52

Delirium: Screening, Prevention, and Diagnosis – 

A Systematic Review of the Evidence Evidence-based Synthesis Program

APPENDIX A. Search Strategies

Delirium screening and diagnosis

Database: Ovid MEDLINE(R)

Search Strategy:

--------------------------------------------------------------------------------

1 confusion.mp. or exp Confusion/

2 exp Delirium/ or delirium.mp.

3 deliri$.tw.

4 (NEECHAM or “Neelon and Champagne Confusion Scale”).tw.

5 (MMSE or mini-mental stat$ exam$).tw.

6 or/1-5

7 sensitiv$.mp.

8 predictive value$.mp.

9 accurac$.tw.

10 or/7-9

11 6 and 10

12 limit 11 to english language

13 mass screening.mp. or exp Mass Screening/

14 diagnosis.mp. or exp Diagnosis/

15 13 or 14

16 12 and 15

Delirium prevention

Database: Ovid MEDLINE(R) <1950 to November Week 2 2010>

Search Strategy:

--------------------------------------------------------------------------------

1 exp Delirium/

2 deliri*.mp.

3 exp Confusion/ or acute confusion.mp.

4 acute organic psychosyndrome.mp.

5 acute brain syndrome.mp.

6 metabolic encephalopathy.mp.

7 acute psycho-organic syndrome.mp.

8 clouded state.mp.

9 clouding of consciousness.mp.

10 exogenous psychosis.mp.

11 toxic psychosis.mp.

12 toxic confusion.mp.

13 or/1-12

14 exp Primary Prevention/

15 prevent*.mp.

16 avoid*.mp.

17 or/14-16
53

Delirium: Screening, Prevention, and Diagnosis – 

A Systematic Review of the Evidence Evidence-based Synthesis Program

18 13 and 17

19 exp Alcohol Withdrawal Delirium/

20 delirium tremens.ti.

21 19 or 20

22 18 not 21

23 exp animals/ not humans.sh.

24 22 not 23

25 limit 24 to english language

26 limit 25 to yr=”1966 -Current”
54

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Study Selection Form

Eligible Study? Y N 

Screening? Y N Prevention? Y N Diagnosis? Y N

If N, what # below? 1 2 3 4 5 6 7 8 9 1 0 1 1

Country Journal Year

Cross-sectional Case-control RCT Non-RCT Review/Meta-analysis

Inclusion Criteria Exclusion Criteria Veteran? Elderly 60+? ICU?

Y N Y N Y N

Gender? Age Range? Ethnicity?

M F

Others/Details: Prevention strategies:

U Nursing interventions

HydrationMusicMedications

stic accuracy Others/Details:

m incidencem duration/severity

of stay

rescue meds

rge to rehab/NH

economics

3 4 5* 6* 7* 8 9 10 11

Alcohol- related Not hospitalized No reference 

standard

Reference standard not done by specialist

Same person did test/ reference standard

Case series/ report, letter, or editorial

Not delirium No outcomes of interest Not screening, 

prevention, diagnosis 
55

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

eer Review Comments/Author Responses

RESPONSE

nd methods for this review clearly described? 

significant complication of hospitalization that warrants further review. The 

on of delirium in medically ill patients is a current need. The objectives of 

 appears that a large data base of research was examined to address the 

es multiple disparate elements “effectiveness” is really answered by 

s is vary in results. In the summary, only does screening improve clinical 

Effectiveness is not adequately addressed by KQ3 “diagnostic accuracy”. While there was no direct evidence of the effectiveness and harms of screening for delirium we have described in the KQ1 results section the pieces of chain of evidence that would need to be addressed for indirect evidence of effectiveness. 

s in our synthesis of the evidence? 

s, but it is hard to identify the source. I am a little worried that your 

e reader will say... well, there is nothing new here since 1970. When in 

 associated with mortality, that some drugs are used more commonly in 

 haldol can attenuate the consequences of delirium, that benzodiazepines 

d......... 

The scope of this report was not to assess all pharmacologic interventions that increase a person’s risk of delirium. However, we have added categories of medications widely recognized to be associated with delirium. We also have described that delirium is associated with mortality. 

published studies that we may have overlooked?

m of information, and I have little to add, especially given comment about 

o include information from, June 2011 article in Annals of Internal Medicine. Thank you

m 2 studies (Boustani and Marcantonio) on cholinesterase inhibitors and 

Our inclusion criteria required articles be published in peer review manuscripts.

y to know. 

were overlooked.
56

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

RESPONSE

ance measures, programs, quality improvement measures, patient 

at will be directly affected by this report? If so, please provide detail. 

Thank you – we will share these suggestions with the people responsible for dissemination of the report.

records for evidence of elevated risk for delirium. Because these efforts are 

ch attention has been drawn to them—but as the data and the outcome 

ucational efforts can be undertaken to support use of the QI and thereby, to 

of these data were presented at a recent VA conference (EES) in Indianapolis 

 in different health delivery settings. In the two preceding years (2009, 2010), 

rium prevention, recognition, and management were also held in Boston and 

or a “Emergency Rooms and the Elderly Veteran” conference for Spring 2012.

l from GEC to adapt a number of the “Assessing Care of Vulnerable Elderly” 

do with documenting mental status upon hospital admission in order to have a 

mental status may be compared.

nded Care currently supports several demonstration pilots (about to embark 

ally directed to delirium prevention in different settings: in San Francisco, 

Connecticut, a home-based presurgical assessment followed by post

 Boston, a “Delirium Toolbox” for reducing risk factors in recent admissions 

elirium; in Durham, a caregiver education program to assist with behaviors 

ndianapolis, a transition management approach that begins during an 

Portland, Boise, and Honolulu, a “Hospital at Home” that provides an inpatient 

 diagnoses, with complete avoidance of delirium.

ering Committee that developed a strategic plan and has educational, clinical, 

ecause dementia is one of the most concerning risk factors for delirium onset, 

ation will unquestionably be of interest. 

ered “Healthcare Workforce for Aging Veterans” Executive Taskforce has 

th Dr. Petzel and, with his approval, is about to be presented to the National 

ocusing resources over the next 5 years on ensuring universal access within 

he inpatient, outpatient, and extended care areas—and for inpatient, that 

ecifically targeting prevention, recognition, and management of inpatient 

ry for Health for Operations and Management last month approved the 

y Committee, charged with advising the GEC office on projects, programs, 

nhancing awareness of and familiarity about delirium on the part of providers 

elirium with some of the tools reviewed. There is some low level evidence 

bly staff education that are useful in preventing delirium. The prevention of 

easures such as length of stay, length of ICU stay, decrease in morbidity, and 

e a positive impact on patient flow and improved discharge to home settings.

ety conference and EES conferences during the last 3 years will be 

ngs. In general, studies in the VA are nearly non-existent, yet VA eligible, 

ny others in the country (Kazis data). In particular, younger veterans 

s of comorbidity (often associated with PTSD as a contributing factor) and 

gh risk” category although they don’t meet usual age criteria. We may also 

included for the same reason. 
57

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

RESPONSE

 to patients with delirium. The evidence in this report about non

event delirium will be especially relevant to nurses in the acute care 

, the Office of Nursing Services Evidence Based Practice Group will 

d Advisory Committee to discuss how the information from this report on 

al interventions can be disseminated to staff nurses and how we might 

e-based interventions.

act the standard of care relative to screening of older Veterans for delirium 

ement project in 5 – 7 ICUs measuring CAM ICU and RASS scores

dations on how this report can be revised to more directly address or 

s to explicitly state that studies are required in this area to improve detection

ment could use the information contained to highlight the incidence/prevalence 

statement that this is a common condition

ing target (again using the EBR)

ed

ent

recent international meeting, it is fair to de-emphasize the CAM or at least 

l mental status testing.

ect links’ – prevention needs to be added to this list

6-7 papers which were excluded based on a Cochrane review. These papers 

e analysis and tables – Why not include them in this EBR to produce the most 

t important around the Marcantonio 2001 trial – which is extensively described

wks ago) are referenced. Did they include the methods (same issue different 

ention, the results of the rivastigmine in the ICU trial for delirium treatment 

might be important to cite/mention.

cluded in the meta analysis?\

s in press on acetylcholinesterase inhibitors and delirium prevention (boustani 

. regional anesthesia is surprising – consider reviewing Mason SE. J Alz Dis 

pharmacological interventions should be mentioned (low risk interventions)

Screeninga. The Future Research section indicates the need for a study of screening.b. We have added incidence/prevalence data to the background section of the executive summary and full report.c. The purpose of the evidence review is to present the evidence so that others make informed recommendations.d. Our report is based on published evidence.e. We have considered this suggestion but believe that prevention is not part of the indirect link. If a preventive strategy has been started, continued assessment of the patient would be considered monitoring of the success of the preventive strategy.Preventiona. We have added the papers from the Cochrane Review and the NICE Guideline that met our study inclusion criteria.b. We have reviewed this document.c. We have reviewed the trial mentioned by the reviewer but have not included it in our review because rivastigmine was used for treatment, not for prevention.d. We have added the Kalisvaart study.e. As noted above, our inclusion criteria required articles be published in peer review manuscripts.f. We have reviewed this systematic review and have included 1 study that we had not already identified that met our inclusion criteria.g. Thank you for this suggestion. We have noted this in the report.
58

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

RESPONSE

mental status testing prior to completion. All validation studies of the CAM have 

etion.

out the education and training needed to complete these instruments and 

e shelf’ stuff

es, limited evidence on pharm interventions, and education / training for 

ed for additional studies and additional instruments for this disease

Diagnosisa., b.. These are important points and we have included this information in the findings for KQ3 and the conclusions. Conclusionsa., b. Thank you for the suggestions. We have attempted to address them in the Conclusions and Future Research Needs sections.

nt of evidence in the field that is nonetheless non-definitive in its clinical 

above) really does require separate investigation. See Comments below.

We agree that the findings are generally of low-quality and/or insufficient.

clear that much more research is needed to identify valid and reliable 

lirium. A screening measure that can be universally implemented is 

seem sufficient for this purpose – it requires supplemental mental status 

estion #3)

en based on currently available evidence (older, sensory or cognitively 

ey Question #1)

d on the non-pharmacological interventions for delirium prevention based in 

ow-risk interventions.(Key Question #2)

arding the need for education among providers that fail to recognize 

erans receive care. ( Key Question #1)

We again emphasize that there are no data about the effectiveness and harms of screening for delirium in hospitalized medical patients. Therefore, we disagree that a screening measure that can be universally implemented is needed (or at least that such an instrument “should be implemented”). The current evidence does not permit making recommendations on who to screen.We have added a table of risk ratios for the non-pharmacological interventions and more detail about the components of the multicomponent interventions.We have attempted to address this in the Key Question 1 conclusions.

mary, when a reader starts with “no convincing improvement in clinical 

 with different drugs, .... Many people won’t get to 3. They want validation 

here is a way to measure brain dysfunction (which we call delirium like in 

The questions are listed in the order originally agreed upon. No further change.

ew of the literature and it was disheartening to see that there is little 

g, identification and prevention of delirium.

ragraph, states “following up” should state “follow up”

29-60% and should be control group “of” 29-60%

Thank you for your comments.We have corrected the typos.

hat may be provoked ONLY by certain medication use (in the absence of 

l; they may well have different prognoses than the multifactorial ones. This 

 offer some “clean” recommendations that could easily be implemented 

Thank you for the suggestion. We have included this in the Future Research section.
59

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

RESPONSE

opic for all staff who care for Veterans with delirium, in particular nursing 

4/7 and understand the profound distress this condition causes for both 

. My comments are as follows:

ew was undertaken are not listed in the order that the 3 key questions 

rt (same inconsistency appears in the first paragraph of the Executive 

 were “careful to make important distinctions between screening for 

 This distinction is somewhat confusing in that the discussion of screening 

 purpose of screening is to detect a condition before symptoms occur and 

for delirium. Later, however, in the discussion of KQ3, CAM is discussed 

#3). Since the CAM items all address identifiable symptoms, is the CAM 

l or both? Are there any screening instruments for delirium that detect 

are the delirium “screening instruments” really diagnostic instruments 

nderlying causes of delirium are listed. The next sentence mentions “risk 

elirium different from risk factors? Is so, what are the risk factors for 

ac surgeries risk factors for delirium or underlying causes of delirium? 

s discussed in KQ2 targeted patients who underwent either cardiac or 

ot mentioned in para 4 on page 13 either as an underlying cause or risk 

 nurse, other staff?) would likely perform screening. In the screening 

ere mention of who completes the screening? This is an important 

ontact a patient has in the inpatient setting is with a nurse. 

We have corrected to ensure consistency.CAM could be used as both as a screening instrument in hospitalized patients (individuals without identifiable signs or symptoms of delirium) or as a diagnostic tool (patients with some signs or symptoms that are consistent with but not definitely determined to be delirium (e.g., a patient with confusion). KQ1 and the overarching goal of this report was to assess the effectiveness and harms as a screening tool including in individuals who may be at increased risk due to patient factors (e.g., age, personal history of delirium), index disease type or severity (e.g., stroke, ICU) or co-existing medical conditions/medications that are not directly the reason for admission (e.g. use of narcotics in a patient admitted for COPD). KQ3 assessed the use of CAM as both a diagnostic and screening tool as many of the studies evaluated patients with signs/symptoms potentially compatible with delirium.We clarified our use of the term “risk factors”. Causality is a strong term that definitely ascribes the outcome to the risk factor.We have clarified regarding surgery.This is a policy issue beyond the scope of the review. Screening if found to be effective could be implemented by several lines of health care staff including nurses and physicians and could be done at the admitting floor or in the clinic/emergency room where the admission decision was made. If screening for delirium is effective then future research should be conducted to assess the most effective/efficient methods for implementation.
60

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

RESPONSE

dies are discussed (pages 21-24 and 30-31). Most of the pharmacological 

zenberg et al (cholinesterase inhibitor) target patients who either 

rgery. The report Conclusions on page 45 state, “Low level evidence 

gies using analgesia via fascia iliaca compartmental block, antipsychotic, 

ul in delirium prevention.” 

ses of and many risk factors for delirium, would these pharmacological 

elirium prevention” as stated on page 45 or more specifically would they be 

ion in patients undergoing surgical procedures? 

pharmacological intervention on page 45 seems to imply that these 

ons would be useful in all patients with delirium when the studies targeted 

 patients. 

at 9 multi-component studies consisted of interventions that significantly 

 In the report Conclusions (page 45), multi-component interventions are 

l for those staff interested in implementing multi-component interventions if 

ntion bundles trialed in some of these studies. 

uestion requires a somewhat different approach, there seems to be some 

ization of this report.

ns has multiple parts.

he subparts of KQ 3 are designated as “a” and “b”

 the 4 subparts of KQ 2 are not designated as a-d, on pages 21-35, the 

gnated as a-d.

f KQ1 are never designated as a-c.

sion”; KQ#2 ends with a “Summary of Finding”; and KQ3 ends abruptly 

mmary of findings. 

We have clarified regarding surgery.We have added information about the interventions in the multicomponent studies.We have corrected these inconsistencies.

der adding the positives... Lacking direct evidence, 3⁄4 criteria establishing 

and outcomes for delirium were satisfied: 1) patents with delirium have 

eening likely improves detection, and 3)harms associated with screening 

wed evidence that treatments for delirium are effective is mixed. 

 adding after Screening for disease or condition is warranted if the disease 

eutic decisions would be altered in the presence of the condition.

We have modified this section. Without a systematic review of the evidence for each criterion, we are hesitant to say that the criteria were satisfied.Thank you – we have modified this statement.

w that emphasizes the need for research in delirium detection and 

g it.

Thank you.
61

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

vidence Tables

eristics of Pharmacologic Prevention Studies

Strategy 

,

ols

Inclusion and Exclusion Criteria,

Recruitment Method

Patient Characteristics

(expressed in means 

unless otherwise 

noted)

Outcomes Evaluated Study Quality

ategy 

n 0.5 

to sleep 

bo (n=73)

Inclusion Criteria: at least 65 years of age and admitted through the emergency department to Internal Medicine in-patient servicesExclusion Criteria: an expected stay or life expectancy of less than 48 hours, were unable to communicate in English or to take oral medications, had an intracranial bleed or seizures, had a markedly non-therapeutic international normalized ratio (INR) less than one or more than four while on warfarin, or had a known allergy to the study compoundsRecruitment method: patients were approached directly in the emergency room or in their rooms by one of the three study clinicians within 24 hours of admission (up to 48 h was allowed on weekends)

N=145Mean age (yrs): 84Gender, male (%): 43Race/ethnicity (%): NRMedical unit: Internal Medicine

Incidence of delirium (diagnosed within 6 days post-operatively with the Confusion Assessment Method (CAM))Delirium severity (Memorial Delirium Assessment Scale)Use of sedativesUse of restraints

Allocation Concealment: adequate (pharmacy controlled)Blinding: double and outcomes assessmentIntention to Treat Analysis (ITT): no, 23 patients excludedWithdrawals adequately described: yes

ategy 

ne 5 

43), 

bo 

Inclusion Criteria: history of postoperative delirium who were scheduled for elective total knee- or total hip-replacement surgery; ability to speak English; and ability to provide informed consentExclusion Criteria: a diagnosis of dementia; active alcohol use; a history of alcohol dependence or abuse; allergy to olanzapine; and current use of an antipsychotic medicationRecruitment method: NR

N=495Mean age (yrs): 74Gender, male (%): 46Race/ethnicity (%): white 98, non white 2Medical unit: orthopedic teaching hospital

Incidence of delirium (defined using the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III)Duration of deliriumDelirium severity (Severity of delirium according to the highest value of the DRSR-98)Time-to-onset of delirium

Allocation Concealment: adequate (pharmacy controlled)Blinding: double and a independent data and safety monitoring committee evaluated all potentially serious adverse eventsIntention to Treat Analysis (ITT): noWithdrawals adequately described: yes
62

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Strategy 

,

ols

Inclusion and Exclusion Criteria,

Recruitment Method

Patient Characteristics

(expressed in means 

unless otherwise 

noted)

Outcomes Evaluated Study Quality

ategy 

dation with 

on depth 

l index imately 

edation 

BIS, ≥80) 

Inclusion Criteria: 65 years or older, undergoing hip fracture repair with spinal anesthesia and propofol sedationExclusion Criteria: preoperative delirium (determined by CAM); contraindications to spinal anesthesia (e.g., clinically important aortic stenosis, coagulopathy, anticoagulant use, spinal cord disease, refusal of spinal anesthesia), prior hip surgery, severe congestive heart failure (New York Heart Association class IV), severe chronic obstructive pulmonary disease (Global Initiative for Chronic Obstructive Lung Disease guidelines, stage III-IV), or mental or language barriers that would preclude data collectionRecruitment method: NR

N=114Mean age (yrs): 82Gender, male (%): 27Race/ethnicity (%): NRMedical unit: multidisciplinary hip fracture service

Incidence of delirium (DSM-III)Delirium duration Time from surgery until dischargeMortality (during hospitalization)

Allocation Concealment: unclearBlinding: double Intention to Treat Analysis (ITT): yesWithdrawals adequately described: yes

ategy 

mine (oral) 

 (n=59), 

y prior to 

en post-op 

bo (n=61)

Inclusion Criteria: age 65 or older and elective cardiac surgery with cardiopulmonary bypassExclusion Criteria: urgent or emergency surgery, previous cardiac surgery, cardiac surgery combined with non-cardiac procedures (typically carotid endarterectomy), insufficient knowledge of German or sensory impairment interfering with neuropsychological testing, a preoperative MiniMental State Examination (MMSE) <15, psychiatric illness necessitating regular use of antidepressants or antipsychotics, preexisting neurologic deficits, previous or ongoing treatment with cholinesterase inhibitors, and known contraindications for rivastigmine Recruitment method: patients screened for eligibility based on the operation schedule for the following day

N=120, demographic information for 113 patientsMean age (yrs): 74Gender, male (%): 68Race/ethnicity (%): NRMedical unit: cardiac surgery

Incidence of delirium (diagnosed within 6 days post-operatively with the CAM)Rescue medication use

Allocation Concealment: adequate, (hospital pharmacy using identical bottles)Blinding: doubleIntention to Treat Analysis (ITT): no, 7 excluded from analysesWithdrawals adequately described: yes
63

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Strategy 

,

ols

Inclusion and Exclusion Criteria,

Recruitment Method

Patient Characteristics

(expressed in means 

unless otherwise 

noted)

Outcomes Evaluated Study Quality

ategy 

e 0.5mg/

bolus 

bo (n=29)

cebo 

uring 

ction in 

f fentanyl 

Inclusion Criteria: at least 55 years of age, provided written informed consent before the initiation of any study-related procedures, scheduled for elective coronary artery bypass graft surgery or valve replacement/repair procedures with cardiopulmonary bypass; patients receiving antidepressants, stimulants, mood stabilizers, anxiolytics, or depressants were eligibleExclusion Criteria: history of cerebrovascular accident within 3 years of randomization, permanent ventricular pacing, previously defined cognitive deficits, patients receiving psychoactive drugs for the treatment of psychosis, hepatic impairment, chronic renal insufficiency, other pre-existing diseases deemed by the investigators to place the patient at an increased risk of perioperative complicationsRecruitment method: NR

N=58Mean age (yrs): 64Gender, male (%): 100Race/ethnicity (%): white 90Medical unit: cardiac surgery

Incidence of delirium (Intensive Care Delirium Screening Checklist)Length of stay

Allocation Concealment: unclear (“sealed envelopes”)Blinding: double and outcomes assessmentIntention to Treat Analysis (ITT): yesWithdrawals adequately described: no withdrawals

ategy 

etomidine 

0.4 

 by a 

rip of 0.2 

g/kg/hr)

fol: 25–50 

38)

–2 mg/hr 

d 

Inclusion Criteria: patients undergoing cardiac-valve operations with cardio-pulmonary bypassExclusion Criteria: preexisting diagnosis of dementia or schizophrenia, the preoperative use of psychotropic medications, active or recent substance abuse or dependence, age less than 18 or older than 90 years, documented stroke within the last 6 months, evidence of advanced heart block, pregnancy, or anticipated intraoperative deep hypothermic circulatory arrestRecruitment method: NR

N=118Mean age (yrs): 58Gender, male (%): 64Race/ethnicity (%): NRMedical unit: cardiac surgery

Incidence of delirium (DSM-IV)Length of stay (hospital and ICU)Rescue medication use (management of delirium)Mortality

Allocation Concealment: unclear Blinding: open-label Intention to Treat Analysis (ITT): no, 28 patients excluded (24%)Withdrawals adequately described: yes
64

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Strategy 

,

ols

Inclusion and Exclusion Criteria,

Recruitment Method

Patient Characteristics

(expressed in means 

unless otherwise 

noted)

Outcomes Evaluated Study Quality

ategy 

aca 

lock 

 - 

3 mL/

se of on 

repeated 

h until 

ence 

was 

hours 

y the 

FICB was 

d and 

every 24 h 

ccurrence 

bo 

Inclusion Criteria: Age 70 years and older admitted for hip fractureExclusion Criteria: Delirium at admission, metastatic hip cancer, history of bupivicaine allergy, use of cholinesterase inhibitors, severe coagulopathy, Parkinsonism, epilepsy, levodopa treatment, delay of surgery of more than 72 h after admission, and inability to participate in interviews (profound dementia, respiratory isolation, intubation, aphasia, coma or terminal illness)Recruitment method: potentially eligible patients identified by systematically screening new admissions to one orthopedic ward

N=219, demographic information for 207patientsMean age (yrs): 73Gender, male (%): 26Race/ethnicity (%): NRMedical unit: orthopedicsRisk classification based on 4 predictive risk factors: (1) severity of illness, measured using acute physiology age and chronic health examination; (2) cognitive impairment, measured using the mini-mental state examination score; (3) index of dehydration, measured using the ratio of blood urea nitrogen to creatinine; and (4) visual impair-ment, measured using the standardized Snellen testHigh risk defined as presence of three or more risk factors

Incidence of delirium (DSM-IV and CAM)Delirium severity (Severity of delirium according to the highest value of the DRSR-98)Delirium duration

Allocation Concealment: adequate, placebo identical in appearance to the active drug and was administered at the same site and in the same way as the FICBBlinding: patients blindedIntention to Treat Analysis (ITT): no, 12 excluded from analysesWithdrawals adequately described: yes
65

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Strategy 

,

ols

Inclusion and Exclusion Criteria,

Recruitment Method

Patient Characteristics

(expressed in means 

unless otherwise 

noted)

Outcomes Evaluated Study Quality

ategy 

ne 1 

 when 

ciousness 

bo (n=63)

Inclusion Criteria: aged 40 years or older undergoing elective cardiac surgery with cardiopulmonary bypassExclusion Criteria: patients undergoing emergency surgery, admitted to intensive care unit, tracheal intubation before arriving to operating room, patients experiencing preoperative delirium, history of psychiatric disordersRecruitment method: NR

N=126Mean age (yrs): 61Gender, male (%): 59Race/ethnicity (%): NRMedical unit: cardiac surgery ICU

Incidence of delirium (CAM) Allocation 

Concealment: possibly (no identical sublingual placebo but nurses taking care of the patient and assessing delirium left patient bedside to ensure blinding)Blinding: doubleIntention to Treat Analysis (ITT): yesWithdrawals adequately described: none reported

ategy 

il 5mg 

g surgery 

post-op x 

bo (n=15)

Inclusion Criteria: patients undergoing elective total hip replacementExclusion Criteria: patients with mini-mental state examination (MMSE) scores of < 26; patients with sensory impairment who could not undertake neuropsychological testing and those with known hypersensitivity to donepezil or piperidine derivatives or contraindications to the use of donepezil Recruitment method: all patients undergoing elective total hip replacement and attending the pre-admission assessment clinic, who were able to give informed consent, were invited to participate

N=50; demographic information for 33 patientsMean age (yrs): 68 Gender, male (%): 52Race/ethnicity (%): NRMedical unit: orthopedics

Incidence of delirium (as indicated by the Delirium Symptom Interview)Length of hospital stay

Allocation Concealment: adequate, by the hospital pharmacyBlinding: double, and data were analyzed blind to randomization codeIntention to Treat Analysis (ITT): no; 14 withdrawn after randomization; 3 excluded after treatment allocation Withdrawals adequately described: yes
66

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Strategy 

,

ols

Inclusion and Exclusion Criteria,

Recruitment Method

Patient Characteristics

(expressed in means 

unless otherwise 

noted)

Outcomes Evaluated Study Quality

ategy 

dol 1.5 

started 

and 

p to 3 

tively

bo 

Inclusion Criteria: aged70 and older admitted for acute/ elective hip surgery and were at intermediate or high risk for postoperative deliriumExclusion Criteria: delirium at admission, no risk factors for postoperative delirium present at baseline, history of haloperidol allergy, use of cholinesterase inhibitors, parkinsonism, epilepsy, levodopa treatment, inability to participate in interviews, delay of surgery > 72 hours after admission, or a prolonged QTc interval of 460 ms or higher for men and 470 ms or higher for women on their electro-cardiogramRecruitment method: a research team of geriatricians and nurses in a single 915- bed teaching hospital identified potentially eligible patients by systematically screening new admissions to two surgical and three orthopedic wards

N=430Mean age (yrs): 79Gender, male (%): 20Race/ethnicity (%): NRMedical unit: Surgical and orthopedic wardsRisk classification based on presence of four predictive risk factors: (1) Visual impairment (binocular near vision worse than 20/70 after correction); (2) severity of illness, measured using the Acute Physiology Age and Chronic Health Examination (score of 16 or higher indicating increased severity); (3) cognitive impairment (MMSE score ≤ 24 on a scale of 0–30); and (4) index of dehydration (ratio of blood urea nitrogen to creatinine of ≥18)Intermediate risk-presence of 1or 2 risk factorsHigh risk - presence of ≥ 3 risk factors

Incidence of post-operative delirium (DSM IV and Confusion Assessment Method criteria)Delirium durationDelirium severity (measured using the Delirium Rating Scale (DRS), revised version-98, range 0 (no severity) to 45 (high severity)).Length of stay

Allocation Concealment: adequate (hospital pharmacist had prepackaged)Blinding: double and members of the research team not involved in the clinical care of the patients performed all baseline and outcome assessmentsIntention to Treat Analysis (ITT): yesWithdrawals adequately described: yes
67

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Strategy 

,

ols

Inclusion and Exclusion Criteria,

Recruitment Method

Patient Characteristics

(expressed in means 

unless otherwise 

noted)

Outcomes Evaluated Study Quality

ategy 

il 14 days 

r surgery 

bo (n=41)

Inclusion Criteria: scheduled for elective total knee or hip arthroplasy and aged 50 or greater; able to give informed consentExclusion Criteria: evidence of gastroesophageal reflux disease or sick-sinus syndrome; currently taking donepezil or previously intolerant of it; did not speak English; already in another trialRecruitment method: recruited from pts scheduled for elective total hip or knee arthroplasty

N=90 (Baseline info for 80; 58 completed trial)Mean age (yrs): 67 Gender, male (%): 43Race/ethnicity (%): white 97.5, other 2.5Medical unit: orthopedic surgery

Incidence of delirium (DSM-IV)Mean duration of post-op deliriumNumber with post-op subsyndromal deliriumMean duration of subsyndromal deliriumMean length of stay

Allocation Concealment: adequate (by pharmacist)Blinding: doubleIntention to Treat Analysis (ITT): no, 10 not operated on were excludedWithdrawals adequately described: yes

ategy 

dural or 

ral 

25)

Inclusion Criteria: aged at least 60 years, scheduled for elective surgery that could be performed under regional or general anesthesia and who had agreed to be randomly allocated to receive either type of anesthesiaExclusion Criteria: illiteracy, severe auditory or visual disturbances, central nervous system disorders, alcoholism or drug dependence, treatment with tranquillizers or antidepressants, Parkinson’s disease and a preoperative MMSE score ≤ 23 points, indicative of dementiaRecruitment method: NR

N=50 (Baseline info for 47)Median age (yrs): 68Gender, male (%): 64Race/ethnicity (%): NRMedical unit: surgery (orthopedic and vascular)

Incidence of delirium (DSM-III) Allocation 

Concealment: unclearBlinding: none statedIntention to Treat Analysis (ITT): no, 3 patients were excludedWithdrawals adequately described: yes

ategy 

free 

urgery; 

mg/kg IM 

azepam 

d pethidine 

uous IV 

hours x 3 

 care 

Inclusion Criteria: patients aged over 70 but less than 86 years of age who underwent resection of gastric or colorectal cancer through an open laparotomy under general anesthesiaExclusion Criteria: liver cirrhosis or liver dysfunction, renal dysfunction, respiratory disturbance, other poor risk factors, mental disorders, visual impairment, or patients who required extensive resection of other organs or emergency surgeryRecruitment method: NR

N=42 (Baseline info for 40; 2 excluded due to incomplete administration of agents)Mean age (yrs): 76Gender, male (%): 65Race/ethnicity (%): NRMedical unit: surgery

Incidence of delirium (DSM-IV)Mean length of stay

Allocation Concealment: unclearBlinding: outcomes assessorIntention to Treat Analysis (ITT): no, 2 were excludedWithdrawals adequately described: yes
68

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Strategy 

,

ols

Inclusion and Exclusion Criteria,

Recruitment Method

Patient Characteristics

(expressed in means 

unless otherwise 

noted)

Outcomes Evaluated Study Quality

ategy 

us 

caine and 

ns (n=26). 

p at first 

in

nuous 

tanyl 

). Initiated 

complaint 

Inclusion Criteria: scheduled for a bilateral knee replacement, speak English as a primary language, and have no serious hearing or vision impairment which would preclude cognitive testingExclusion Criteria: none statedRecruitment method: bilateral knee surgery patients were approached

N=51Mean age (yrs): 68Gender, male (%): 45Race/ethnicity (%): NRMedical unit: Urban referral hospital specializing in elective orthopedic surgery

Incidence of delirium (DSM-III) Allocation 

Concealment: unclearBlinding: physicians and nurses administering care not aware of purpose of study; study personnel not involved in patient care/treatment decisionsIntention to Treat Analysis (ITT): noWithdrawals adequately described: yes

ategy 

ous 

mg in 

m 1st to 

ve day 

 volume 

e injection 

Inclusion Criteria: patients scheduled for elective gastrointestinal surgery, admitted to High and Intensive Care Unit before scheduled surgeryExclusion Criteria: none statedRecruitment method: iInterviewed after admission

N=80 (2 patients excluded, unclear if excluded before or after randomization)Mean age (yrs): 72.8Gender, male (%): 63Race/ethnicity (%): NRMedical unit: high and Intensive Care Unit for gastrointestinal surgery

Incidence of delirium (DSM-III-R) Allocation 

Concealment: unclearBlinding: none reportedIntention to Treat Analysis (ITT): unclear Withdrawals adequately described: no – unclear when 2 patients were excluded
69

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Strategy 

,

ols

Inclusion and Exclusion Criteria,

Recruitment Method

Patient Characteristics

(expressed in means 

unless otherwise 

noted)

Outcomes Evaluated Study Quality

ategy 

28)

hane

29)

Inclusion Criteria: patients admitted to the orthopedic wards for femoral neck fractures and were fully lucidExclusion Criteria: none statedRecruitment method: NR

N=57Mean age (yrs): 78Gender, male (%): 19Race/ethnicity (%): NRMedical unit: orthopedic wards

Incidence of delirium (DSM-III)Mean length of stayMortality

Allocation Concealment: unclearBlinding: outcomes assessorIntention to Treat Analysis (ITT): yesWithdrawals adequately described: yes

ategy 

n=676)

atins (383)

Inclusion Criteria: patients undergoing cardiac surgeryExclusion Criteria: patients undergoing congenital 

or redo surgery, or requiring circulatory arrest, were excludedRecruitment method: NA

N=1059Mean age (yrs): NAGender, male (%): 71Race/ethnicity (%): NRMedical unit: cardiovascular ICU

Incidence of delirium (diagnosed with CAM), presented as an odds ratio and also stratified by age groups (age <60 years and ≥ 60 years)

Allocation Concealment: Not applicable (NA)Blinding: single blinded (nursing staff)Intention to Treat Analysis (ITT): NAWithdrawals adequately described: NA
70

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Strategy 

,

ols

Inclusion and Exclusion Criteria,

Recruitment Method

Patient Characteristics

(expressed in means 

unless otherwise 

noted)

Outcomes Evaluated Study Quality

ategy 

ontrolled 

analgesia 

enous 

0) 

Inclusion Criteria: ≥ 50 years old; underwent hip fracture surgery with intradural anesthesiaExclusion Criteria: received general· anesthesia or epidural analgesia, presented failure of femoral analgesia, or had localized infection or coagulopathyRecruitment method: NA, chart review

N=99Mean age (yrs): 81Gender, male (%): Intervention: 20, Control: 38, p=0.08Race/ethnicity (%): NRMedical unit: orthopedics

Incidence of delirium (documentation of altered mental status (confusion, disorientation, changes of level of consciousness, changes in the sleep-wake cycle)) Delirium severity (classified into two degrees of severity, low or severe, according to the need of prescription of any antipsychotic drug) Rescue medication use

Allocation Concealment: NABlinding: NAIntention to Treat Analysis (ITT): NAWithdrawals adequately described: NA

ategy 

mine 

n=11)

ers (n=29)

Inclusion Criteria: patients who were treated by the geriatric consultation team and had the appearance of a delirium or were considered to be at high-risk of develop delirium by their treating physicianExclusion Criteria: NRRecruitment method: group of 366 hospitalized patients, treated by the geriatric consultation team from January 2002 to June 2003, chronic rivastigmine users compared with randomly selected subgroup of all patients not treated with rivastigmine.

N=40Mean age (yrs): 79 Gender, male (%): 40Race/ethnicity (%): NRMedical unit: Nongeriatric wards

Diagnosed delirium during the time of hospitalization of the patient (based on DSM-IV criteria, and recorded in the medical record)Length of hospital stayMortality

Allocation Concealment: NABlinding: NAIntention to Treat Analysis (ITT): NAWithdrawals adequately described: NA

ategy 

gmine 

(n=68)

Inclusion Criteria: randomly selected pts who underwent elective surgery and were either Status I or II (American Society of Anesthesiologists)Exclusion Criteria: bradycardia, bronchial asthma, obstructive pulmonary disease, pregnancy, Parkinson’sRecruitment method: NA

N=113Mean age (yrs): NRGender, male (%): NRRace/ethnicity (%): NRMedical unit: surgical

Subjects were evaluated, postsurgery, on the following scale: 1) restless, thrashing, a score of 1; 2) mumbling, incoherent, a score of 2; 3) reacting, quiet, but nonverbal, a score of 3; 4) and appropriate verbal responses, a score of 4

Allocation Concealment: NABlinding: nurses who graded delirium, were blinded to interventionIntention to Treat Analysis (ITT): NAWithdrawals adequately described: NA
71

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Prevention Outcomes of Pharmacologic Studies

cidence/

 n/N (%)

Delirium Severity

(SD unless noted)

Delirium Duration, days

(SD unless noted)

Length of Stay, days

(SD unless noted)

Use of Rescue Medications n/N (%)

Control Intervention Control Intervention Control Intervention Control Intervention Control

19/61 (31.1) MDAS

delirium only10.5 (5.3)p=0.77

delirium only11.4 (3.0)

18.5 (26.4)p=0.36

14.5 (21.6) PRN sedatives

33/61 (54.1)p=0.46

PRN sedatives

82/204 (40.2)

DRSR-9816.4 (3.7)p=0.02

DRSR-9814.5 (2.7)

2.2 (1.3)p=0.02

1.6 (0.7) A trend toward use of fewer narcotics 

in the intervention arm but difference not significant

Deep sed.23/57 (40)

MMSE score2 days post-op23.1 (5.5)p=0.08Change from baseline-2.1 (3.4)p=0.06

MMSE score2 days postop20.0 (9.3)Change from baseline-4.4 (6.1)

Light sed.All0.5 (1.5)delirium only2.8 (2.3) p=0.77

Deep sed.All1.4 (4.0)p=0.01delirium only3.4 (5.7)

Light sed.mean4.7 (3.1)p=0.69

Deep sed.Mean4.5 (2.3)

17/57* (29.8) Median 2.5 

(range 1-5)p=0.30

Median 3 (range 1-5)

Median 13 (range 7-39)p=0.3

Median 13 (range 7-39)

Haloperidol 17/56 (30.4)p=0.90Lorazepam 35/56 (62.5)p=0.70

Haloperidol 18/57 (30.4)Lorazepam 38/57 (66.7)

9/29 (31.0) 8 (4.0)

p=0.36

7 (3.0)

Propofol16/36 (44.4) Midazolam17/40 (42.5)Per protocolPropofol15/30 (50.0) Midazolam15/30 (50.0) 

Dexmedet.2.0 (0.0)p=0.93 vs. propofol, 0.63 vs. midazolam

Propofol3.0 (3.1)Midazolam5.4 (6.6)

Dexmedet.7.1 (1.9)p=0.42 vs. propofol, 0.12 vs. midazolam

Propofol8.2 (3.8)Midazolam8.9 (4.7)

HaloperidolDexmedet.0/30p=0.07 vs. propofol, 0.15 vs. midazolamLorazepam Dexmedet.1/30 (3.3)p=0.06 vs. propofol, 0.11 vs. midazolam

HaloperidolPropofol3/30 (10.0)Midazolam2/30 (6.7)Lorazepam Propofol7/30 (23.3)Midazolam6/30 (20.0)
72

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

cidence/

 n/N (%)

Delirium Severity

(SD unless noted)

Delirium Duration, days

(SD unless noted)

Length of Stay, days

(SD unless noted)

Use of Rescue Medications n/N (%)

Control Intervention Control Intervention Control Intervention Control Intervention Control

All*25/105 (23.8)High risk group10/16 (62.5)

DRSR-98Highest value14.3 (3.6)p<0.001

DRSR-98Highest value18.6 (3.4)

5.2 (4.3)p<0.001

11 (7.2)

20/63 (31.7)5/14 (35.7) 9.9 (0.7)

p=0.09

12.1 (1.1)

36/218 (16.5)

Based on DRS, range 0-4514.4 (3.4)p<0.001

Based on DRS, range 0-4518.4 (4.3)

5.4 (4.9)p<0.001

11.8 (7.5) All

13.8 (7.7)p=0.84Delirious pts. only17.1 (11.1)p<0.001

All13.6 (7.8)Delirious pts. only22.6 (16.7)

DSM-IV7/41 (17.1)Sub.27/41 (65.8)

DSM-IV1.0 (SE 0.0)p=0.12Sub.1.71 (SE 0.19)

DSM-IV1.3 (SE 0.19)Sub.2.04 (SE 0.23)

4.4 (SE 0.13) 4.2 (SE 

0.08)

General6/28†† (21.4)Control7/20 (35.0)Accidents cause by delirium‡5/20 (25.0)

DFP25.6 (9.4)p=0.74

Control29.9 (16.2)
73

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

cidence/

 n/N (%)

Delirium Severity

(SD unless noted)

Delirium Duration, days

(SD unless noted)

Length of Stay, days

(SD unless noted)

Use of Rescue Medications n/N (%)

Control Intervention Control Intervention Control Intervention Control Intervention Control

Fentanyl11/25 (44.0)13/40 (32.5)Halothane11/29 (37.9)All49/383 (12.8)Age < 6012/197(6.1)Age 60+37/186(19.9)21/50 (42.0)Severe11/50 (22)

7.7 (3.0)p=0.16

8.6 (3.5) Opioids

0/49p<0.001

Opioids14/50 (28)

26/29 (88.9) 40.6 (95%CI 

-20-101.2);p=0.73

28.4 (95%CI(-16.8-73.6)

Score of 1 or 2†29/68 (42.6)Score of 1, 2 or 3†47/68 (69.1)

rovided, they were calculated by the reviewers.

s a danger to himself and required physical restraint; 2 = a mumbling, groaning, incoherent, unresponsive patient; 3 = a reacting, quiet, non-verbal patient who 

an awake patent who appropriate verbal responses.

patients each were randomized to the regional and general anesthesia arms, respectively. 4 patients receiving regional anesthesia failed and crossed over to 

eral) refused to go with study and were then excluded. Final n=47 (19 regional and 28 general).

, one pulled out central vein line, and all showed “strange behavior” like peeling off dressing gauze or fumbling with tubes. 
74

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

eristics of Non-Pharmacologic or Mixed Treatments Prevention Studies

tion Strategy Used,

Controls

Inclusion and Exclusion 

Criteria,

Recruitment Method

Patient Characteristics

(expressed in means unless 

otherwise noted)

Outcomes 

Evaluated

Study Quality

ategy Used: post operative 

ntervention program 

ention consisted of staff 

sing on the assessment, 

d treatment of delirium and 

mplications

operative care in the 

partment according to the 

rative care routines (n=97)

Inclusion Criteria: aged 70 years or older, consecutively admitted to the Orthopedic Department at the University Hospital in Umea, Sweden, between May 2000 and December 2002 with femoral neck fractureExclusion Criteria: severe rheumatoid arthritis, severe hip osteoarthritis, severe renal failure, pathological fracture, bedridden status prior to fracture Recruitment Method: in emergency room, patients were asked both in writing and orally if they were willing to participate in the study; in the case of patients with cognitive impairment, nextof-kin were also asked

N=199Mean age (yrs): 82Gender, male (%): 26Race/ethnicity (%): NRMedical unit: specialized geriatric ward or conventional orthopedic ward

Delirium prevalence (defined as DSM IV)Delirium durationLength of stayMortality

Allocation Concealment: yes (sealed and opaque envelopes)Blinding: outcomes assessorIntention to Treat Analysis (ITT): yesWithdrawals adequately described: yes

ategy Used: bright light 

ral lighting environment 

Inclusion Criteria: middle-aged or aged patients who had no mental or ophthalmologic disorders and were capable of communication in JapaneseExclusion Criteria: NRRecruitment Method: Patients undergoing surgery for esophageal cancer were recruited

N=15Mean age (yrs): 58Gender, male (%): 100Race/ethnicity (%): NRMedical unit: ICU

Delirium incidence (defined using Japanese version (2001) of the NEECHAM Confusion Scale)

Allocation Concealment: unclearBlinding: NRIntention to Treat Analysis (ITT): no, 4 excluded from analysesWithdrawals adequately described: yes (reintubated patients and patients with complications excluded)
75

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

tion Strategy Used,

Controls

Inclusion and Exclusion 

Criteria,

Recruitment Method

Patient Characteristics

(expressed in means unless 

otherwise noted)

Outcomes 

Evaluated

Study Quality

ategy Used: usual postplus music (patient’s choice 

ided) played at least 1 hour, 

=62)

l post-operative care (no 

) (n=62)

Inclusion Criteria: elders undergoing elective hip or knee surgery; over 65 years of age; alert and oriented to provide consent to surgery and to complete preoperative paperwork independently; able to hear musicExclusion Criteria: NARecruitment Method: recruited during pre-op interview

N=126 (124 completed the study)Mean age (yrs): 77Gender, male (%): 36Race/ethnicity (%): NRMedical unit: large tertiary care center (orthopedic)

Delirium incidence (based on review of nurses’ notes after patient was discharged)

Allocation Concealment: unclear Blinding: noneIntention to Treat Analysis (ITT): noWithdrawals adequately described: yes

ategy Used: intervention 

multi-component including 

eriatric medicine focusing on 

revention, and treatment of 

ation concerning caregiver

ion focusing on patients with 

delirium, reorganization from 

n care system to a patient

em with individualized care, 

nce for nursing staff

ol ward care (usual hospital 

Inclusion Criteria: aged 70 and olderExclusion Criteria: patient refusalRecruitment Method: patients mainly (93.8%) admitted from the emergency room in the same proportion to each ward

N=400Mean age (yrs): 80.1Gender, male (%): 44Race/ethnicity (%): NRMedical unit: general internal medicine

Delirium incidence,(defined by DSMIV)Delirium duration 

Allocation Concealment: unclearBlinding: outcomes assessorIntention to Treat Analysis (ITT): yesWithdrawals adequately described: all included

ategy Used: proactive 

ultation, preoperatively or 

s of surgery (n=62)

al care (n=64)

Inclusion Criteria: patients 65 years or older admitted for primary surgical repair of hip fractureExclusion Criteria: presence of metastatic cancer or other comorbid illness likely to reduce life expectancy to less than 6 months, or inability to give informed consent with 24 hours of surgery or 48 hours from admissionRecruitment Method: patients approached by investigators after admitted 

N=126Mean age (yrs): 79 Gender, male (%): 21Race/ethnicity (%): white 90Medical unit: orthopedic surgery

Delirium incidence (CAM)Severe delirium incidence (CAMdefined delirium with MDAS score ≥18)Delirium durationLength of stay

Allocation Concealment: unclear (“sealed envelopes”)Blinding: outcomes assessor for delirium incidenceIntention to Treat Analysis (ITT): yesWithdrawals adequately described: all included
76

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

tion Strategy Used,

Controls

Inclusion and Exclusion 

Criteria,

Recruitment Method

Patient Characteristics

(expressed in means unless 

otherwise noted)

Outcomes 

Evaluated

Study Quality

ategy Used: postoperative 

dified protocols were 

examined (n=41)

cal myelopathy patients 

ctively examined about 

of post- operative delirium 

Inclusion Criteria: patients who met indication criteria for cervical decompression surgeryExclusion Criteria: dementia, other psychological disordersRecruitment Method: NA

N=122Mean age (yrs): Intervention: 68 Control: 70Gender, male (%): NRRace/ethnicity (%): NRMedical unit: neurology (spinal surgery)

Delirium incidence(based on DSM-IV criteria)

Allocation Concealment: NABlinding: NAIntention to Treat Analysis (ITT): NAWithdrawals adequately described: NA

ategy Used: quality 

program with two major 

n educational program 

ging the approach of 

staff to patient care 

ecific targeted actions 

domains (orientation, 

eption, sleep preservation, 

ydration, nutrition, drug list 

2)

dard care provided by 

es, and additional staff 

ehabilitation team, social 

n needed (n=372)

Inclusion Criteria: aged 70 and older, with any of the risk criteria for delirium (cognitive impairment, visual impairment, acute disease severity, dehydration)Exclusion Criteria: presence of severe dementia that impaired communication, aphasia of any origin, coma, agonic status, or expected hospital stay less than 48 hoursRecruitment Method: patients who did not have delirium at the time of admission and had ≥ 1 of the four risk factors of delirium (cognitive impairment, visual impairment, acute disease severity, and dehydration) were included

N=542Mean age (yrs):Intervention: 86 Control: 82p<0.001Gender, male (%): Intervention: 38Control: 47 p=0.04Race/ethnicity (%): NRMedical unit: Internal medicine or geriatricsNote: there were significant differences (p<0.05)in several of the baseline characteristics 

Delirium incidence (defined according to the criteria of the CAM)Delirium severity (measured using an additive score for the four delirium symptoms included in the CAM; evaluator rated each delirium symptom, except fluctuation, as absent (0 points), mild (1 point), or severe (2 points); fluctuation was rated as absent (0 points) or present (1 point); sum of these points ranged from 0 to 7 with higher scores indicating greater severity)Delirium duration Mortality

Allocation Concealment: NABlinding: A trained research assistant, who was not involved in the intervention, conducted all interviews. Intention to Treat Analysis (ITT): yesWithdrawals adequately described: NA
77

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

tion Strategy Used,

Controls

Inclusion and Exclusion 

Criteria,

Recruitment Method

Patient Characteristics

(expressed in means unless 

otherwise noted)

Outcomes 

Evaluated

Study Quality

ategy Used: acute 

) protocol, an evidence

which focused on 3 

atient orientation (2) 

logic sleep; and (3) 

ion; implemented by an y team (pharmacists, 

herapists, physical 

ses, and nurses’ aides)

o units each chose an 

 implement for 1 month

 study, implementation of all 

s initiated

study: one unit continued 

he elderly 

Inclusion Criteria: 70 years or older, admitted for more than 23 hours, and without a communication barrier or having an alcohol withdrawal experienceExclusion Criteria: none statedRecruitment Method: NA

N=137 (pilot study)Mean age (yrs): NR, all >70 years of ageGender, male (%): NRRace/ethnicity (%): NRMedical unit: medical/surgical

Delirium (AC) incidence in the pilot studyRate of fallsUse of restraintsUsage of anti-anxiety medications (known to cause acute confusion)

Allocation Concealment: NABlinding: NAIntention to Treat Analysis (ITT): NAWithdrawals adequately described: NA

ategy Used: delirium 

ventions from the HELP 

trategies suggested by  (2003)* - implemented in 

ntion group; interventions 

y nursing assistants and 

fic approaches for patients 

 hearing impairment, vision 

nd mobility impairment 

hed convenience sample 

r the age of 65 with any 

 the risk factors of the post

oup who were admitted 

plementation of the delirium 

tocol (n=80)

 Mion LC, Trygstad LJ, 

03). Delirium: Strategies for 

 treating. In M. Mezey, et al. 

c nursing protocols for best 

d., pp. 63–75). New York: 

Inclusion Criteria: over the age of 65 with any combination of the risk factors of dementia, vision impairment, hearing impairment, and mobility impairmentExclusion Criteria: NRRecruitment Method: on admission, patients over 65 were assessed for risk factors of dementia, vision impairment, hearing impairment, and mobility impairment by the registered nurse admitting the patient

N=160Mean age (yrs): Pre-intervention (control) group: 79.2Post-intervention group: 78.8Gender, male (%):46% Race/ethnicity (%): NRMedical unit: renal 

Delirium incidence (defined accordingto the criteria of the CAM)

Allocation Concealment: NABlinding: NAIntention to Treat Analysis (ITT): NAWithdrawals adequately described: NA
78

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

tion Strategy Used,

Controls

Inclusion and Exclusion 

Criteria,

Recruitment Method

Patient Characteristics

(expressed in means unless 

otherwise noted)

Outcomes 

Evaluated

Study Quality

ategy Used: volunteervention of daily orientation, 

tivities, feeding and 

stance, vision and hearing 

d on the Hospital Elder 

HELP) developed at Yale 

ool of Medicine; training 

hased through the HELP 

ogram and adapted to 

 the whole intervention 

ered by volunteers; 

dinator employed to select, 

see volunteers delivering 

ntions to elderly patients 

l care (n=21)

Inclusion Criteria: at least one of the following risk factors for developing delirium: mini-mental state examination < 24, sleep deprivation, any activities of daily living, impairment or immobility, vision impairment, hearing impairment or dehydrationExclusion Criteria: severe dementia (MMSE < 10), psychotic disorder; unable to consent or refused; terminal condition receiving comfort care; to be discharged within 48; any behavioral or medical condition that may place the volunteer’s health and safety at risk Recruitment Method: patients able to communicate and aged greater than 70 years were enrolled on admission to the geriatric wards

N=37Mean age (yrs): Intervention: 84Control: 86 p=0.4Gender, male (%): 22Race/ethnicity (%): NRMedical unit: Geriatrics 

Delirium incidence (CAM)Delirium severity (assessed using Memorial Delirium Assessment Score (MDAS))Length of stayCost analysis data provided

Allocation Concealment: NABlinding: NRIntention to Treat Analysis (ITT): yesWithdrawals adequately described: none

ategy Used: proactive 

eople undergoing surgery 

ultidisciplinary preoperative e geriatric assessment 

st-operative follow-up (n=54)

POPS (n=54)

Inclusion Criteria: elective orthopedic patients, age 65 and olderExclusion Criteria: none statedRecruitment Method: POPS targeted patients with risk factors for post-surgery complications; sought referrals for older patients needing surgery but considered too ‘medically unfit” 

N=108Mean age (yrs): 74.6 Gender, male (%): 39.8Race/ethnicity (%): NRMedical unit: elective orthopedic surgery

Delirium incidence (defined as acute change in mental status post-op with improvement predischarge)Length of stay Mortality (within 30 days)

Allocation Concealment: NABlinding: outcomes assessment was nonblindedIntention to Treat Analysis (ITT): NAWithdrawals adequately described: all included
79

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

tion Strategy Used,

Controls

Inclusion and Exclusion 

Criteria,

Recruitment Method

Patient Characteristics

(expressed in means unless 

otherwise noted)

Outcomes 

Evaluated

Study Quality

ategy Used: multifactorial: ysicians educated and 

valuate patients >75 years 

ia & delirium and to admit ementia or delirium to 

atric Unit (AGU); AGU 

ing nurse, physician and 

 interventions; nurse and 

cation and feedback on 

(4-Month Outcome (n=154) 

Outcome (n=110))

st/ baseline patients 

11/98 to general med 

) 

Inclusion Criteria: >75 years, admitted to non-critical-care medical service of Buffalo General Hospital 4 months and 9 months after multi-factorial prevention program startedExclusion Criteria: admitted from nursing home, declined to be interviewedRecruitment Method: consecutive admissions to medical service

N=cohort of 110 patients evaluated at baseline (before prevention strategy implemented); cohort of154 patients evaluated 4 months after implementation; cohort of 110 patients evaluated 9 months after implementation; (total N=374)Mean age (yrs): baseline cohort: 81+6.2; 4-month cohort: 81+6.1; 9-month cohort: 82+5.9Gender, male (%): baseline cohort: 41 (37%); 4-month cohort: 52 (34%); 9-month cohort: 38 (35%)Race/ethnicity (%): NRMedical unit: baseline cohort: general medicine; 4-month cohort: Acute Geriatric Unit (AGU; N=84) & general medicine (N=70); 9-month cohort: AGU (N=37) & general medicine (N=73)

Delirium prevalence (defined as +CAM)Medication use (benzodiazepines, antidepressants, antihistamines, opiates, neuroleptics)

Allocation Concealment: NABlinding: NA Intention to Treat Analysis (ITT): NA Withdrawals adequately described: NA
80

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

tion Strategy Used,

Controls

Inclusion and Exclusion 

Criteria,

Recruitment Method

Patient Characteristics

(expressed in means unless 

otherwise noted)

Outcomes 

Evaluated

Study Quality

ategy Used: intervention 

onal package s delivered to 

ursing staff; 3 components: 

sion including a formal 

nd small group discussion; 

rmation and guidelines on 

t, recognize and manage 

er people; (3) regular 

d small group discussions n hour during which staff 

ged to discuss discharged 

ses they had encountered 

 enhancing their learning 

h specific examples (n=122)

ol ward -no educational 

stablished practice was 

oughout (n=128)

Inclusion Criteria: 70 years of age or older, understood and spoke English, agreed to take part, had no recorded symptoms of delirium in medical and nursing notes on admission, and had been in hospital for longer than 24 hoursExclusion Criteria: NRRecruitment Method: all admissions to the two medical units between December 2001 and August 2002 were considered eligible for inclusion if they met the above criteria

N=250Mean age (yrs): Intervention: 81Control: 79 p=0.007Gender, male (%): 48Race/ethnicity (%): NRMedical unit: medicine

Point prevalence of delirium (defined using a modified Delirium Rating Scale (DRS))

Allocation Concealment: NABlinding: single (patients)Intention to Treat Analysis (ITT): yes, however case notes of 6 patients on the intervention ward and 8 on the control ward could not be traced by the Medical Records Department and therefore were not examinedWithdrawals adequately described: none reported

ategy Used: program group 

vement methods including 

 and use of a checklist to 

f the 10 strategies, including 

ce of adequate brain oxygen 

aintenance of fluid and 

ance; (3) pain protocol; (4) 

f discontinuing or minimizing 

5) regulation of bladder/ 

 (6) adequate nutrition; 

zation and rehabilitation; 

 early detection and ajor peri- and post

plications; (9) appropriate  stimuli; (10) treatment 

tated delirium (n=71)

ogram group (n=28)

Inclusion Criteria: all patients with osteoporotic hip fracture aged over 50 years admitted during the study periodExclusion Criteria: < 50 years of ageRecruitment Method: consecutive patients with hip fracture admitted to the orthopedic unit at Fremantle Hospital

N=99Mean age (yrs): 82 Gender, male (%): 28Race/ethnicity (%): NRMedical unit: orthopedic

Delirium incidence (assessed using CAM)Delirium duration Length of hospital stay

Allocation Concealment: NABlinding: noneIntention to Treat Analysis (ITT): yesWithdrawals adequately described: NA
81

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

tion Strategy Used,

Controls

Inclusion and Exclusion 

Criteria,

Recruitment Method

Patient Characteristics

(expressed in means unless 

otherwise noted)

Outcomes 

Evaluated

Study Quality

ategy Used: education 

f; systematic cognitive 

sultative services by 

rce nurse, geriatric 

st, or psychogeriatrician; 

n protocol (n=60)

 care prior to 

n of intervention (n=60)

Inclusion Criteria: admitted to emergency department of one hospital with traumatic fracture of proximal femur and hospitalized in 1 of 2 traumatological nursing units within 24 hrs of surgery; Dutch speaking and verbally testableExclusion Criteria: multiple trauma, concussion, pathological fractures, surgery occurring more than 72 hours after admission, aphasia, blindness, deafness, fewer than 9 years of formal educationRecruitment Method: all patients approached by research nurses within 48 hours after admission

N=120Median age (yrs): 81Gender, male (%): 19Race/ethnicity (%): NRMedical Unit: traumatological wards 

Delirium incidence (based on CAM)Duration of deliriumMortalityLength of stay

Allocation Concealment: NABlinding: NAIntention to Treat Analysis (ITT): yesWithdrawals adequately described: NA
82

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

tion Strategy Used,

Controls

Inclusion and Exclusion 

Criteria,

Recruitment Method

Patient Characteristics

(expressed in means unless 

otherwise noted)

Outcomes 

Evaluated

Study Quality

ategy Used: multiategy (Elder Life Program); 

nsisted of standardized 

he management of six risk 

rium: cognitive impairment, 

on, immobility, visual 

earing impairment, and 

=426)

pectively matched patients 

ion strategy was 

y a trained interdisciplinary 

onsisted of a geriatric nurse

specially trained Elder , a certified therapeutic

cialist, a physical therapy 

eriatrician, and trained 

Inclusion Criteria: at least 70 years old, no delirium at the time of admission, and at intermediate or high risk for delirium at baselineExclusion Criteria: inability to participate in interviews (because of profound dementia that precluded verbal communication, language barrier, profound aphasia, or intubation or respiratory isolation), coma or terminal illness, hospital stay of 48hours or less, prior enrollment in this studyRecruitment Method: all subjects in intervention unit who met the eligibility criteria were enrolled; concurrently, eligible patients from two usual-care units were identified, so subject pool was sufficiently large to permit use of a computerized algorithm designed to match patients according to age within five years, sex, and base-line risk of delirium (intermediate or high)

N=852Mean age (yrs): 80Gender, male (%): 39Race/ethnicity (%): white 87Medical unit: General medicine

Delirium incidence (defined according to the criteria of the CAM)Total days of deliriumNo. of episodes of deliriumDelirium-severity scoreRecurrence (two or more episodes)

Allocation Concealment: Not feasible, but a prospective, individual 

matching strategy was chosen as an alternative to randomizationBlinding: none statedIntention to Treat Analysis (ITT): yesWithdrawals adequately described: yes

ategy Used: intervention 

education, co-operation 

pedic surgeons and geri

dual care and planning of 

mproved ward environment, 

 improved continuity of care 

 and treatment of complica

d with delirium (n=49)

nts from two studies, one a 

e a medical intervention; all 

5 years of age and older 

dmitted to an orthopedic 

oral neck fracture repair 

03) 

Inclusion Criteria: patients operated on for fractured neck of the femurExclusion Criteria: NRRecruitment Method: patients with hip fractures from the study catchment area admitted to the department in which the orthopedic surgeon and the geriatricians co-operate in the treatment and care of the patients

N=49 (Intervention)Mean age (yrs): 79.7 Gender, male (%): 35N=111 (Control 1)Mean age (yrs): 79.3 Gender, male (%): 25N=103 (Control 2)Mean age (yrs): 79.5 Gender, male (%): 27All Groups:Race/ethnicity (%): NRMedical unit: orthopedics

Diagnosed delirium (based on DSMIII-R criteria).

Allocation Concealment: NABlinding: NRIntention to Treat Analysis (ITT): NAWithdrawals adequately described: NA
83

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

tion Strategy Used,

Controls

Inclusion and Exclusion 

Criteria,

Recruitment Method

Patient Characteristics

(expressed in means unless 

otherwise noted)

Outcomes 

Evaluated

Study Quality

ategy Used: nursing 

, subject orientation, 

n with family, mobilization, 

 modifications, caregiver 

dication management, 

ning (n=135)

ng care per unit staff (usual 

Inclusion Criteria: age 70 and older, admitted to study medical unit between Sunday noon and Friday noonExclusion criteria: transferred from another unit within the hospital, admitted for short-stay procedure, admitted only for terminal careRecruitment Method: Consent sought within 24 hours of admission to study unit or control units

N=235 Mean age (yrs): 77Gender, male (%): NRRace/ethnicity (%): NRMedical unit: non-critical care general medicine units with geriatric clinical specialist nurses in Intervention unit

Diagnosed delirium (based on Delirium Screening Assessment [MMSE#, BPRS#, 

and clinical exam] with psychiatrist making final diagnosis based on DSM-III)Hospital mortalityLength of stay

#MMSE=MiniMental State 

ExaminationBPRS=Brief Psychiatric Rating Scale

Allocation Concealment: NABlinding: psychiatrist who made final diagnosis blinded to Delirium Screening AssessmentIntention to Treat Analysis (ITT): NAWithdrawals adequately described: NA

ategy Used: 1) surgical 

 as soon as possible), 

e assessment and 

ophylaxis 3) oxygen therapy, 

echnique, and 5) post

ssment and treatments 

nts seen in the same 

partment approximately 3 

study period (n=111)

Inclusion Criteria: consecutive patients, 65 and older, fractured neck of the femurExclusion criteria: none statedRecruitment Method: consecutive admissions

N=103 (Intervention)Mean age (yrs): 79.5 Gender, male (%): 27N=111 (Controls)Mean age (yrs): 79.3 Gender, male (%): 25Both Groups: Race/ethnicity (%): NRMedical unit: Orthopedic Surgery

Delirium incidence (acute confusion based in DSM-III criteria)Duration of deliriumOrthopedic ward stayMortality 

Allocation Concealment: NABlinding: NRIntention to Treat Analysis (ITT): NAWithdrawals adequately described: NA
84

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Prevention Outcomes of Non-Pharmacologic or Mixed Studies

cidence/

e n/N (%)

Delirium Severity Delirium Duration, days

(SD unless noted)

Length of Stay, days

(SD unless noted)

Use of Rescue Medications

n/N (%)

Control Intervention Control Intervention Control Intervention Control Intervention Control

73/97 (75.3)Delirium ≥ 1during hosp. after day 750/97 (51.5)Delirious on day of discharge20/97 (20.6)

5.0 (7.1)p=0.01

10.2 (13.3) 28.0 (17.9)

p=0.03Delirious pts. only31.4 (19.3)p=0.03

38.0 (40.6)Delirious pts. only43.6 (42.7)

Sedatives(delirious pts.)6/39 (15.4)p<0.01Opioids(delirious pts.)12/39 (30.8)p<0.01

Sedatives (delirious pts.)20/48 (41.7)Opioids(delirious pts.)29/47 (61.7)

2/5 (40.0)36/62 (58.1)62/200 (31.0)Remain delirious on day 737/62 (59.7)p<0.01

9.4 (8.2)p<0.001

13.4 (12.3)

32/64 (50)Severe delirium 18/64 (29)Delirium at discharge 12/64 (19)

2.9 (2.0) (per episode)p=NS

3.1 (2.3) (per episode)

5 (2) (median and IQR) p=NS

5 (2) (median and IQR)
85

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

cidence/

e n/N (%)

Delirium Severity Delirium Duration, days

(SD unless noted)

Length of Stay, days

(SD unless noted)

Use of Rescue Medications

n/N (%)

Control Intervention Control Intervention Control Intervention Control Intervention Control

23/81(28.4)69/372 (18.5) Based on 

CAM, range 0-74.9 (0.4)p=0.08

Based on CAM,range 0-75.3 (1.0)

Hours31.1 (43.0)p=0.73

Hours33.6 (22.0)

Control units (11.0)Pre-protocol30/80 (37.5) 
86

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

cidence/

e n/N (%)

Delirium Severity Delirium Duration, days

(SD unless noted)

Length of Stay, days

(SD unless noted)

Use of Rescue Medications

n/N (%)

Control Intervention Control Intervention Control Intervention Control Intervention Control

8/21 (38.1) Based on 

MDAS (scale not provided)1.2p<0.05

Based on MDAS (scale not provided)5.1

5 (only 1 subject, no SD)p=0.64

12.5 (14.5) 22.5 (9.6)

p=0.35

26.8 (17.8)

Pre-Protocol10/54 (18.5)

11.5 (5.2)p=0.03

15.8 (13.2)

Baseline45/110 (40.9)

Non-delirious pts only4- and 9 month cohorts combined (n=208) 8.2

Delirious pts onlyBaseline (n=45) 11.5 

Significant differences from baseline4-mo cohort:Antidepressants:

29/154 (19%);p<0.059-mo cohort:Benzodiazepines: 11/110 (10%);p<0.01Antihistamines: 

4/110 (4%);p<0.01Opiates: 25/110 (23%);p<0.01

Benzodiazepines: 34/110 (31%)Antidepressants:11/110 (10%)Antihistamines: 17/110 (16%)Opiates: 47/110(43%)Neuroleptics: 12/110 (11%)

25/128 (19.5)Baseline period10/28 (35.7)

Baseline period5 (2-6)p=0.43

PostinterventionMedian (range)3 (2-4)

Baseline periodMedian (range)8 (3-41);p=NS

PostinterventionMedian (range)10 (2-44)
87

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

cidence/

e n/N (%)

Delirium Severity Delirium Duration, days

(SD unless noted)

Length of Stay, days

(SD unless noted)

Use of Rescue Medications

n/N (%)

Control Intervention Control Intervention Control Intervention Control Intervention Control

14/60 (23.3) Post-op 

Day 1: 2.73Day 3: 3.82Day 5: 3.36Day 8: 1.91(Total CAM score), p=0.02

Post-op

Day 1: 6.92Day 3: 5.78Day 5: 6.54 Day 8: 6.0

(Total CAM score)

1 (1)(median and IQR)p=0.03

4 (5.5)(median and IQR)

13 (6.5)(median and IQR)p=NS

16 (5.25)(median and IQR)

90First episode64/426 (15.0)

‡3.85±1.27;p=0.25

3.52±1.44 Total days

105p=0.02

161

Median 7 days

Median 7 days

Post-opC168/111 (61.3) C249/103 (47.6)Delirium ≥ 7 daysControl 144/111 (39.6)Control 229/103 (29.1)

Ward (orthopedic) stay12.5; p=NR

Ward (orthopedic) stayC1 17.4C2 11.6

22/100 (22.0)Post-op68/111 (61.3)Severe33/111 (29.7)More than 7 days44/111 (39.6)

Orthopedic Ward12.8 (10.4)p<0.01

Orthopedic Ward 20.0 (15.4)
88

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

eristics of Intensive Care Unit Diagnostic Accuracy Studies

Inclusion and Exclusion Criteria

Recruitment Method

Patient Characteristics Index Test(s) and Examiner

Reference Standard and 

Examiner

Outcomes 

Evaluated

clusion: admitted to medical and surgical 

U for >24 hours

xclusion: diagnosis of delirium on 

dmission, comatose or stuporous

N= 93Mean age (yrs): 62 Gender, male (%): 52VETERAN (Y/N): NRace/ethnicity (%): NRMedical unit: med/surg ICUComorbid conditions (list): NRAPACHE II 14 (8-21)

ICDSC – ICU physicianDiagnosis by consulting board certified psychiatrist 

Validation of ICDSC

clusion: consecutive patients admitted to 

U, >65 years

xclusion: no appropriate surrogate, 

ansferred from another ICU, non-English 

eaking, inability to communicate, 

tubated, mechanically ventilated, or 

hysically restrained

N= 22Mean age (yrs): 78Gender, male (%): 36 VETERAN (Y/N): NRace/ethnicity (%): caucasian 73Medical unit: ICUComorbid conditions (list): visual/hearing impairments (38%), history of alcohol use (33%), disability in ADLs (37%), preexisting cognitive impairment (45%)APACHE 25.9 CHARLSON 2.0 

CAM-ICU - trained clinician researchersCAM - trained clinician researchers

Sensitivity and specificity of CAM and CAMICU

clusion: non intubated, score of at least 10 

n Glasgow Coma Scale, 18 years or older; 

U stay of at least 24 hours before first 

sessment

xclusion: none stated

N= 172Mean age (yrs): 60Gender, male (%): 59 VETERAN (Y/N): NRace/ethnicity (%): NRMedical unit: ICUComorbid conditions (list): NRAPACHE II: 21

NEECHAM – trained nurse researcherCAM-ICU - same nurse researcher

Comparison of NEECHAM with CAM-ICULength of stay

clusion: patients with delirium (from ICU), 

hizophrenia (inpatient), or depressive 

ness(inpatient) (all by DSM-III-R criteria) or 

ementia (outpatient)

xclusion: history of substance abuse, major 

edical illness, or neurologic disorders

N= 103 (22 with delirium)For Delirium Patients:Mean age (yrs): 62.5Gender, male (%): 54.5VETERAN (Y/N): NRace/ethnicity (%): African American 50, caucasian 50 Medical unit: ICUComorbid conditions (list): NRAPACHE: NR

CTD – bachelor’s level psychologist technicianDSM III-R-psychiatrist

How well CTD performed across 4 populations (delirium, dementia, depression, schizophrenia)
89

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Inclusion and Exclusion Criteria

Recruitment Method

Patient Characteristics Index Test(s) and Examiner

Reference Standard and 

Examiner

Outcomes 

Evaluated

clusion: admitted to ICU

xclusion: history of severe dementia, 

ychosis or neurologic disease; patient or 

mily refusal; comatose

N= 38Mean age (yrs): 60Gender, male (%): 60VETERAN (Y/N): NRace/ethnicity (%): caucasian 84, African American 14, Hispanic 2Medical unit: ICUComorbid conditions* (list): acute respiratory distress 29%, MI or arrhythmia 16%, CHF 16%, hepatic or renal failure 13%, COPD 11%, GI bleeding 8%, malignancy 5% APAHCE II: 17.1

CAM-ICU – study nurses and intensivistsDSM IV – geriatrician, geriatric consult-liaison psychiatrist

Validation of CAM-ICU

clusion: medical ICU patients, 60 years 

nd older

xclusion: no proxy, patient died during 

oxy interview, transfer from other ICU; in 

U<24h, non-English speaking

N= 178Mean age (yrs): 74.2Gender, male (%): 52VETERAN (Y/N): NRace/ethnicity (%): non-caucasian 12 Medical unit: ICUComorbid conditions (list): dementia (29%), disability in ADLs (31%), GI hemorrhage* (16%), respiratory* (51%), neurologic* (2%), sepsis* (17%)APACHE II: 23.4 CHARLSON: 1.9 

Chart-based delirium method – trained research nurseCAM-ICU-–trained research nurses

Validation of chart-based delirium detection method

clusion: medical and coronary ICU 

atients, mechanically ventilated

xclusion: history of psychosis and 

eurologic disease, inability to communicate 

on-English speaking, deaf, comatose), 

xtubated before assessment, previously nrolled in the study, refusal to participate

N= 96Mean age (yrs): 55.3Gender, male (%): 47.9VETERAN (Y/N): NRace/ethnicity (%): caucasian 79.2, black 19.8, Hispanic 1.0Medical unit: ICUComorbid conditions* (list): acute respiratory distress 35%, cancer 15%, myocardial infarction or arrhythmia 9%, hepatic or renal failure 9%, CHF 6%, COPD 6%, GI bleeding 5%, drug overdose 3%, other 12%APACHE II: 22.9 

CAM-ICU – critical care study nursesDSM IV – geriatrician delirium expert, board certified geriatric consultliaison psychiatrist, or neuropsychologist

Validation of CAM-ICULength of stay

clusion: ICU stay >48 hours

xclusion: preexisting neurocognitive 

ysfunction, documented dementia, 

nguage barriers or deafness, active 

ychiatric disorder, severe neurologic 

sorder

N= 46Mean age (yrs): 73Gender, male (%): 65VETERAN (Y/N): NRace/ethnicity (%): NRMedical unit: ICUComorbid conditions (list): NRAPACHE II: 18 

Clinical judgment – ICU nurses and physiciansCAM-ICU - research nurses 

Validation of clinical judgmentLength of stayMortality
90

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Inclusion and Exclusion Criteria

Recruitment Method

Patient Characteristics Index Test(s) and Examiner

Reference Standard and 

Examiner

Outcomes 

Evaluated

clusion: all (adult) admissions to ICU 

medical 24%, surgical 25%, cardiothoracic 

rgical 29%, neurological/neurosurgical 

2%)

xclusion: deeply sedated, comatose, deaf; 

d not speak Dutch or English, did not 

nsent

N= 126Mean age (yrs): 62.4Gender, male (%): 72VETERAN (Y/N): NRace/ethnicity (%): NRMedical unit: ICUComorbid conditions (list): NRAPACHE II: 20.9 

CAM ICU – trained ICU study nursesICDSC – patient’s bedside ICU nurseDiagnostic impression –critical care intensivist, fellow, or resident DSM IV - psychiatrist, neurologist, geriatrician

Validation of CAM-ICU, ICDSC, and physician impression

clusion: all admissions to ICU

xclusion: coma, acute stroke, refusal, non

ermanspeaking

N= 54Mean age (yrs): 67Gender, male (%): 69VETERAN (Y/N): NRace/ethnicity (%): NR Medical unit: ICUComorbid conditions* (list): Abdominal surgery 13%, vascular surgery 6%, urology 2%, lung surgery 1%, cardiac surgery 23%, trauma 4%, ear/nose/throat surgery 2%APACHE: NR

CAM-ICU Flowsheet – intensivist, trained medical studentDSM IV - psychiatrist

Validation of CAM-ICU Flowsheet

clusion: admitted to ICU after elective 

rgery or after emergency, age 18 or older

xclusion: profound hearing or vision 

pairment, non-German speaking, coma or 

nconscious

N= 174Mean age (yrs): 62.4Gender, male (%): 70.1VETERAN (Y/N): NRace/ethnicity (%): NRMedical unit: ICUComorbid conditions* (list): pancreas resection 32%, GI 21%, cardiorespiratory 19%, urology/renal failure 10%, metabolic disease 9%, polytrauma 4%, other 5%APACHE II: 25 p/m

ICDSC - trained nursesCAM-ICU - physician researcherNOTE: study compared agreement of these 2 tools

Agreement of the ICDSC and CAM-ICULength of stayMortality

clusion: admitted to medical or cardiac 

U, age 13 or older

xclusion: unable to speak, intubated, 

fused consent

N= 120Mean age (yrs): 54.9Gender, male (%): 72.5VETERAN (Y/N): NRace/ethnicity (%): NRMedical unit: ICUComorbid conditions (list): NRAPACHE: NR 

MDAS – junior residentICD-10 (International Classification of Diseases, 10th revision) – psychiatrist 

(unclear if all patients were evaluated by psychiatrist)

Validation of MDASInterrater reliability
91

, and Diagnosis – A Systematic Review of the Evidence Evidence-based Synthesis Program

Inclusion and Exclusion Criteria

Recruitment Method

Patient Characteristics Index Test(s) and Examiner

Reference Standard and 

Examiner

Outcomes 

Evaluated

clusion: admitted after elective cardiac 

rgery, >21 years of age

xclusion: refused, death

N= 15Mean age (yrs): 63Gender, male (%): 80VETERAN (Y/N): NRace/ethnicity (%): NRMedical unit: ICUComorbid conditions (list): NRAPACHE: NR

Observation checklist (based on DRS) - study physiciansDSM III R - unclear

clusion: in ICU, mechanically ventilated

xclusion: history of dementia, psychosis, 

ental retardation, other neurologic disease; 

ceiving antipsychotics or high dose 

orphine or midazolam; under general 

nesthesia or heavily sedated, refused

N= 102Mean age (yrs): 73.4Gender, male (%): 53VETERAN (Y/N): NRace/ethnicity (%): NRMedical unit: ICUComorbid conditions* (list): pneumonia (31%), lung disease (24%), stroke (11%), cancer (8%), CHF (5%), GI disease (5%), diabetes or metabolic disorder (5%), myocardial infarction (3%), drug intoxication (3%)APACHE III: 64.9

CAM-ICU - 2 research assistantsDSM IV - psychiatrists

Validation of CAM-ICUMortalityInterrater reliability

clusion: newly admitted to ICU after 

rgery, age > 60, LOS at least 24h

xclusion: preexisting psychosis, dementia, 

epression, non-German speaking, inability 

 communicate

N= 156Mean age (yrs): 69.8Gender, male (%): 55VETERAN (Y/N): NRace/ethnicity (%): NRMedical unit: ICUComorbid conditions* (list): general surgery (39%), cardiac (25%), trauma (16%), gynecologic (9), urologic (4%), otorhinolaryngological (4%), vascular (2%), oral (1%)APACHE II: 18

CAM-ICU, Nu-DESC, DDS – trained physicians and nursesDSM IV – board-certified psychiatrist or intensivist

Validation of CAM-ICU, NuDESC, and DDSInterrater reliabilityLength of stayDischarge disposition

hronic Health Evaluation; NR = not reported; ADLs = Activities of Daily Living;

Method – Intensive Care Unit; CAM = Confusion Assessment Method; CTD = Cognitive Test for Delirium; DDS = Delirium Detection Score; DSM 

of Mental Disorders; ICDSC = Intensive Care Delirium Screening Checklist; MDAS = Memorial Delirium Assessment Scale; NEECHAM = Neelon 

Nu-DESC: Nursing Delirium Screening Scale