Topic Delerium:

What methods are effective for identifying individuals with delirium, subsyndromal delirium or a high risk of developing delirium (e.g., risk prediction models, screening and assessment tools)?

What patient characteristics influence the identification of individuals with delirium or subsyndromal delirium? Examples of relevant patient characteristics would include demographic factors (e.g., age, sex, race/ethnicity, socioeconomic status) and co-occurring conditions (e.g., medical, alcohol and other substance use, dementia and other psychiatric disorders).

What are the efficacy and comparative effectiveness (benefits and harms) of pharmacological and nonpharmacological interventions to prevent delirium in adults?

What are the efficacy and comparative effectiveness (benefits and harms) of pharmacological and nonpharmacological interventions to treat adults with delirium?

What patient characteristics affect the benefits and harms of pharmacological and non-pharmacological treatments in adults with delirium? Examples of relevant patient characteristics would include demographic factors (e.g., age, sex, race/ethnicity, socioeconomic status), co-occurring conditions (e.g., medical, alcohol and other substance use, dementia and other psychiatric disorders) and concomitant use of specific categories of medication (e.g., potentially harmful medications listed in Beers' criteria).

Non-pharmacological treatments would include multi-component programs and environmental and supportive interventions. They could also include non-pharmacological somatic therapies, if relevant studies have been conducted.

Outcome measures of interest would include sensitivity, specificity and positive and negative predictive values for identifying individuals with delirium or a high risk of delirium (for clinical question 1), delirium free days, delirium severity, length of time on mechanical ventilation, length of stay in critical care and in hospital, time in restraints, time on continuous observation (including 1:1 observation), need for post-hospital rehabilitation or long-term care, significant in-hospital complications (e.g. falls, mortality), and post-hospital complications (e.g., readmissions, cognitive impairment, falls, mortality, PTSD).

Delirium is common in hospitalized patients (about 30%, Salluh et al. BMJ. 350:h2538, 2015), particularly in critical care settings and in the context of specific high-volume surgical procedures (e.g., cardiac surgery, orthopedic procedures). However, delirium is often under-recognized, particularly when subsyndromal or when hypoactive delirium is present (Cole et al. Int J Geriatr Psychiatry. 28(8):771-80, 2013), with up to half of the patients in an intensive care unit not detected even when using a screening tool (Neto et al. Crit Care Med. 40(6):1946-51, 2012). Identification of delirium can also be important in recognizing other treatable but clinically urgent conditions such as alcohol withdrawal, medication related toxicities, or infection.

Delirium is associated with multiple negative health outcomes for patients, including mortality (Kennedy et al. J Am Geriatr Soc. 62(3):462-9, 2014; Salluh et al. BMJ. 350:h2538, 2015; Zhang et al. Gen Hosp Psychiatry. 35(2):105-11, 2013; Witlox et al. JAMA. 304(4):443-51, 2010; de Boissieu J Nutr Health Aging. 19(6):702-7, 2015), increased risk of falls (Pendlebury et al., BMJ Open. 5(11):e007808, 2015), greater time on mechanical ventilation (Salluh et al. BMJ. 350:h2538, 2015; Zhang et al. Gen Hosp Psychiatry. 35(2):105-11, 2013), higher rates of overall complications (Zhang et al. Gen Hosp Psychiatry. 35(2):105-11, 2013), longer lengths of stay (both in critical care units and in hospital) (Kennedy et al. J Am Geriatr Soc. 62(3):462-9, 2014; Salluh et al. BMJ. 350:h2538, 2015; Zhang et al. Gen Hosp Psychiatry. 35(2):105-11, 2013) and greater need for post-hospitalization rehabilitation (Kennedy et al. J Am Geriatr Soc. 62(3):462-9, 2014; Zhang et al. Gen Hosp Psychiatry. 35(2):105-11, 2013; Witlox et al. JAMA. 304(4):443-51, 2010). Patients with residual delirium may also be at increased risk of readmission (Kennedy et al. J Am Geriatr Soc. 62(3):462-9, 2014) due to factors such as associated cognitive impairment (Salluh et al. BMJ. 350:h2538, 2015), or increased risk of falls (Pendlebury et al., BMJ Open. 5(11):e007808, 2015). Specific negative psychiatric outcomes may include greater rates of longer term cognitive deficits (Salluh et al. BMJ. 350:h2538, 2015; Witlox et al. JAMA. 304(4):443-51, 2010) and an increased risk of developing post-traumatic stress disorder as a result of a hospital stay (Wade et al. Minerva Anestesiol. 79(8):944-63, 2013; Karnatovskaia et al., J Crit Care. 30(1):130-7, 2015).

In addition to the many negative effects of delirium for patients and their families, many of these negative outcomes associated with delirium have significant resource implications for health care delivery systems and policy makers in terms of health care costs and staffing.

An up-to-date evidence-based review of the efficacy and comparative effectiveness of treatments for delirium would inform development of a clinical practice guideline aimed at optimizing clinical interventions and patient outcomes for individuals with delirium. The most recent practice guideline of the American Psychiatric Association was published in 1999, with an updated discussion of subsequent literature in 2004. A substantial body of literature has been published since that time, including studies of several newer antipsychotic medications. We anticipate that this review will result in modifications to current guideline recommendations and will improve care to patients.

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Professional society; developer of clinical practice guidelines

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American Psychiatric Association

Please tell us how you heard about the Effective Health Care Program

The American Psychiatric Association has been aware of the Effective Health Care Program for a long time. We are now using the systematic reviews produced by the Effective Health Care Program for guideline development and we track the status of Effective Health Care Program projects that are under development through e-mail alerts and frequent use of the Effective Health Care Program website.