1. SIGN GUIdeline: diagnosis and management of delirium
Ailsa Stein,
Programme Manager, SIGN

2. Scottish Intercollegiate Guidelines Network
Public funding but professional ownership
evidence-based clinical guidelines produced using transparent methodology
internationally validated methodology .

3. SIGN Delirium guideline development group Consultant Physicians
A & E Consultant
Consultant Psychiatrists
Consultant in Geriatricians
General Practitioner
SIGN
Nurse Practitioner
Pharmacist
Health economist
Consultant in
Critical Care
and Anaesthesia
Lay representatives
Anaesthetist

4. Patient/carer issues identified previously by Healthcare Improvement Scotland in relation to delirium
Value of family members – skills and experience in detecting early warning signs
Suitable approach from staff
Education and training for staff – early warning signs
Role of NHS 24 in getting expert knowledge from carers
Opportunity to discuss dreams or nightmares
Support for carers
Being kept in the loop - updates for family members
Staff could suggest to families keeping a diary

5. Key questions
What assessment tool(s) should be used to detect delirium and when?
What tool(s) should be used for monitoring purposes and when should they be used?
What (other) investigations are useful when assessing a patient for delirium?
What risk reduction strategies for patients at risk of delirium are effective?
What are the most effective non-pharmacological strategies for managing patients with delirium?
What are the most effective pharmacological strategies for managing patients with delirium?
What follow-up care should patients receive after experiencing delirium?

6. Key questions
Adults over 18 years at risk of, or experiencing, delirium
Home, long-term care, hospital, hospice
Excludes: delirium secondary to alcohol, patients with delirium tremens, paediatric delirium
Comborbidities considered: dementia, depression, frailty, head injury, learning disability, Parkinson’s disease, stroke

7. Key questions
What assessment tool(s) should be used to detect delirium and when?
What tool(s) should be used for monitoring purposes and when should they be used?
Tools considered:
4AT, CAM, 3D CAM, Delirium Observation Screening Scale, SQID, MDAS, RADAR, DRS-R98, ICD-SC, CAM-ICU, Modified RASS, Family CAM (FAM- CAM), Brief CAM (B-CAM), NU desk, Organic Brain Syndrome (OBS) scale
Comparators: DSM 5, ICD 10, between tools
Outcomes: sensitivity, specificity, evidence of adherence in clinical practical

8. Key questions
3. What (other) investigations are useful when assessing a patient for delirium?
imaging (CT or MRI scans)
lumbar puncture
electroencephalogram (EEG)
testing for antibodies for autoimmune encephalitis
toxicology screening
Comparison: usual care
Outcomes: sensitivity, specificity, cost effectiveness

9. Key questions
4. What risk reduction strategies for patients at risk of delirium are effective?
Non-pharmacological:
hydration
catheterization avoidance
sensory impairment
constipation
sleep hygiene and promotion
falls prevention and mobility
providing means of communication
impact of ward moves
environmental factors
proactive screening of delirium and pre-existing cognitive impairment
including dementia
Pharmacological:
medication reconciliation
pain relief
antipsychotics and benzodiazepines
sedation for night-time sleep

10. Key questions
5. What are the most effective non-pharmacological strategies for managing patients with delirium?
staff behavioural adaptations (calm manner, one-to-one nursing, cognitive stimulation, reassurance, reorientation, distraction/de-escalation techniques)
environmental adaptations (single room, lighting, clear signage for orientation, familiar objects, family input, minimise bed moves, address sensory impairment, OT, sleep promotion, facilitating mobility)
address specific causes of stress (pain, hunger, feeling hot or cold, thirsty, urinary retention, specific fears, not understanding what is happening, hallucinations, delusions, aggression, agitation, and searching)

11. Key questions
6. What are the most effective pharmacological strategies for managing patients with delirium?
antipsychotics
benzodiazepines
acetylcholinesterase inhibitors
melatonin
antidepressants
dexmedetomidine
clonidine
propanolol
withdrawal of culprit drugs

12. Key questions
7. What follow-up care should patients receive after experiencing delirium?
Screening for:
dementia
functional psychiatry disorders – PTSD, depression

13. Evidence review

14. Forming recommendations
Help clinicians with decision-making
Systematically summarise the evidence base
Consider the quality of the evidence base
Balance the benefits and harms
Consider the realities of healthcare delivery
Create evidence-based, implementable recommendations

15. Forming recommendations
Quality of evidence
Applicability
quantity of evidence
consistency of results
relevance to the target
population
any publication bias
benefits
harms
impact on patients (patient
preferences)
feasibility (eg cost, service
provision)

16. Drafting the guideline
Evidence statement
Evidence level
A Cochrane Review found ibuprofen to be superior to placebo in all doses between 200 mg to 600 mg for pain free at two hours and sustained pain relief at 24 hours for patients with acute migraine with moderate to severe baseline pain. For two hour pain free the NNT was 9.7 for 200 mg and 7.2 for 400 mg.23
1++ R
Ibuprofen 400 mg is recommended as first line treatment for patients with acute migraine.
Recommendation

17. Additional content Recommendations for further research
Provision of information for patients and carers
Audit points
Cost impact analysis (if needed)

18. Consultation
open consultation
peer review
early 2018

19. Publication and implementation
August