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## Complete Summary

#### GUIDELINE TITLE

Delirium: prevention, early recognition, and treatment. In:
Evidence-based geriatric nursing protocols for best practice.

#### BIBLIOGRAPHIC SOURCE(S)

Tullmann DF, Mion LC, Fletcher K, Foreman MD. Delirium: prevention,
early recognition, and treatment. In: Capezuti E, Zwicker D, Mezey M,
Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best
practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan.
p. 111-25. \[53 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Foreman MD, Mion LC, Trygstad
L, Fletcher K. Delirium: strategies for assessing and treating. In:
Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing
protocols for best practice. 2nd ed. New York (NY): Springer Publishing
Company, Inc.; 2003. p. 116-40.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Delirium

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Geriatrics\
Nursing

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide a standard of nursing practice to reduce the incidence of
delirium in hospitalized older adults

#### TARGET POPULATION

Hospitalized older adults

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Assessment**

1.  Risk factors for delirium

2.  Features of delirium

**Management/Treatment**

1.  Collaborate with physician/nurse practitioner to treat underlying
    pathology and contributing factors

2.  Eliminate or minimize risk factors

3.  Provide therapeutic environment

#### MAJOR OUTCOMES CONSIDERED

-   Long-term cognitive impairment

-   Postoperative complications

-   Functional status

-   Hospital length of stay

-   Discharge destination

-   Need for institutionalization

-   Health care cost

-   Satisfaction with care

-   Mortality

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Although the AGREE instrument (which is described in Chapter 1 of the
original guideline document) was created to critically appraise clinical
practice guidelines, the process and criteria can also be applied to the
development and evaluation of clinical practice protocols. Thus the
AGREE instrument has been expanded for that purpose to standardize the
creation and revision of the geriatric nursing practice guidelines.

**The Search for Evidence Process**

Locating the best evidence in the published research is dependent on
framing a focused, searchable clinical question. The PICO format---an
acronym for population, intervention (or occurrence or risk factor),
comparison (or control), and outcome---can frame an effective literature
search. The editors enlisted the assistance of the New York University
Health Sciences librarian to ensure a standardized and efficient
approach to collecting evidence on clinical topics. A literature search
was conducted to find the best available evidence for each clinical
question addressed. The results were rated for level of evidence and
sent to the respective chapter author(s) to provide possible
substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation to its level of evidence,
each citation was given a general classification, coded as \"Risks,\"
\"Assessment,\" \"Prevention,\" \"Management,\"
\"Evaluation/Follow-up,\" or \"Comprehensive.\" The citations were
organized in a searchable database for later retrieval and output to
chapter authors. All authors had to review the evidence and decide on
its quality and relevance for inclusion in their chapter or protocol.
They had the option, of course, to reject or not use the evidence
provided as a result of the search or to dispute the applied level of
evidence.

**Developing a Search Strategy**

Development of a search strategy to capture best evidence begins with
database selection and translation of search terms into the controlled
vocabulary of the database, if possible. In descending order of
importance, the three major databases for finding the best primary
evidence for most clinical nursing questions are the Cochrane Database
of Systematic Reviews, Cumulative Index to Nursing and Allied Health
Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO
database was used to ensure capture of relevant evidence in the
psychology and behavioral sciences literature for many of the topics.
Synthesis sources such as UpToDate^®^ and British Medical Journal (BMJ)
Clinical Evidence and abstract journals such as *Evidence Based Nursing*
supplemented the initial searches. Searching of other specialty
databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit
the search to articles tagged with the publication type
\"meta-analysis\" in Medline or \"systematic review\" in CINAHL.
Filtering by standard age groups such as \"65 and over\" is another
standard categorical limit for narrowing for relevance. A literature
search retrieves the initial citations that begin to provide evidence.
Appraisal of the initial literature retrieved may lead the searcher to
other cited articles, triggering new ideas for expanding or narrowing
the literature search with related descriptors or terms in the article
abstract.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Level I**: Systematic reviews (integrative/meta-analyses/clinical
practice guidelines based on systematic reviews)

**Level II**: Single experimental study (randomized controlled trials
\[RCTs\])

**Level III**: Quasi-experimental studies

**Level IV**: Non-experimental studies

**Level V**: Care report/program evaluation/narrative literature reviews

**Level VI**: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti,
E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) *Evidence Based
Geriatric Nursing Protocols for Best Practice*, (3^rd^ ed). New York:
Springer Publishing Company.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note from the National Guideline Clearinghouse (NGC)**: In this update
of the guideline, the process previously used to develop the geriatric
nursing protocols has been enhanced.

Levels of evidence (I --VI) are defined at the end of the \"Major
Recommendations\" field.

**Parameters of Assessment**

-   Assess for risk factors

    -   Baseline or pre-morbid cognitive impairment

    -   Medications review

    -   Pain

    -   Metabolic disturbances (i.e., hypoglycemia, hypercalcemia,
        hyponatremia, hypokalemia)

    -   Dehydration (physical signs/symptoms, intake/output, Na^+^,
        blood urea nitrogen/creatinine \[BUN/Cr\])

    -   Infection (fever, white blood cells \[WBCs\] with differential,
        cultures)

    -   Environment (sensory overload or deprivation)

    -   Impaired mobility

-   Features of delirium should be assessed every shift (see
    [www.ConsultGeriRN.org](http://www.consultgerirn.org/) for resources
    for validated instruments)

    -   Acute onset; evidence of underlying medical condition

    -   Alertness: Fluctuates from stuporous to hypervigilant

    -   Attention: Inattentive, easily distractible, and may have
        difficulty shifting  attention from one focus to another; has
        difficulty keeping track of what is being said

    -   Orientation: Disoriented to time and place; should not be
        disoriented to person

    -   Memory: Inability to recall events of hospitalization and
        current illness; unable to remember instructions; forgetful of
        names, events, activities, current news, and so on

    -   Thinking: Disorganized thinking; rambling, irrelevant,
        incoherent conversation; unclear or illogical flow of ideas; or
        unpredictable switching from topic to topic; difficulty in
        expressing needs and concerns; speech may be garbled

    -   Perception: Perceptual disturbances such as illusions and visual
        or auditory hallucinations; and misperceptions such as calling a
        stranger by a relative\'s name

    -   Psychomotor activity: May fluctuate between hypoactive,
        hyperactive, and mixed subtypes

**Nursing Care Strategies**

Based on protocols in multi-component delirium prevention studies
(Inouye, et al., 1999; Marcantonio et al., 2001 **\[Level II\]**)

Collaborate with physician/nurse practitioner to treat the underlying
pathology and contributing factors. If available, consult with
geriatrician and/or Geriatric Nurse Practitioner or Clinical Nurse
Specialist.

-   Eliminate or minimize risk factors

    -   Administer medications judiciously; avoid high-risk medications.

    -   Prevent/promptly and appropriately treat infections.

    -   Prevent/promptly treat dehydration and electrolyte disturbances.

    -   Provide adequate pain control.

    -   Maximize oxygen delivery (supplemental oxygen, blood, and blood
        pressure \[BP\] support as needed).

    -   Use sensory aids as appropriate.

    -   Regulate bowel/bladder function.

    -   Provide adequate nutrition.

-   Provide a therapeutic environment

    -   Foster orientation: frequently reassure and reorient patient
        (unless patient becomes agitated); utilize easily visible
        calendars, clocks, caregiver identification; carefully explain
        all activities; communicate clearly

    -   Provide appropriate sensory stimulation: quiet room; adequate
        light; one task at a time; noise-reduction strategies

    -   Facilitate sleep: back massage, warm milk or herbal tea at
        bedtime; relaxation music/tapes; noise-reduction measures; avoid
        awakening patient

    -   Foster familiarity: encourage family/friends to stay at bedside;
        bring familiar objects from home; maintain consistency of
        caregivers; minimize relocations

    -   Maximize mobility: avoid restraints and urinary catheters;
        ambulate or active range of motion three times daily

    -   Communicate clearly, provide explanations

    -   Reassure and educate family

    -   Minimize invasive interventions

    -   Consider psychotropic medication as a last resort

**Follow-up to Monitor Condition**

-   Decreased delirium to become a measure of quality care

-   Incidence of delirium to decrease

-   Patient\'s days with delirium to decrease

-   Staff competence in recognition and treatment of acute
    confusion/delirium

-   Documentation of a variety of interventions for acute
    confusion/delirium

**Definitions**:

**Level I**: Systematic reviews (integrative/meta-analyses/clinical
practice guidelines based on systematic reviews)

**Level II**: Single experimental study (randomized controlled trials
\[RCTs\])

**Level III**: Quasi-experimental studies

**Level IV**: Non-experimental studies

**Level V**: Care report/program evaluation/narrative literature reviews

**Level VI**: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti,
E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) *Evidence Based
Geriatric Nursing Protocols for Best Practice*, (3^rd^ ed). New York:
Springer Publishing Company.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=12261)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Patient**

-   Absence of delirium

-   Cognitive status returned to baseline

-   Functional status returned to baseline

-   Discharge to prehospitalization destination

**Health Care Provider**

-   Increased detection of delirium

-   Implementation of appropriate interventions to prevent/treat
    delirium

-   Use of standardized delirium-prevention protocol

-   Decreased use of physical restraints

-   Decreased use of antipsychotic medications

-   Increased satisfaction in care of hospitalized elderly

**Institution**

-   Decreased overall cost

-   Decreased length of stays

-   Decreased morbidity and mortality

-   Increased referrals and consultation to the specified specialists

-   Improved satisfaction of patients, families, nursing staff

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Tullmann DF, Mion LC, Fletcher K, Foreman MD. Delirium: prevention,
early recognition, and treatment. In: Capezuti E, Zwicker D, Mezey M,
Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best
practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan.
p. 111-25. \[53 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 (revised 2008 Jan)

#### GUIDELINE DEVELOPER(S)

Hartford Institute for Geriatric Nursing - Academic Institution

#### GUIDELINE DEVELOPER COMMENT

The guidelines were developed by a group of nursing experts from across
the country as part of the Nurses Improving Care for Health System
Elders (NICHE) project, under sponsorship of The John A. Hartford
Foundation Institute for Geriatric Nursing.

#### SOURCE(S) OF FUNDING

Supported by a grant from The John A. Hartford Foundation.

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Dorothy F. Tullmann, Lorraine C. Mion, Kathleen
Fletcher, Marquis D. Foreman

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Foreman MD, Mion LC, Trygstad
L, Fletcher K. Delirium: strategies for assessing and treating. In:
Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing
protocols for best practice. 2nd ed. New York (NY): Springer Publishing
Company, Inc.; 2003. p. 116-40.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Hartford Institute for Geriatric
Nursing Web
site](http://consultgerirn.org/topics/delirium/want_to_know_more).

Copies of the book *Geriatric Nursing Protocols for Best Practice*, 3rd
edition: Available from Springer Publishing Company, 536 Broadway, New
York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web:
[www.springerpub.com](http://www.springerpub.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The followings are available:

-   The confusion assessment method (CAM). Try this: best practices in
    nursing care to older adults. 2007. Electronic copies available from
    the [Hartford Institute for Geriatric Nursing Web
    site](http://www.hartfordign.org/publications/trythis/issue13_cam.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on February 2, 2004. The information
was verified by the guideline developer on March 15, 2004. This summary
was updated by ECRI Institute on June 19, 2008. The updated information
was verified by the guideline developer on August 4, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
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those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
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Readers with questions regarding guideline content are directed to
contact the guideline developer.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008