Table 3 Synthesis of recommendations for delirium. Refer to Additional file 3: Appendix 3 for footnote details

Allard et al.

Guideline on the Assessment and Treatment of Delirium in Older Adults at the End of Life

•Risk factors include socio-demographic, physical, medical, and mental status, laboratory findings, surgery, and anesthesia ^a

•Provide educational training for healthcare professionals ^b

•Use validated screening tools for diagnosis ^c

•Use nonpharmacological interventions ^d

•Monitor environmental and patient risk factors for recurrence ^e

•Use non-opioid analgesics first, and if an opioid is needed use the minimum effective dose

•Use the lowest dose of psychotropic medications

•Haloperidol is the antipsychotic drug of choice, while benzodiazepines are only recommended for alcohol or sedative withdrawal delirium

•There is insufficient evidence to recommend for or against psychotropic medications for hypoactive delirium

•Avoid pharmacologic interventions aggravating delirium ^f

American Geriatrics Society

American Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older Adults

•Provide educational training for healthcare professionals

•Evaluate reversible medical causes

•Use nonpharmacological interventions

•Avoid using pharmacological interventions with a high risk of aggravating delirium

•Use non-opioid analgesia for prevention of post-surgical delirium

•Avoid new use of cholinesterase inhibitors and benzodiazepines

•Hypoactive delirium should not be treated with benzodiazepines or antipsychotics

Andersen et al.

Screening, Assessment, and Care of Anxiety and Depressive Symptoms in Adults with Cancer: An American Society of Clinical Oncology Guideline Adaptation

•Refer patients with signs of delirium to a psychiatrist, psychologist, or equivalently trained mental health professional

•Use validated screening tools

•Treat reversible medical causes of delirium first

•Use nonpharmacological interventions to create a safe environment and reduce risk of harm to self and others

BC Guidelines and Protocols Advisory Committee

Palliative Care for the Patient with Incurable Cancer or Advanced Disease Part 2: Pain and Symptom Management

•Assess delirium using factors like level of consciousness, hallucinations, fluctuation in mental state or confusion

•Treat reversible medical causes of delirium if consistent with goals of care

•Use non-pharmacological interventions which include changing the environment, lighting, and safety protocols

•Use different pharmacological interventions if delirium is hypoactive ^g, hyperactive ^h, or hyperactive and a risk to self and others ⁱ

•Consider palliative sedation when delirium is not reversible

Brajtman et al.

Developing Guidelines on the Assessment and Treatment of Delirium in Older Adults at the End of Life

•Detect delirium using the CAM along with other validated tools ^j but these should only be used as a diagnostic aid

•Remain vigilant for any changes in mental status, cognition, behavior, or functional ability, and investigate any new changes

•Prioritize educating healthcare professionals about the care of older adults

•Ensure adequate hydration by oral fluid intake or hypodermoclysis

•Use the minimum effective dose of analgesics to control pain, and consider opioid rotation

•Use antipsychotics for delirium that is not a result of alcohol or benzodiazepine withdrawal

•Acquire a second professional opinion before treatment of hyperactive or mixed delirium, and treat with alternative strategies (switching antipsychotics, combining two antipsychotics including one with a sedative effect, and combining a benzodiazepine with an antipsychotic)

•Minimize physical restraints and use only in exceptional circumstances

Bush et al.

Delirium in adult cancer patients: ESMO Clinical Practice Guidelines

•Risk factors include direct ^k (cancer related) and indirect ^l (secondary) complications

•Diagnose delirium by administering validated clinical assessments based on DSM or ICD criteria with a trained healthcare professional

•Provide delirium education for family caregivers

•Identify and treat the reversible medical causes of delirium through a comprehensive initial assessment ^m

•Non-pharmacological interventions specific to adult cancer patients do not have enough evidence base for a recommendation

•Consider deprescribing medication and cancer therapy

•Use pharmacological interventions ⁿ

Dans et al.

NCCN Guidelines Palliative Care, Version 2.2017

•Risk factors include patient with cancer and moderate to severe pain, nausea, anxiety, depression, shortness of breath, drowsiness, well-being, loss of appetite, and tiredness in the last weeks of life

•Follow different intervention course ^o based on length of estimated life expectancy to reduce patient distress

Devlin et al.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

•Risk factors include benzodiazepine use, blood transfusions, greater age, dementia, prior coma, pre-ICU emergency surgery or trauma, and increasing APACHE and ASA scores

•Use validated delirium predictive models ^p

•Assess ICU patients regularly for delirium with a valid tool like the CAM-ICU or the ICDSC, however the level of arousal may influence the results

•Non-pharmacological bright light therapy is not recommended

•Use multicomponent, non-pharmacological interventions ^q

•Some pharmacologic interventions ^r should not be used to prevent delirium

•Subsyndromal delirium should not be treated using haloperidol or an atypical antipsychotic

•Use a pharmacological treatment like dexmedetomidine for agitated patients during extubation

•Pharmacological interventions for delirium using haloperidol, an atypical antipsychotic, or a statin are not recommended

ACR expert panel

ACR Appropriateness Criteria Acute Mental Status Change, Delirium, and New Onset Psychosis

•Risk factors include medical and environmental factors ^s

•Diagnose delirium using the DSM-V criteria •Use screening tools like the CAM and briefer variants (CAM-ICU, B-CAM)

•Use CT head without contrast for initial imaging of new onset delirium

•Consider MRI and contrast enhanced MRI for further evaluation of a brain abnormality (space occupying legion or infection) linked to delirium and previously detected using CT

Fraser Health

Delirium/Restlessness Symptom Guidelines

•Risk factors are usually multi-factorial ^u •Assess delirium using the acronym OPQRSTUV ^t in addition to laboratory studies ^v

•Diagnose delirium using the DSM-IV criteria

•Use non-pharmacological interventions ^w

•Use pharmacological interventions ^x based on level of confusion after treating reversible medical causes

•Consider palliative sedation when all other measures have failed

Grover and Avasthi

Clinical Practice Guidelines for Management of Delirium in Elderly

•“Robust” risk factors include higher age, presence of cognitive impairment, severe concomitant medical illness and receiving medications however others ^y can also contribute to delirium

•Diagnose delirium using the DSM-V criteria

•Use various screening and diagnosis instruments ^z to diagnose the presence and severity of delirium

•Identify and treat reversible medical causes of delirium ^aa

•Monitor for changes or recurrence in hospital ^ab

•Use non-pharmacological interventions for support and orientation, maintaining of patient competence, and creating an unambiguous environment ^ac

•Use pharmacological interventions ^ad when non-pharmacological interventions have failed, or when severe agitation is present

•Use scales like the Anticholinergic Burden Classification to minimize anticholinergic load

•Follow-up after discharge from hospital and educate family on signs of recurrence

Harle et al.

Cancer Care Ontario's Symptom Management Guide-to-Practice: Delirium

•Risk factors are usually multi-factorial, use the acronym DELIRIUM ^ae to facilitate assessment

•Assess delirium using the acronym OPQRSTUV (adapted from Fraser Health)

•Diagnose delirium using the DSM-IV criteria

•Screen for delirium using the Mini-Mental State Exam, Confusion Rating Scale, Nursing Delirium Screening Scale, Memorial Delirium Assessment Scale

•Use non-pharmacological interventions and pharmacological interventions based on level of confusion after treating reversible medical causes (adapted from Fraser Health) ^af

Hogan and McCabe

National Guidelines for Seniors' Mental Health: The Assessment and Treatment of Delirium

•Risk factors are multifactorial ^ag

•Diagnose delirium using the DSM-IV criteria

•Detect and routinely screen for delirium using validated tools ^ah

•Monitor delirium using reliable tools ^ah

•Treat reversible medical causes first such as infection, pain, and sensory deficits

•Use non-pharmacological interventions to treat and prevent delirium ^ai

•Remove medication that precipitates of aggravates delirium ^aj

•Use pharmacological management only if patient is distressed ^ak

•Only use physical restraints in exceptional circumstances where the benefits outweigh the risks to patient

Jacobi et al.

Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult

•Diagnose delirium using the DSM-IV criteria

•Routinely screen for delirium using the validated CAM-ICU tool

•Use haloperidol as a pharmacological intervention, and monitor for electrocardiographic changes after prescribing

Martin et al.

Evidence and Consensus-based German Guidelines for the Management of Analgesia, Sedation and Delirium in Intensive Care - Short Version

•Screen for delirium using validated tools like the CAM-ICU and the ICDSC

•Use non-pharmacological interventions for example maintaining day-night rhythm, environment reorganisation, cognitive stimulation, and early mobilization

•Use antipsychotics for the treatment and prevention of delirium

•During substance withdrawal, use alpha-2 agonists and benzodiazepines as a pharmacological intervention

•Taper analgesics and sedatives to reduce risk of withdrawal

McNeill et al.

Delirium, Dementia, and Depression in Older Adults: Assessment and Care, Second Edition

•Assess risk factors ^al on admission and if a change in condition occurs

•Use clinical assessment and validated tools ^am to assess patients at risk for delirium at least daily where appropriate or when changes in cognition are observed

•Educate family to recognise signs of delirium

•Use multicomponent non-pharmacological ^al and pharmacological interventions tailored to risk factors in collaboration with the patient, the family, and the interprofessional team

•Use physical restraints as a last resort

Michaud et al.

Delirium: Guidelines for General Hospitals

•Risk factors ^an are multifactorial and include predisposing factors on admission, precipitating factors during stay and aggravating environmental factors

•Use validated tools ^ao for screening, diagnosing, and rating the severity of delirium

•The use of electroencephalogram, brain imaging and lumbar puncture is controversial

•Use non-pharmacological interventions ^ap

•Minimize drug effects and withdrawal symptoms

•Use pharmacological interventions ^aq when non-pharmacological interventions fail and patient remains agitated

•Restraint may be needed for dangerous patients, however a restraint protocol must be used and routinely evaluated

Neufeld et al.

Antipsychotics for the Prevention and Treatment of Delirium

NS

•There is little to no evidence to determine the effect of antipsychotics for prevention of delirium

•Second-generation antipsychotics may lower the occurrence of delirium in post-surgical patients

•Treating or preventing delirium using haloperidol or second-generation antipsychotics may lead to heart-related side effects and little or no difference in sedation

NICE rapid guideline development group

COVID-19 Rapid Guideline: Managing Symptoms (including at the end of life) in the Community

NS

•Treat reversible medical causes of delirium

•Use non-pharmacological interventions like adequate lighting, effective communication, and orientation techniques

•Consider a benzodiazepine like levomepromazine based on patient swallowing capacity or level of distress ^ar

Potter et al.

The Prevention, Diagnosis and Management of Delirium in Older People: Concise Guidelines

•All healthcare professionals can diagnose delirium using the CAM screening tool

•Routinely screen all older patients admitted to hospital

•Senior doctors and nurses should ensure that doctors in training and nurses are able to recognise and treat delirium

•Treat reversible medical causes first

•Incorporate non-pharmacological interventions ^as into the care plan of patients at high risk

•Minimize the use of sedatives and major tranquilisers

•Use one drug only (haloperidol is currently recommended) starting at the lowest dose and increasing every two hours if necessary

• Review all medications at least every 24 hours and provide one-to-one care when using pharmacological interventions

Thomson et al.

Diagnosis and Management of Delirium

•Risk factors include advancing age, dementia, hip fracture, previous history of delirium, multiple co-morbidities, and polypharmacy

•Screen using validated tool like the 4AT, NEWS2, CAM or CAM-ICU

•Treat reversible medical causes identified by the PINCH-ME ^at acronym

•Attempt non-pharmacological interventions ^au before pharmacological interventions

•Use pharmacological interventions ^av only if patient is at risk of harming themselves and others, or have very distressing symptoms such as hallucinations

•Prevent recurrence by continuing non-pharmacological interventions

Tropea et al.

Clinical Practice Guidelines for the Management of Delirium in Older People

•Diagnose delirium using the DSM-IV criteria

•Screen for delirium in all older people using a structured process which includes formative cognitive function assessment and validated tools like the CAM, DRS, and CAM-ICU

•Treat reversible medical causes such as pain, constipation, urinary retention, and hypoxia

•Use non-pharmacological interventions ^aw to prevent delirium across all health-care settings

•Consider pharmacological interventions ^ax and review dosage and symptoms continually if severe behavioural or emotional disturbance is present

•Include professional follow-up, monitoring, and treatment in the discharge process

Trzepacz et al.

Practice Guideline for the Treatment of Patients with Delirium

•Risk factors are multifactorial ^ay

•Diagnose delirium using the DSM-IV criteria

•Use formal measures for test for delirium ^az

•Treat reversible medical causes ^ba and co-morbid psychiatric disorders first

•Psychiatrists should be actively involved in caring and decision processes

•Use non-pharmacological interventions to ensure environmental orientation

•Use pharmacological interventions ^bb, preferably a short acting agent and not a benzodiazepine

Virani et al.

Caregiving Strategies for Older Adults with Delirium, Dementia and Depression

•Maintain high attention for prevention, early recognition, and urgent treatment of delirium

•Diagnose delirium using the DSM-IV criteria and validated screening methods, and document if delirium is hypoactive or hyperactive

•Implement multi-component interventions (consultation to specialised services, addressing reversible medical causes, using pharmacological interventions, using non-pharmacological interventions like family communication and education)

•Monitor interventions on an ongoing basis to address fluctuating course of delirium

Weldon et al.

Guidelines for the Prevention, Recognition and Management of Delirium in Adults in the Acute Hospital Setting

•Risk factors include age of 65 years or older, current hip fracture, cognitive impairment or dementia, and other medical illnesses ^bc

•Use the acronym DELIRIUM ^bd to recognise medical factors

•Use the Single Question in Delirium (‘Has [named person]… been more confused in the last 72 hours?’) and CAM as screening tools

•Assess for rapid onset of altered cognitive function, inattention, and altered consciousness with a fluctuated course

•Treat delirium as a medical emergency

•Treat reversible medical causes first

•Use non-pharmacological interventions ^be

•Consider short term (a week or less) pharmacological intervention using one drug ^bf when essential treatment is needed, patient is a risk to themselves or others, or patient is highly agitated or hallucinating

White et al.

Guidelines for the Peri-operative Care of People with Dementia

•Risk factors for post-surgical delirium are multifactorial ^bg

•Diagnose delirium using formal assessment tools like the CAM and 4AT, paying attention to both hypoactive and hyperactive delirium

•Assess delirium using new occurrence or changes in cognition, concentration, perception, behaviour, or physical function

•Treat reversible medical causes ^bg

•Optimize non-pharmacological interventions such as sleep, nutrition, hydration, sensory aids, bowel, and bladder care

•Use single, lowest dose, and shortest use pharmacological intervention (intravenous incremental doses of 0.5 mg haloperidol, or benzodiazepines for alcohol or Parkinsonian-related symptoms)

Young et al.

Delirium: Prevention, Diagnosis and Management

•Risk factors include age of 65 years or older, cognitive impairment or dementia, current hip fracture, and severe illness

•Diagnose delirium using the DSM-V criteria •Assess for recent changes or fluctuations in behavior indicative of hyperactive or hypoactive delirium ^bh using the validated CAM or CAM-ICU

•Treat reversible medical causes ^bi

•Use non-pharmacological interventions to prevent delirium ^bj

•Observe daily for changes

•Consider short-term (a week or less) pharmacological intervention using haloperidol if distress is significant or patients are a risk to themselves or others