- Email: [email protected]
A survey of delirium guidelines in Europe
Journal of Psychosomatic Research 61 (2006) 123 – 128
A survey of delirium guidelines in Europe Albert F.G. Leentjensa,4, Albert Diefenbacher b a
Department of Psychiatry, Maastricht University Hospital, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands b Department of Psychiatry, Ko¨nigin Elisabeth Herzberge Hospital, Berlin, Germany Received 8 August 2005; received in revised form 11 January 2006; accepted 11 January 2006
Abstract Objective: The aim of this study was to investigate the existence and content of delirium guidelines of the national psychiatric associations in Europe. Method: A survey was sent by email to national coordinators of the European Association for Consultation–Liaison Psychiatry and Psychosomatics. Results: Responses were obtained for 12 of the 14 countries that were approached. Of these 12 countries, only two national psychiatric associations reported having national delirium guidelines. The Dutch Psychiatric Association was the only national psychiatric association that had developed a comprehensive multidisciplinary guideline on the diagnosis and treatment of delirium. The German Association of Scientific Medical Societies has a comprehensive
guideline on the treatment of alcohol withdrawal delirium, in which the German Society for Psychiatry, Psychotherapy, and Mental Disorders participated. In addition, the delirium guideline of the British Geriatrics Society and the guideline for alcohol withdrawal delirium of the German Neurological Society were mentioned by respondents. Conclusions: Although the development of evidence-based treatment guidelines is considered an important way to improve clinical practice, the national psychiatric associations of only two countries have such a guideline for the diagnosis and treatment of delirium. The advantages of supranational collaboration in the development of guidelines are stressed. D 2006 Elsevier Inc. All rights reserved.
Keywords: Delirium; Practice guideline; Europe
Introduction Professional psychiatric organisations are increasingly developing evidence-based guidelines in an attempt to improve clinical practice. Some national psychiatric organisations have set out on an extensive programme of such guidelines, which includes all major psychiatric disorders. Delirium is an attractive disorder for formulating a guideline as it occurs with a high frequency in a well-defined population. In general hospital patients, the prevalence of delirium in general hospital patients ranges from 10% to 30%, with even higher prevalences in selected populations, such as the elderly and the critically ill [1–3]. Moreover, it usually presents in a typical way, has a serious impact on morbidity and mortality, is associated with higher costs, and can often be treated effectively [4– 6]. Finally, when treated, the disorder usually resolves within a few days and does 4 Corresponding author. Tel.: +31 43 3877443; fax: +31 43 3875444. E-mail address: [email protected] (A.F.G. Leentjens). 0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2006.01.009
not require long-term follow-up. Because of these wellcircumscribed features, it is not surprising that delirium was amongst the first disorders that the American Psychiatric Association (APA) developed a treatment guideline for [1]. This guideline has also had a major international impact and served as an example for delirium guidelines in other countries. In this article, the authors review the existence and content of delirium guidelines of the national psychiatric associations in Europe.
Methods An email survey was sent out to the national coordinators of the 14 countries represented in the European Association of Consultation–Liaison Psychiatry and Psychosomatics (EACLPP, www.eaclpp.org). They were asked to complete the questionnaire themselves or ask somebody from their department to do so. In the event of nonresponse, a reminder was sent after 3 weeks by the authors. If this did not lead to a
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Table 1 EACLPP survey of European delirium guidelines Please state your country’s name: 1. Does your national psychiatric association have an official guideline on the diagnosis and treatment of delirium? No Yes 2. Do any other specialist organisations in your country have a delirium guideline (internists, surgeons, anesthesiologists)? Yes: state which specialization: No Do not know 3. Does any nursing association in your country have a delirium guideline? Yes No Do not know 4. Do you use delirium guidelines from another country or association? No Yes: please indicate which guideline: The APA guideline? Other: . . .. . .. . .. . .. . .. . .. . .. Questions 5 to 14 only need to be completed if you answered byesQ to question 1 5. Is this a monodisciplinary guideline (i.e., developed by psychiatrists only)? If yes: continue with Question 6. If no: please indicate which professions have participated in the guideline: - general practitioners - psychologists - general physicians (internists) - psychiatric nurses - surgeons - psychosomatic specialists - neurologists - nursing home doctors - geriatricians - other: . . .. . .. . .. . .. . .. . .. 6. Is there a role for a psychiatric consultation nurse described in the guideline? - No, this nursing speciality does not exist in my country. - No, there is no role for such a nurse. - Yes 7. How can this guideline be best characterized: - evidence-based guideline - consensus-based guideline - expert opinion - other: . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 8. In what year was this guideline released? . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. Is it regularly updated: No: go to Question 9 Yes: how many years is the guideline valid before being updated: . . .. . .. . .. . .. . .. . .. . .. 9. Please indicate to which of the following aspects your guideline pays attention: - primary prevention - secondary prevention - diagnosis - environmental treatment/supportive measures - pharmacological treatment - psychotherapeutic treatment - psychoeducation/patient information - other : 10. Does your guideline differentiate withdrawal delirium from other forms of delirium? Yes No 11. In your guideline, what is the first choice treatment for: Delirium: - haloperidol - another antipsychotic: . . .. . .. . .. . .. . .. . .. . .. - a benzodiazepine - other: . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .
Table 1 (continued) 12. In your guideline, what is the first choice treatment for: Withdrawal delirium: - haloperidol - another antipsychotic: . . .. . .. . .. . .. . .. - a benzodiazepine - other: . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 13. Is your associations’ guideline accessible via internet? No Yes, for members only. Yes, for everybody. Please state the web address: . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . . 14. Can you give the full reference of the guideline (authors or editor, title, publisher, place, year, and number of pages), for reasons of reference. (It is also possible to make a photocopy of this information from the guideline and fax it to the number mentioned below.) 15. Would you be in favour of a harmonization of the guidelines for delirium from the different countries? Yes: please state why: No: please state why: No opinion 16. Any remarks or suggestions: Please save this page in word and mail it to [email protected] or print the page and fax it to: Albert F.G. Leentjens, MD, PhD. Department of Psychiatry, Maastricht University Hospital, The Netherlands Fax: ++ 31 43 3877443 We very much appreciate that you took the time to fill out this questionnaire and hope to meet you in Istanbul. Albert Diefenbacher Albert Leentjens Kfnigin Elisabeth Herzberge Maastricht University Hospital Hospital Berlin Maastricht Germany The Netherlands
response, another EACLPP contact in that country was personally asked to respond. Respondents were informed beforehand about the fact that the results of the survey would be written down as a paper and submitted for publication. The survey consisted of 15 questions. The first three questions pertained to the existence of delirium guidelines by the national psychiatric association and other medical specialist or nursing organisations. In the absence of a national guideline, the fourth question asked about the use of other, or foreign guidelines, such as the APA guideline. If a national guideline existed, Questions 5 to 14 referred to the factual content of the guideline. The last question was an open question that asked whether the respondent would be in favour of harmonizing delirium guidelines from different European countries. At the end of the questionnaire, there was room for comments and suggestions. The survey is attached as Table 1.
Results Response Of the 14 countries that were approached, responses were obtained from 12: Sweden, Finland, Denmark, the United Kingdom, The Netherlands, Belgium, Germany, Switzerland,
A.F.G. Leentjens, A. Diefenbacher / Journal of Psychosomatic Research 61 (2006) 123 – 128
Austria, Italy, Spain, and Portugal. As several countries have more than one EACLPP representative, we received more than one answer from some countries. These were never contradictory. For three countries, responses were obtained from other contact persons than the EACLPP representatives. Existence of national guidelines Much to our surprise only two of the 12 countries that responded to the survey have a national guideline on delirium. The Dutch Psychiatric Association, Nederlandse Vereniging voor Psychiatrie (NVvP), was the only one with a comprehensive guideline on delirium (download address: http:// www.cbo.nl/product/richtlijnen/folder20021023121843/ delirium_rl_2005.pdf?) [7,8]. Moreover, the German bArbeitsgemeinschaft der Wissenschaftlichen Medizinischen FachgesellschaftenQ (AWMF, the Association of Scientific Medical Societies) has a guideline on the bacute treatment of alcohol-related disorders Q, which includes a section on alcohol withdrawal delirium (downloadable via http://www. leitlinien.net/). In addition, two guidelines on delirium were mentioned by the respondents in which national psychiatric associations did not participate: the guideline on alcohol withdrawal delirium by the German Society of Neurology (downloadable via http://www.leitlinien net) and the delirium guideline by the British Geriatrics Society (downloadable at http://www.bgs.org.uk). In other countries, none of the national psychiatric associations have an official, evidence-based guideline on delirium. However, in some countries, the APA guideline is commonly used and adapted as an informal standard of practice, as was reported for Finland, Switzerland, and Italy. In other countries, locally developed guidelines are used in individual institutions, which sometimes are very elaborate and of high quality, such as the guideline of the University of Zaragoza, Spain, and the forthcoming guideline of the Institute for Preventive and Social Medicine of the University of Lausanne, Switzerland. The response from the United Kingdom also mentioned the joint report of the Royal College of Psychiatrists and the Royal College of Physicians on b the psychological care of medical patientsQ as practice guideline [9]. This report includes some practical recommendations on the clinical management of delirium but no detailed guidelines on diagnosis and treatment and, hence, is not considered here. Description of guidelines The following descriptions of guidelines are not solely based on the respondents answers but checked against the original sources. The Netherlands’ guideline is a multidisciplinary guideline, initiated by the b Commission on Quality of Care Q (Commissie Kwaliteitszorg) of the Dutch Psychiatric Association (Nederlandse Vereniging voor Psychiatrie, NVvP) and developed in collaboration with the Association
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of Clinical Geriatrics (Vereniging voor Klinische Geriatrie) and a nursing specialist. After completion, the guideline was commented on by other medical specialist organisations and endorsed by the Dutch Association of General Medicine (Neederlandsche Internisten Vereeniging) and the Dutch Association of Neurology (Nederlandse Vereniging voor Neurologie). The guideline followed the criteria of the bappraisal of guidelines research and evaluationQ (www. agreecollaboration.org). The Dutch guideline took the APA practice guideline of 1999 as a starting point. The source documentation of this guideline was requested and received. Additional evidence was searched for the period from 1998 to 2003. Compared to the APA practice guideline, the Dutch guideline is more comprehensive and up-to-date and includes more information on the use of delirium rating scales, predisposing and precipitating factors, nonpharmacological intervention, and primary and secondary prevention. Separate chapters are concerned with patients suffering from dementia or extrapyramidal syndromes and with alcohol withdrawal delirium. The Dutch guideline recommends the use of the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) for diagnosis of delirium [10]. The medical and nonmedical recommendations are grossly the same as those described in the APA practice guideline, with haloperidol being the first choice for any delirium, except in patients with extrapyramidal symptoms, where atypical neuroleptics or procholinergic drugs may be indicated. For alcohol withdrawal deliria, benzodiazepines are the treatment of choice. On one point, the Dutch guideline takes controversial stand. This pertains to delirium in somatic patients with alcohol dependence. Because of the relatively low incidence of alcohol withdrawal delirium and the fact that withdrawal deliria cannot be differentiated clinically from the more frequent deliria due to other causes, the guideline states that all deliria in somatically ill patients with alcohol dependence should be considered bregularQ deliria and treated with haloperidol. A benzodiazepine can be added in case of coexisting autonomic symptoms of withdrawal or when symptoms do not improve with 24 h after the initiation of haloperidol. Similar to the APA guideline, revisions of the guideline are planned every five years. The German guideline for alcohol withdrawal was a multidisciplinary initiative of the Deutsche Gesellschaft fqr Psychiatrie, Psychotherapie und Nervenheilkunde (the German Society for Psychiatry, Psychotherapy, and Mental Disorders) and the Deutsche Gesellschaft fqr Suchtforschung and Suchttherapie (the German Society of Addiction Research and Addiction Therapy), that was conducted in collaboration with 15 other professional organisations, including an insurance company and a self-help organisation for patients. The guideline is evidence-based, and its construction followed the criteria of the guideline manual of ¨ rtzlichen Zentralstelle fqr Qualit7tssicherung and of the A the AWMF. In its description of the diagnosis and treatment of withdrawal syndromes, including withdrawal deliria, this
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guideline is more detailed than the APA practice guideline and the Dutch NVvP guideline. The criteria of the International Statistical Classification of Diseases, 10th Revision are adapted as diagnostic criteria [11]. In accordance with the Dutch as well as the APA guideline, benzodiazepines are advised as treatment of choice in the outpatient treatment of alcohol withdrawal delirium. Interestingly, the advice for inpatient treatment of alcohol withdrawal delirium differs from that of the Dutch and American guidelines. Clomethiazol (chlormethiazol) is advised as treatment of choice instead of benzodiazepines [12]. The German guideline takes the stand that benzodiazepines cannot be recommended because they are not formally registered for the treatment of alcohol withdrawal delirium in Germany. However, this is also the case in the Netherlands, but this off-label prescription is generally accepted and is still recommended as first choice. Moreover, clomethiazol is not registered in the Netherlands. On the guidelines website, the German Neurological Society gives no details about the way the alcohol withdrawal delirium was established. In this guideline, the diagnosis is based on symptomatology specified in the text and not on established diagnostic criteria. A distinction in incomplete, complete, and life-threatening delirium is made on the basis of increasing severity of symptoms. bIncompleteQ delirium is characterized by autonomic symptoms of withdrawal and occasional hallucinations; bcompleteQ delirium is characterized by disturbances of consciousness, disorientation, and affective and vegetative disturbances; blife-threatening deliriumQ is characterized by severe disturbances of consciousness and life-threatening somatic complications. Treatment recommendations for these subgroups are different. For bincomplete delirium,Q carbamazepine, clomethiazol, diazepam, and chlordiazepoxide are considered first choice treatment. For bcomplete delirium,Q clomethizol or a combination of haloperidol and clomethiazol or diazepam are recommended. For blife threatening delirium,Q a combination of diazepam and haloperidol or droperidol or the combination of midazolam and droperidol is recommended, with the comment that clonidine may be added if necessary. The British Geriatrics Society guideline stems from a formal multidisciplinary consensus process with a panel of 21 professionals and carers of patients who had experienced delirium using a two-stage Delphi technique. It includes medical and nonmedical recommendations stressing the importance of environmental factors and the involvement of relatives. The guideline gives more concrete recommendations than the previously mentioned ones on additional examinations with regard to the etiological diagnosis of delirium. It also pays more attention to the management of potential complications of delirium, such as falls, pressure sores, nosocomial infections, functional impairment, continence problems, and oversedation. Obviously, there is an important role for the nursing profession in this area, and the use of restraints is also discussed. Diagnostic criteria are
based on the DSM IV. For drug treatment, haloperidol and droperidol are mentioned as preferred choices. Atypical neuroleptics are not mentioned. For the treatment of alcohol withdrawal delirium, benzodiazepines and chlormethiazole are suggested, but the guideline explicitly states that detailed recommendations for this specific condition were considered to be beyond the scope of the guideline. Referral to old age psychiatric services is recommended in case of underlying dementia and in case of failure of symptomatic improvement after treatment and resolution of the underlying cause. Except for the guidelines of the Dutch Psychiatric Association and the British Geriatrics Society, where nursing specialists were involved, to the best of our knowledge, in Europe, other than, e.g., in Canada (see also: www.guidelines.gov), there are no guidelines on caregiving strategies for patients with delirium by nurses’ associations [13]. Opinions about harmonisation of guidelines The question about the desirability of harmonisation of guidelines in the different European countries was an open question, and answers to this question will more likely reflect the personal opinion of the respondent than an official standpoint of the EACLPP or the national organisation. Of the 12 countries that responded, four were clearly in favour of harmonisation of guidelines, and one was opposed. The other seven respondents did not have a strong opinion about harmonisation. One argument that was quoted in favour of harmonisation was that it would be good for the quality of care to have procedures which are internationally approved and evidence-based. Another argument was that producing joint guidelines will spare time and effort and opens the road for closer scientific collaboration between the different European countries. One respondent expressed concerns about the feasibility and implementation of a joint guideline. The one opposing answer, coming from a country without a national guideline, did not see the use of harmonisation as long as each country institutes effective national guidelines.
Discussion Even though evidence-based medicine and the formulation of treatment guidelines are considered to enhance the quality of clinical practice, we were surprised by the fact that the Dutch Psychiatric Association was the only national psychiatric association that has a comprehensive guideline on the diagnosis and treatment of delirium. Moreover, the German Association of Scientific Medical Societies has a guideline on withdrawal delirium. Other countries report a number of local initiatives, but no guidelines developed or endorsed by national psychiatric associations are available. Since there are no comprehensive guidelines available for the treatment of delirium not due to alcohol withdrawal other than that of the Dutch Psychiatric Association, no comparison with other psychiatric guidelines can be made.
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However, there seems to be a great variety in treatment recommendations for alcohol withdrawal delirium, as is also reflected in the fact that treatments other than those mentioned in the guidelines discussed above are used. Austria, for instance, reported the use of piracetam and meprobamate for alcohol withdrawal delirium. The observation that the clinical approach to alcohol withdrawal delirium greatly differs in the different countries is surprising because the available scientific evidence is the same for all. This interesting finding requires further exploration: apparently, factors other than scientific evidence play a role in the establishment of treatment guidelines. Obviously, a survey has some inherent limitations. Even though the respondents may be expected to be aware of any guideline of delirium in their country, this does not guarantee completeness. Moreover, as it was not the objective of this survey to investigate guidelines other than those of the national psychiatric associations, we do not expect to be complete in this respect. Guidelines by other national medical specialist organisations were only discussed if they were mentioned by the respondents. Local initiatives without a national status were not discussed even if they had been mentioned by the respondents. We think that some factors may be held responsible for the lack of development of national guidelines in many countries, such as the level of organisation of the national psychiatric and other professional associations, as well as the scientific tradition of the respective countries. The status of the field of general hospital psychiatry may also have played a role in the choice of bdeliriumQ as a subject for a guideline. Given the number of local initiatives, it seems a logical thought to join efforts. There are a number of good reasons for the supranational development of practice guidelines in Europe. First, the development of guidelines is a timeconsuming and costly effort. The Dutch guideline required 13 meetings of 14 experts over a two-year period. The German guideline took four guideline conferences of a large number of experts over a period of more than 2 years, with additional personal meetings and teleconferences. This investment may not be realistic in countries that are less affluent or in which psychiatric associations are less well organised. Thus, a lot of time, money, and effort can be saved by joining efforts of the different countries. A second reason is that access to medical scientific information is globalized to such an extent that everybody has access to the same information. bMedlineQ and other electronic medical databases include a vast number of scientific journals, including a large number of journals in languages other than English. The available evidence is the same for everybody, and given the level of standardisation of the assessment of studies and guideline development, it would be logical to assume that everybody will draw the same conclusions, even if this is not substantiated in our survey. It seems a waste to have everybody discover the wheel by themselves. Thirdly, the supranational status of guidelines may constitute an important instrument to influence idiosyncratic
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national approaches and accelerate efforts to bring legislation in accordance with the guidelines, such as the approach to off-label prescription of medication. Finally, a supranational approach will lead to better availability and dissemination of guidelines because it will automatically include those countries that, for whichever good reason, have not set out on a guideline programme (yet). Supranational organisations, such as the EACLPP in case of delirium, should play an important role in striving towards harmonisation of the different national guidelines and developing supranational ones. In a multinational composition of guideline task forces, less input in terms of people, time and money is required from the respective national organisations. On the other side, it may create the feeling that the distance between practicing psychiatrists and guideline committees is too great, or clinicians may fear that local cultural aspects in providing care may be ignored. Therefore, national organisations should keep playing an important role in participating in guideline committees and providing input to the guideline. The savings of a multinational approach could be invested in dissemination and better implementation of guidelines by the respective national associations. Moreover, closer collaboration within multidisciplinary guideline committees, will bring specialists from different countries closer together, stimulate exchange of ideas, and facilitate multinational research efforts. In conclusion, we would like to stress the following general points: 1.
2.
3.
4.
As there is evidence that patients with delirium benefit from treatment by multidisciplinary teams, other disciplines and, notably, the nursing profession should be included in the guideline development process. Furthermore, as ward environment may be crucial to the management of delirious patients, hospital administrations should be involved as well. Finally, additional input may be solicited from carers and relatives of patients that have experienced delirium [9,14]. Input from different physician specialties is crucial. A guideline developed upon evidence-based studies is not equivalent to an bevidence based guidelineQ: each guideline that deserves that label ought to be tested against treatment as usual first [15]. It must be remembered that guidelines alone do not bautomaticallyQ improve the management of delirium. They have to be implemented along with educational and organisational change of staff knowledge and ward environments [14]. Finally, the diagnosis and management of delirium, which can be regarded as a bpsychosomatic illnessQ strictu sensu, may be regarded as a bmarkerQ of the overall quality of care given by a general hospital. Awareness of that aspect of care should be sharpened by consultation–laision psychiatry and be used
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for the integration of psychiatry in the general hospital [14,16].
Acknowledgments We would like to thank Ms. G. Dunkerley, secretary to the EACLPP, for logistic support to the survey. Furthermore, we would like to thank the national EACLPP coordinators and other colleagues for their participation.
References [1] American Psychiatric Association. Practice guidelines for the treatment of patients with delirium. Am J Psychiatry 1999;5(156 (Suppl. 5));1 – 20. [2] Arolt V, Diefenbacher A. Psychiatrie in der klinischen Medizin. Darmstadt7 Steinkopf, 2004. [3] Ely EW, et al. Delirium in mechanically ventilated patients: validity and relaibility of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286(21);2703 – 10. [4] Leentjens AFG, Van der Mast RC. Delirium in elderly people: an update. Curr Opin Psychiatry 2005;18:325 – 30. [5] Ely EW, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291(14);1753 – 62.
[6] Milbrandt EB, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2004;32(4);1080 – 1. [7] Van der Mast RC, et al. Richtlijn delirium. Amsterdam7 Nederlandse Vereniging voor Psychiatrie, 2004. [8] Van der Mast RC, Huyse FJ, Rosier PFWM. Richtlijn bDeliriumQ. Nederlands Tijdschrift voor Geneeskunde 2005;149(19);1027 – 32. [9] Royal College of Physicians and Royal College of Psychiatrists. The psychological care of medical patients. A practical guide. London7 Royal College of Physicians and Royal College of Psychiatrists, 2003. [10] American Psychiatric Association. Diagnostic and Statistical Manual Of Mental Disorders (DSM IV). 4th ed. Washington (DC)7 American Psychiatric Association, 1994. [11] World Health Organisation (WHO). The ICD 10 classification of mental and behavioural disorders. Geneva7 WHO, 1992. [12] Majumdar SK. Chlormethiazole: current status in the treatment of the acute ethanol withdrawal syndrome. Drug Alcohol Depend 1990; 27:201 – 7. [13] Registered Nurses Association of Ontario (RNAO). Caregiving strategies for older adults with delirium, dementia and depression. Toronto (ON)7 RNAO, 2004. [14] Young LY, George J. Do guidelines improve the process and outcomes of care in delirium? Age Ageing 2003;32:525 – 8. [15] Linden M. The impact of guidelines, standards and economic restrictions on clinical decision-making processes. Zeitschrift fqr 7rztliche Fortbildung und Qualit7t im Gesundheitswesen 2004; 98:200 – 5. [16] Innouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med 1999;106:565 – 73.
A survey of delirium guidelines in Europe Albert F.G. Leentjensa,4, Albert Diefenbacher b a
Department of Psychiatry, Maastricht University Hospital, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands b Department of Psychiatry, Ko¨nigin Elisabeth Herzberge Hospital, Berlin, Germany Received 8 August 2005; received in revised form 11 January 2006; accepted 11 January 2006
Abstract Objective: The aim of this study was to investigate the existence and content of delirium guidelines of the national psychiatric associations in Europe. Method: A survey was sent by email to national coordinators of the European Association for Consultation–Liaison Psychiatry and Psychosomatics. Results: Responses were obtained for 12 of the 14 countries that were approached. Of these 12 countries, only two national psychiatric associations reported having national delirium guidelines. The Dutch Psychiatric Association was the only national psychiatric association that had developed a comprehensive multidisciplinary guideline on the diagnosis and treatment of delirium. The German Association of Scientific Medical Societies has a comprehensive
guideline on the treatment of alcohol withdrawal delirium, in which the German Society for Psychiatry, Psychotherapy, and Mental Disorders participated. In addition, the delirium guideline of the British Geriatrics Society and the guideline for alcohol withdrawal delirium of the German Neurological Society were mentioned by respondents. Conclusions: Although the development of evidence-based treatment guidelines is considered an important way to improve clinical practice, the national psychiatric associations of only two countries have such a guideline for the diagnosis and treatment of delirium. The advantages of supranational collaboration in the development of guidelines are stressed. D 2006 Elsevier Inc. All rights reserved.
Keywords: Delirium; Practice guideline; Europe
Introduction Professional psychiatric organisations are increasingly developing evidence-based guidelines in an attempt to improve clinical practice. Some national psychiatric organisations have set out on an extensive programme of such guidelines, which includes all major psychiatric disorders. Delirium is an attractive disorder for formulating a guideline as it occurs with a high frequency in a well-defined population. In general hospital patients, the prevalence of delirium in general hospital patients ranges from 10% to 30%, with even higher prevalences in selected populations, such as the elderly and the critically ill [1–3]. Moreover, it usually presents in a typical way, has a serious impact on morbidity and mortality, is associated with higher costs, and can often be treated effectively [4– 6]. Finally, when treated, the disorder usually resolves within a few days and does 4 Corresponding author. Tel.: +31 43 3877443; fax: +31 43 3875444. E-mail address: [email protected] (A.F.G. Leentjens). 0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2006.01.009
not require long-term follow-up. Because of these wellcircumscribed features, it is not surprising that delirium was amongst the first disorders that the American Psychiatric Association (APA) developed a treatment guideline for [1]. This guideline has also had a major international impact and served as an example for delirium guidelines in other countries. In this article, the authors review the existence and content of delirium guidelines of the national psychiatric associations in Europe.
Methods An email survey was sent out to the national coordinators of the 14 countries represented in the European Association of Consultation–Liaison Psychiatry and Psychosomatics (EACLPP, www.eaclpp.org). They were asked to complete the questionnaire themselves or ask somebody from their department to do so. In the event of nonresponse, a reminder was sent after 3 weeks by the authors. If this did not lead to a
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Table 1 EACLPP survey of European delirium guidelines Please state your country’s name: 1. Does your national psychiatric association have an official guideline on the diagnosis and treatment of delirium? No Yes 2. Do any other specialist organisations in your country have a delirium guideline (internists, surgeons, anesthesiologists)? Yes: state which specialization: No Do not know 3. Does any nursing association in your country have a delirium guideline? Yes No Do not know 4. Do you use delirium guidelines from another country or association? No Yes: please indicate which guideline: The APA guideline? Other: . . .. . .. . .. . .. . .. . .. . .. Questions 5 to 14 only need to be completed if you answered byesQ to question 1 5. Is this a monodisciplinary guideline (i.e., developed by psychiatrists only)? If yes: continue with Question 6. If no: please indicate which professions have participated in the guideline: - general practitioners - psychologists - general physicians (internists) - psychiatric nurses - surgeons - psychosomatic specialists - neurologists - nursing home doctors - geriatricians - other: . . .. . .. . .. . .. . .. . .. 6. Is there a role for a psychiatric consultation nurse described in the guideline? - No, this nursing speciality does not exist in my country. - No, there is no role for such a nurse. - Yes 7. How can this guideline be best characterized: - evidence-based guideline - consensus-based guideline - expert opinion - other: . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 8. In what year was this guideline released? . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. Is it regularly updated: No: go to Question 9 Yes: how many years is the guideline valid before being updated: . . .. . .. . .. . .. . .. . .. . .. 9. Please indicate to which of the following aspects your guideline pays attention: - primary prevention - secondary prevention - diagnosis - environmental treatment/supportive measures - pharmacological treatment - psychotherapeutic treatment - psychoeducation/patient information - other : 10. Does your guideline differentiate withdrawal delirium from other forms of delirium? Yes No 11. In your guideline, what is the first choice treatment for: Delirium: - haloperidol - another antipsychotic: . . .. . .. . .. . .. . .. . .. . .. - a benzodiazepine - other: . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .
Table 1 (continued) 12. In your guideline, what is the first choice treatment for: Withdrawal delirium: - haloperidol - another antipsychotic: . . .. . .. . .. . .. . .. - a benzodiazepine - other: . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 13. Is your associations’ guideline accessible via internet? No Yes, for members only. Yes, for everybody. Please state the web address: . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . . 14. Can you give the full reference of the guideline (authors or editor, title, publisher, place, year, and number of pages), for reasons of reference. (It is also possible to make a photocopy of this information from the guideline and fax it to the number mentioned below.) 15. Would you be in favour of a harmonization of the guidelines for delirium from the different countries? Yes: please state why: No: please state why: No opinion 16. Any remarks or suggestions: Please save this page in word and mail it to [email protected] or print the page and fax it to: Albert F.G. Leentjens, MD, PhD. Department of Psychiatry, Maastricht University Hospital, The Netherlands Fax: ++ 31 43 3877443 We very much appreciate that you took the time to fill out this questionnaire and hope to meet you in Istanbul. Albert Diefenbacher Albert Leentjens Kfnigin Elisabeth Herzberge Maastricht University Hospital Hospital Berlin Maastricht Germany The Netherlands
response, another EACLPP contact in that country was personally asked to respond. Respondents were informed beforehand about the fact that the results of the survey would be written down as a paper and submitted for publication. The survey consisted of 15 questions. The first three questions pertained to the existence of delirium guidelines by the national psychiatric association and other medical specialist or nursing organisations. In the absence of a national guideline, the fourth question asked about the use of other, or foreign guidelines, such as the APA guideline. If a national guideline existed, Questions 5 to 14 referred to the factual content of the guideline. The last question was an open question that asked whether the respondent would be in favour of harmonizing delirium guidelines from different European countries. At the end of the questionnaire, there was room for comments and suggestions. The survey is attached as Table 1.
Results Response Of the 14 countries that were approached, responses were obtained from 12: Sweden, Finland, Denmark, the United Kingdom, The Netherlands, Belgium, Germany, Switzerland,
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Austria, Italy, Spain, and Portugal. As several countries have more than one EACLPP representative, we received more than one answer from some countries. These were never contradictory. For three countries, responses were obtained from other contact persons than the EACLPP representatives. Existence of national guidelines Much to our surprise only two of the 12 countries that responded to the survey have a national guideline on delirium. The Dutch Psychiatric Association, Nederlandse Vereniging voor Psychiatrie (NVvP), was the only one with a comprehensive guideline on delirium (download address: http:// www.cbo.nl/product/richtlijnen/folder20021023121843/ delirium_rl_2005.pdf?) [7,8]. Moreover, the German bArbeitsgemeinschaft der Wissenschaftlichen Medizinischen FachgesellschaftenQ (AWMF, the Association of Scientific Medical Societies) has a guideline on the bacute treatment of alcohol-related disorders Q, which includes a section on alcohol withdrawal delirium (downloadable via http://www. leitlinien.net/). In addition, two guidelines on delirium were mentioned by the respondents in which national psychiatric associations did not participate: the guideline on alcohol withdrawal delirium by the German Society of Neurology (downloadable via http://www.leitlinien net) and the delirium guideline by the British Geriatrics Society (downloadable at http://www.bgs.org.uk). In other countries, none of the national psychiatric associations have an official, evidence-based guideline on delirium. However, in some countries, the APA guideline is commonly used and adapted as an informal standard of practice, as was reported for Finland, Switzerland, and Italy. In other countries, locally developed guidelines are used in individual institutions, which sometimes are very elaborate and of high quality, such as the guideline of the University of Zaragoza, Spain, and the forthcoming guideline of the Institute for Preventive and Social Medicine of the University of Lausanne, Switzerland. The response from the United Kingdom also mentioned the joint report of the Royal College of Psychiatrists and the Royal College of Physicians on b the psychological care of medical patientsQ as practice guideline [9]. This report includes some practical recommendations on the clinical management of delirium but no detailed guidelines on diagnosis and treatment and, hence, is not considered here. Description of guidelines The following descriptions of guidelines are not solely based on the respondents answers but checked against the original sources. The Netherlands’ guideline is a multidisciplinary guideline, initiated by the b Commission on Quality of Care Q (Commissie Kwaliteitszorg) of the Dutch Psychiatric Association (Nederlandse Vereniging voor Psychiatrie, NVvP) and developed in collaboration with the Association
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of Clinical Geriatrics (Vereniging voor Klinische Geriatrie) and a nursing specialist. After completion, the guideline was commented on by other medical specialist organisations and endorsed by the Dutch Association of General Medicine (Neederlandsche Internisten Vereeniging) and the Dutch Association of Neurology (Nederlandse Vereniging voor Neurologie). The guideline followed the criteria of the bappraisal of guidelines research and evaluationQ (www. agreecollaboration.org). The Dutch guideline took the APA practice guideline of 1999 as a starting point. The source documentation of this guideline was requested and received. Additional evidence was searched for the period from 1998 to 2003. Compared to the APA practice guideline, the Dutch guideline is more comprehensive and up-to-date and includes more information on the use of delirium rating scales, predisposing and precipitating factors, nonpharmacological intervention, and primary and secondary prevention. Separate chapters are concerned with patients suffering from dementia or extrapyramidal syndromes and with alcohol withdrawal delirium. The Dutch guideline recommends the use of the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) for diagnosis of delirium [10]. The medical and nonmedical recommendations are grossly the same as those described in the APA practice guideline, with haloperidol being the first choice for any delirium, except in patients with extrapyramidal symptoms, where atypical neuroleptics or procholinergic drugs may be indicated. For alcohol withdrawal deliria, benzodiazepines are the treatment of choice. On one point, the Dutch guideline takes controversial stand. This pertains to delirium in somatic patients with alcohol dependence. Because of the relatively low incidence of alcohol withdrawal delirium and the fact that withdrawal deliria cannot be differentiated clinically from the more frequent deliria due to other causes, the guideline states that all deliria in somatically ill patients with alcohol dependence should be considered bregularQ deliria and treated with haloperidol. A benzodiazepine can be added in case of coexisting autonomic symptoms of withdrawal or when symptoms do not improve with 24 h after the initiation of haloperidol. Similar to the APA guideline, revisions of the guideline are planned every five years. The German guideline for alcohol withdrawal was a multidisciplinary initiative of the Deutsche Gesellschaft fqr Psychiatrie, Psychotherapie und Nervenheilkunde (the German Society for Psychiatry, Psychotherapy, and Mental Disorders) and the Deutsche Gesellschaft fqr Suchtforschung and Suchttherapie (the German Society of Addiction Research and Addiction Therapy), that was conducted in collaboration with 15 other professional organisations, including an insurance company and a self-help organisation for patients. The guideline is evidence-based, and its construction followed the criteria of the guideline manual of ¨ rtzlichen Zentralstelle fqr Qualit7tssicherung and of the A the AWMF. In its description of the diagnosis and treatment of withdrawal syndromes, including withdrawal deliria, this
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guideline is more detailed than the APA practice guideline and the Dutch NVvP guideline. The criteria of the International Statistical Classification of Diseases, 10th Revision are adapted as diagnostic criteria [11]. In accordance with the Dutch as well as the APA guideline, benzodiazepines are advised as treatment of choice in the outpatient treatment of alcohol withdrawal delirium. Interestingly, the advice for inpatient treatment of alcohol withdrawal delirium differs from that of the Dutch and American guidelines. Clomethiazol (chlormethiazol) is advised as treatment of choice instead of benzodiazepines [12]. The German guideline takes the stand that benzodiazepines cannot be recommended because they are not formally registered for the treatment of alcohol withdrawal delirium in Germany. However, this is also the case in the Netherlands, but this off-label prescription is generally accepted and is still recommended as first choice. Moreover, clomethiazol is not registered in the Netherlands. On the guidelines website, the German Neurological Society gives no details about the way the alcohol withdrawal delirium was established. In this guideline, the diagnosis is based on symptomatology specified in the text and not on established diagnostic criteria. A distinction in incomplete, complete, and life-threatening delirium is made on the basis of increasing severity of symptoms. bIncompleteQ delirium is characterized by autonomic symptoms of withdrawal and occasional hallucinations; bcompleteQ delirium is characterized by disturbances of consciousness, disorientation, and affective and vegetative disturbances; blife-threatening deliriumQ is characterized by severe disturbances of consciousness and life-threatening somatic complications. Treatment recommendations for these subgroups are different. For bincomplete delirium,Q carbamazepine, clomethiazol, diazepam, and chlordiazepoxide are considered first choice treatment. For bcomplete delirium,Q clomethizol or a combination of haloperidol and clomethiazol or diazepam are recommended. For blife threatening delirium,Q a combination of diazepam and haloperidol or droperidol or the combination of midazolam and droperidol is recommended, with the comment that clonidine may be added if necessary. The British Geriatrics Society guideline stems from a formal multidisciplinary consensus process with a panel of 21 professionals and carers of patients who had experienced delirium using a two-stage Delphi technique. It includes medical and nonmedical recommendations stressing the importance of environmental factors and the involvement of relatives. The guideline gives more concrete recommendations than the previously mentioned ones on additional examinations with regard to the etiological diagnosis of delirium. It also pays more attention to the management of potential complications of delirium, such as falls, pressure sores, nosocomial infections, functional impairment, continence problems, and oversedation. Obviously, there is an important role for the nursing profession in this area, and the use of restraints is also discussed. Diagnostic criteria are
based on the DSM IV. For drug treatment, haloperidol and droperidol are mentioned as preferred choices. Atypical neuroleptics are not mentioned. For the treatment of alcohol withdrawal delirium, benzodiazepines and chlormethiazole are suggested, but the guideline explicitly states that detailed recommendations for this specific condition were considered to be beyond the scope of the guideline. Referral to old age psychiatric services is recommended in case of underlying dementia and in case of failure of symptomatic improvement after treatment and resolution of the underlying cause. Except for the guidelines of the Dutch Psychiatric Association and the British Geriatrics Society, where nursing specialists were involved, to the best of our knowledge, in Europe, other than, e.g., in Canada (see also: www.guidelines.gov), there are no guidelines on caregiving strategies for patients with delirium by nurses’ associations [13]. Opinions about harmonisation of guidelines The question about the desirability of harmonisation of guidelines in the different European countries was an open question, and answers to this question will more likely reflect the personal opinion of the respondent than an official standpoint of the EACLPP or the national organisation. Of the 12 countries that responded, four were clearly in favour of harmonisation of guidelines, and one was opposed. The other seven respondents did not have a strong opinion about harmonisation. One argument that was quoted in favour of harmonisation was that it would be good for the quality of care to have procedures which are internationally approved and evidence-based. Another argument was that producing joint guidelines will spare time and effort and opens the road for closer scientific collaboration between the different European countries. One respondent expressed concerns about the feasibility and implementation of a joint guideline. The one opposing answer, coming from a country without a national guideline, did not see the use of harmonisation as long as each country institutes effective national guidelines.
Discussion Even though evidence-based medicine and the formulation of treatment guidelines are considered to enhance the quality of clinical practice, we were surprised by the fact that the Dutch Psychiatric Association was the only national psychiatric association that has a comprehensive guideline on the diagnosis and treatment of delirium. Moreover, the German Association of Scientific Medical Societies has a guideline on withdrawal delirium. Other countries report a number of local initiatives, but no guidelines developed or endorsed by national psychiatric associations are available. Since there are no comprehensive guidelines available for the treatment of delirium not due to alcohol withdrawal other than that of the Dutch Psychiatric Association, no comparison with other psychiatric guidelines can be made.
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However, there seems to be a great variety in treatment recommendations for alcohol withdrawal delirium, as is also reflected in the fact that treatments other than those mentioned in the guidelines discussed above are used. Austria, for instance, reported the use of piracetam and meprobamate for alcohol withdrawal delirium. The observation that the clinical approach to alcohol withdrawal delirium greatly differs in the different countries is surprising because the available scientific evidence is the same for all. This interesting finding requires further exploration: apparently, factors other than scientific evidence play a role in the establishment of treatment guidelines. Obviously, a survey has some inherent limitations. Even though the respondents may be expected to be aware of any guideline of delirium in their country, this does not guarantee completeness. Moreover, as it was not the objective of this survey to investigate guidelines other than those of the national psychiatric associations, we do not expect to be complete in this respect. Guidelines by other national medical specialist organisations were only discussed if they were mentioned by the respondents. Local initiatives without a national status were not discussed even if they had been mentioned by the respondents. We think that some factors may be held responsible for the lack of development of national guidelines in many countries, such as the level of organisation of the national psychiatric and other professional associations, as well as the scientific tradition of the respective countries. The status of the field of general hospital psychiatry may also have played a role in the choice of bdeliriumQ as a subject for a guideline. Given the number of local initiatives, it seems a logical thought to join efforts. There are a number of good reasons for the supranational development of practice guidelines in Europe. First, the development of guidelines is a timeconsuming and costly effort. The Dutch guideline required 13 meetings of 14 experts over a two-year period. The German guideline took four guideline conferences of a large number of experts over a period of more than 2 years, with additional personal meetings and teleconferences. This investment may not be realistic in countries that are less affluent or in which psychiatric associations are less well organised. Thus, a lot of time, money, and effort can be saved by joining efforts of the different countries. A second reason is that access to medical scientific information is globalized to such an extent that everybody has access to the same information. bMedlineQ and other electronic medical databases include a vast number of scientific journals, including a large number of journals in languages other than English. The available evidence is the same for everybody, and given the level of standardisation of the assessment of studies and guideline development, it would be logical to assume that everybody will draw the same conclusions, even if this is not substantiated in our survey. It seems a waste to have everybody discover the wheel by themselves. Thirdly, the supranational status of guidelines may constitute an important instrument to influence idiosyncratic
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national approaches and accelerate efforts to bring legislation in accordance with the guidelines, such as the approach to off-label prescription of medication. Finally, a supranational approach will lead to better availability and dissemination of guidelines because it will automatically include those countries that, for whichever good reason, have not set out on a guideline programme (yet). Supranational organisations, such as the EACLPP in case of delirium, should play an important role in striving towards harmonisation of the different national guidelines and developing supranational ones. In a multinational composition of guideline task forces, less input in terms of people, time and money is required from the respective national organisations. On the other side, it may create the feeling that the distance between practicing psychiatrists and guideline committees is too great, or clinicians may fear that local cultural aspects in providing care may be ignored. Therefore, national organisations should keep playing an important role in participating in guideline committees and providing input to the guideline. The savings of a multinational approach could be invested in dissemination and better implementation of guidelines by the respective national associations. Moreover, closer collaboration within multidisciplinary guideline committees, will bring specialists from different countries closer together, stimulate exchange of ideas, and facilitate multinational research efforts. In conclusion, we would like to stress the following general points: 1.
2.
3.
4.
As there is evidence that patients with delirium benefit from treatment by multidisciplinary teams, other disciplines and, notably, the nursing profession should be included in the guideline development process. Furthermore, as ward environment may be crucial to the management of delirious patients, hospital administrations should be involved as well. Finally, additional input may be solicited from carers and relatives of patients that have experienced delirium [9,14]. Input from different physician specialties is crucial. A guideline developed upon evidence-based studies is not equivalent to an bevidence based guidelineQ: each guideline that deserves that label ought to be tested against treatment as usual first [15]. It must be remembered that guidelines alone do not bautomaticallyQ improve the management of delirium. They have to be implemented along with educational and organisational change of staff knowledge and ward environments [14]. Finally, the diagnosis and management of delirium, which can be regarded as a bpsychosomatic illnessQ strictu sensu, may be regarded as a bmarkerQ of the overall quality of care given by a general hospital. Awareness of that aspect of care should be sharpened by consultation–laision psychiatry and be used
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for the integration of psychiatry in the general hospital [14,16].
Acknowledgments We would like to thank Ms. G. Dunkerley, secretary to the EACLPP, for logistic support to the survey. Furthermore, we would like to thank the national EACLPP coordinators and other colleagues for their participation.
References [1] American Psychiatric Association. Practice guidelines for the treatment of patients with delirium. Am J Psychiatry 1999;5(156 (Suppl. 5));1 – 20. [2] Arolt V, Diefenbacher A. Psychiatrie in der klinischen Medizin. Darmstadt7 Steinkopf, 2004. [3] Ely EW, et al. Delirium in mechanically ventilated patients: validity and relaibility of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286(21);2703 – 10. [4] Leentjens AFG, Van der Mast RC. Delirium in elderly people: an update. Curr Opin Psychiatry 2005;18:325 – 30. [5] Ely EW, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291(14);1753 – 62.
[6] Milbrandt EB, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2004;32(4);1080 – 1. [7] Van der Mast RC, et al. Richtlijn delirium. Amsterdam7 Nederlandse Vereniging voor Psychiatrie, 2004. [8] Van der Mast RC, Huyse FJ, Rosier PFWM. Richtlijn bDeliriumQ. Nederlands Tijdschrift voor Geneeskunde 2005;149(19);1027 – 32. [9] Royal College of Physicians and Royal College of Psychiatrists. The psychological care of medical patients. A practical guide. London7 Royal College of Physicians and Royal College of Psychiatrists, 2003. [10] American Psychiatric Association. Diagnostic and Statistical Manual Of Mental Disorders (DSM IV). 4th ed. Washington (DC)7 American Psychiatric Association, 1994. [11] World Health Organisation (WHO). The ICD 10 classification of mental and behavioural disorders. Geneva7 WHO, 1992. [12] Majumdar SK. Chlormethiazole: current status in the treatment of the acute ethanol withdrawal syndrome. Drug Alcohol Depend 1990; 27:201 – 7. [13] Registered Nurses Association of Ontario (RNAO). Caregiving strategies for older adults with delirium, dementia and depression. Toronto (ON)7 RNAO, 2004. [14] Young LY, George J. Do guidelines improve the process and outcomes of care in delirium? Age Ageing 2003;32:525 – 8. [15] Linden M. The impact of guidelines, standards and economic restrictions on clinical decision-making processes. Zeitschrift fqr 7rztliche Fortbildung und Qualit7t im Gesundheitswesen 2004; 98:200 – 5. [16] Innouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med 1999;106:565 – 73.