Clinical practice guidelines for delirium management: potential application in palliative care

doi:10.1016/j.jpainsymman.2013.09.023

Review

. 2014 Aug;48(2):249-58.

doi: 10.1016/j.jpainsymman.2013.09.023. Epub 2014 Apr 21.

Clinical practice guidelines for delirium management: potential application in palliative care

Affiliations

¹ Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada. Electronic address: sbush@bruyere.org.
² The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
³ Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Division of Critical Care, Department of Medicine, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
⁴ The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada.
⁵ Institute of Public Health, University of Cambridge, Cambridge, United Kingdom.
⁶ Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia.
⁷ McGill University, Montreal, Québec, Canada.
⁸ Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Division of Critical Care, Department of Medicine, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada.
⁹ Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia.
¹⁰ Département de médecine familiale et de médecine d'urgence, Université Laval, Québec City, Québec, Canada; Centre de recherche du CHU de Québec, Québec City, Québec, Canada.
¹¹ Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Department of Internal Medicine, University of Calgary, Calgary, Alberta, Canada.
¹² Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada.

PMID: 24766743
PMCID: PMC4128754
DOI: 10.1016/j.jpainsymman.2013.09.023

Review

Clinical practice guidelines for delirium management: potential application in palliative care

Shirley H Bush et al. J Pain Symptom Manage. 2014 Aug.

. 2014 Aug;48(2):249-58.

doi: 10.1016/j.jpainsymman.2013.09.023. Epub 2014 Apr 21.

Authors

Affiliations

¹ Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada. Electronic address: sbush@bruyere.org.
² The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
³ Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Division of Critical Care, Department of Medicine, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
⁴ The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada.
⁵ Institute of Public Health, University of Cambridge, Cambridge, United Kingdom.
⁶ Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia.
⁷ McGill University, Montreal, Québec, Canada.
⁸ Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Division of Critical Care, Department of Medicine, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada.
⁹ Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia.
¹⁰ Département de médecine familiale et de médecine d'urgence, Université Laval, Québec City, Québec, Canada; Centre de recherche du CHU de Québec, Québec City, Québec, Canada.
¹¹ Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Department of Internal Medicine, University of Calgary, Calgary, Alberta, Canada.
¹² Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada.

PMID: 24766743
PMCID: PMC4128754
DOI: 10.1016/j.jpainsymman.2013.09.023

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 (1990-2013), Scopus, U.S. National Guideline Clearinghouse, Google, and relevant reference lists to identify published guidelines for the management of delirium. This was supplemented with 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.

Keywords: Delirium; palliative care; practice guidelines.

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Figures

**Fig. 1**
Summary of results of non-systemic literature search for delirium guidelines. CPG = Clinical Practice Guideline. ^a“Relevance” determined by S. H. B.’s review of titles, abstract, and/or content. ^bNote: Reference 18 and are different sources/citations for the National Institute for Health and Clinical Excellence (NICE) CPG.

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Cited by

Adaptation, implementation, and mixed methods evaluation of an interprofessional modular clinical practice guideline for delirium management on an inpatient palliative care unit.
Bush SH, Skinner E, Lawlor PG, Dhuper M, Grassau PA, Pereira JL, MacDonald AR, Parsons HA, Kabir M. Bush SH, et al. BMC Palliat Care. 2022 Jul 16;21(1):128. doi: 10.1186/s12904-022-01010-6. BMC Palliat Care. 2022. PMID: 35841014 Free PMC article.
Clinical Practice Guidelines for Management of Delirium in Elderly.
Grover S, Avasthi A. Grover S, et al. Indian J Psychiatry. 2018 Feb;60(Suppl 3):S329-S340. doi: 10.4103/0019-5545.224473. Indian J Psychiatry. 2018. PMID: 29535468 Free PMC article. No abstract available.
Clinical Assessment and Management of Delirium in the Palliative Care Setting.
Bush SH, Tierney S, Lawlor PG. Bush SH, et al. Drugs. 2017 Oct;77(15):1623-1643. doi: 10.1007/s40265-017-0804-3. Drugs. 2017. PMID: 28864877 Free PMC article. Review.
Quality of clinical practice guidelines in delirium: a systematic appraisal.
Bush SH, Marchington KL, Agar M, Davis DH, Sikora L, Tsang TW. Bush SH, et al. BMJ Open. 2017 Mar 10;7(3):e013809. doi: 10.1136/bmjopen-2016-013809. BMJ Open. 2017. PMID: 28283488 Free PMC article.
Neuroleptics in the management of delirium in patients with advanced cancer.
Hui D, Dev R, Bruera E. Hui D, et al. Curr Opin Support Palliat Care. 2016 Dec;10(4):316-323. doi: 10.1097/SPC.0000000000000236. Curr Opin Support Palliat Care. 2016. PMID: 27661210 Free PMC article. Review.

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References

1. Candy B, Jackson KC, Jones L, et al. Drug therapy for delirium in terminally ill adult patients. Cochrane Database Syst Rev. 2012:CD004770. - PubMed
1. Field M, Lohr KN. Clinical practice guidelines: Directions for a new program. National Academy Press; Washington, DC: 1990. - PubMed
1. Davis D, Goldman J, Palda VA. Handbook on clinical practice guidelines. Canadian Medical Association; Ottawa: 2007. - PMC - PubMed
1. Connis RT, Nickinovich DG, Caplan RA, Arens JF. The development of evidence-based clinical practice guidelines. Integrating medical science and practice. Int J Technol Assess Health Care. 2000;16:1003–1012. - PubMed
1. Falagas ME, Pitsouni EI, Malietzis GA, Pappas G. Comparison of PubMed, Scopus, Web of Science, and Google Scholar: strengths and weaknesses. FASEB J. 2008;22:338–342. - PubMed

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[1] Candy B, Jackson KC, Jones L, et al. Drug therapy for delirium in terminally ill adult patients. Cochrane Database Syst Rev. 2012:CD004770. - PubMed

[2] Candy B, Jackson KC, Jones L, et al. Drug therapy for delirium in terminally ill adult patients. Cochrane Database Syst Rev. 2012:CD004770. - PubMed

[3] Field M, Lohr KN. Clinical practice guidelines: Directions for a new program. National Academy Press; Washington, DC: 1990. - PubMed

[4] Field M, Lohr KN. Clinical practice guidelines: Directions for a new program. National Academy Press; Washington, DC: 1990. - PubMed

[5] Davis D, Goldman J, Palda VA. Handbook on clinical practice guidelines. Canadian Medical Association; Ottawa: 2007. - PMC - PubMed

[6] Davis D, Goldman J, Palda VA. Handbook on clinical practice guidelines. Canadian Medical Association; Ottawa: 2007. - PMC - PubMed

[7] Connis RT, Nickinovich DG, Caplan RA, Arens JF. The development of evidence-based clinical practice guidelines. Integrating medical science and practice. Int J Technol Assess Health Care. 2000;16:1003–1012. - PubMed

[8] Connis RT, Nickinovich DG, Caplan RA, Arens JF. The development of evidence-based clinical practice guidelines. Integrating medical science and practice. Int J Technol Assess Health Care. 2000;16:1003–1012. - PubMed

[9] Falagas ME, Pitsouni EI, Malietzis GA, Pappas G. Comparison of PubMed, Scopus, Web of Science, and Google Scholar: strengths and weaknesses. FASEB J. 2008;22:338–342. - PubMed

[10] Falagas ME, Pitsouni EI, Malietzis GA, Pappas G. Comparison of PubMed, Scopus, Web of Science, and Google Scholar: strengths and weaknesses. FASEB J. 2008;22:338–342. - PubMed

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Clinical practice guidelines for delirium management: potential application in palliative care

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Clinical practice guidelines for delirium management: potential application in palliative care

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