcomes using a cluster
randomized trial design involving multiple
palliative care units and evaluating different
guideline implementation strategies. Other
quantitative and qualitative studies also are
required for process evaluation, quality of
care, and cost-effectiveness analysis.3,58,64e66
The evaluation of pharmacological delirium
protocols and their impact on outcomes is
another area for further research.38
Multidisciplinary Contributions at the
SUNDIPS International Delirium Study
Planning Meeting
With respect to delirium practice guidelines,
participants’ opinions were divided into two
groups. Even in the absence of a strong evi-
dence base, many clinical guidelines have
been developed but do not appear to have
been embraced or taken up to guide health
professional practice.47 Some participants
advocated for the systematic implementation
of adapted guidelines into clinical practice,
notwithstanding the limitations in the levels
of evidence. The impact of the guideline on
patient and process outcomes would be sys-
tematically evaluated using standardized, vali-
dated, low-burden bedside instruments that
assess pertinent outcomes such as the severity
of delirium, agitation, and hallucinations and
also show the effect on standardization of
care among members of the palliative care
community. Evaluation of implemented guide-
lines also enables the assessment of the differ-
ence in outcomes (effectiveness and harms) in
the real world where prescribers are not bound
7
by the constraints of the clinical trial environ-
ment. It also could include, for example, pro-
cesses to systematically assess and document
the impact of rescue doses of antipsychotic
medications. In contrast, some participants
felt that at this stage, given the ongoing rela-
tive lack of research evidence, current delirium
guidelines should not be used as they are
mainly expert consensus statements. Instead,
research efforts should be focused on gener-
ating new high-level evidence first to
strengthen the current evidence base for
delirium practice. However, the limitation to
this approach is that, given the challenges in
conducting research in end-of-life popula-
tions, let alone in patients with cognitive defi-
cits, we would have to wait for many years
before being ready to develop delirium guide-
lines based entirely on high level (randomized
placebo-controlled studies) evidence.
Next Steps in Advancing Delirium Guideline
Use in Palliative Care
Our non-systematic literature search with
selected databases demonstrated that delirium
guidelines can be difficult to source. To source
all potential guidelines, a formal, librarian-
assisted, systematic search should be conduct-
ed, including the grey literature. There is an
outstanding need for a formal critical assess-
ment of the quality and validity of published
delirium guidelines, using tools such as
AGREE,42,43 by independent reviewers. This
process will then enable the selection of a
high-quality and applicable delirium guideline
to be adapted and then implemented into a
local palliative care clinical setting by the inter-
professional team. We have begun this process
in our institution (S. H. B., P. G. L. and J. L. P.).
Conclusion
Further trials are needed to increase the ev-
idence base from which delirium guidelines
are derived and thus ensure best practice guid-
ance. After first generating a robust body of
research evidence, high-quality guidelines can
then be developed and implemented strategi-
cally to disseminate this evidence. Even in
the interim absence of a robust evidence
base, implementation of current guidelines
into clinical practice may facilitate the
8 Bush et al.
standardization of care and improve on the
current choice of drugs and dosing regimens
as well as generate new research ideas. The ef-
ficacy of guidelines implemented in different
palliative care settings and with different
implementation strategies needs further
evaluation.
Disclosures and Acknowledgments
There was no funding source or sponsorship
for this article. Drs. S. H. B., P. G. L., and J. L. P.
receive research awards from the Department
of Medicine, University of Ottawa. Dr. E. B. is
supported in part by National Institutes of
Health grant numbers RO1 NR010162-01A1,
RO1 CA122292-01, and RO1 CA124481-01,
and in part by the M. D. Anderson Cancer Cen-
ter support grant #CA 016672. Dr. D. H. J. D. is
funded by the Wellcome Trust as a Research
Training Fellow. Dr. B. G. is the recipient of
the ‘‘Chercheur-Boursier’’ award, from the
Fonds de la recherche du Qu ebec, Sante
(FRQS). The authors have no conflicts of in-
terest to disclose.
The authors acknowledge input from the
participants (listed in the Foreword to this Sec-
tion) at the SUNDIPS Meeting, Ottawa, June
2012. This meeting received administrative
support from Bruy ere Research Institute and
funding support through a joint research
grant to Dr. P. G. L. from the Gillin Family
and Bruy ere Foundation.
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