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Study Protocol

Clinical Practice Guidelines on Delirium - Consensus and Gaps: A Scoping Review Protocol

[version 1; peer review: awaiting peer review]
Mary Faherty
https://orcid.org/0009-0009-0812-9128
1, Rowan Harwood2, Giuseppe Bellelli
https://orcid.org/0000-0001-5430-0947
3,4, Alasdair MacLullich5, Suzanne Timmons
https://orcid.org/0000-0001-7790-9552
1
Mary Faherty
https://orcid.org/0009-0009-0812-9128
1, Rowan Harwood2, [...] Giuseppe Bellelli
https://orcid.org/0000-0001-5430-0947
3,4, Alasdair MacLullich5, Suzanne Timmons
https://orcid.org/0000-0001-7790-9552
1
PUBLISHED 07 Nov 2025
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS AWAITING PEER REVIEW

Abstract

Background

Delirium is a fluctuating neuropsychiatric syndrome, with significant consequences including increased mortality, prolonged hospitalization, and long-term cognitive decline. Despite being a serious yet reversible syndrome, delirium is often poorly managed. Clinical practice guidelines providing evidence-based recommendations have become increasingly important for improving healthcare quality, consistency, and cost-effectiveness. The implementation of high-quality guidelines can play a crucial role in delivering good delirium care.

Objective

To identify national or major regional delirium clinical practice guidelines, relating to an adult population, appraise their development process, and identify areas of consensus/disagreement and gaps in their coverage of topics and recommendations.

Methods

Reporting will comply with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. Systematic literature searches will be carried out in four academic databases (Medline Ovid, Embase, CINAHL EBSCO and PsycInfo EBSCO) and 19 grey literature sources comprising databases (TRIP, Google Scholar, Google), guideline repositories, delirium organisation websites and other sources. Two reviewers will independently perform title and abstract screening, then full text screening, against defined eligibility criteria. Data will be charted using standardised forms. Due to the nature of the scoping review, ethical approval is not required. This protocol was registered with Open Science Framework https://osf.io/kfh3m.

Discussion

This scoping review will contribute data to a larger project aimed at developing an international clinical practice guideline for delirium. Results from this scoping review will be disseminated in a peer-reviewed journal and at international conferences.

Keywords

Delirium, guideline, guidance, clinical pathway, quality appraisal, scope

Corresponding author: Mary Faherty
Competing interests: ST and GB were co-chairs of the European Geriatric Medicine Society Special Interest Group in Delirium at the time of conceiving this study.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright:  © 2025 Faherty M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Faherty M, Harwood R, Bellelli G et al. Clinical Practice Guidelines on Delirium - Consensus and Gaps: A Scoping Review Protocol [version 1; peer review: awaiting peer review]. HRB Open Res 2025, 8:118 (https://doi.org/10.12688/hrbopenres.14269.1) First published: 07 Nov 2025, 8:118 (https://doi.org/10.12688/hrbopenres.14269.1) Latest published: 07 Nov 2025, 8:118 (https://doi.org/10.12688/hrbopenres.14269.1)

Introduction

Delirium is an acute and fluctuating neuropsychiatric syndrome characterised by disturbances in attention, awareness, and cognition1. This prevalent and serious condition is particularly common in older adults2 and is associated with adverse outcomes including increased mortality3, prolonged hospitalisation3,4 and long-term cognitive decline5–8. Predisposing risk factors include advanced age, pre-existing cognitive impairment and prior delirium, while precipitating factors include infections, surgery and medications2,9,10. Delirium prevalence varies across hospital settings, from 15% in the emergency department11 to 25% in geriatric wards2 and to 34.5% post-operative delirium after cardiac surgery12. A 2022 meta-analysis of 26 studies reported delirium prevalence of 17–24% in hospitalised older adults13 while a worldwide delirium point-prevalence study reported a rate of 18% across 1664 wards/units14. Gibb et al. (2020) found in-hospital delirium occurrence of 23% (95% CI, 19-26%)15. Delirium can have a profoundly negative impact, not just on patients, but also families and clinicians16–18.

Clinical practice guidelines (CPGs) have been defined as "statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options"5, p.4, which distinguishes them from consensus statements and expert advice19. CPGs have gained momentum in recent decades as a means of addressing issues of healthcare quality, consistency, and cost-effectiveness19–21. A systematic appraisal of CPGs in delirium, published in 2017, found 21 guidelines (11 published pre-2010) of variable quality, many of which were found through grey literature sources22. While that study covered delirium CPGs up to December 2013 and a more recent systematic review synthesised CPG recommendations for anxiety, depression and PTSD in adults with delirium in acute care23, to the best of our knowledge, no evidence synthesis has focused exclusively on delirium CPGs in the last decade.

Given the role CPGs play in providing evidence-based recommendations on disease or syndrome detection, prevention, and management, it is important to explore the quantity and quality of current guidelines. Scoping reviews can play an important role in the guideline development process, by identifying existing guidelines (for adoption or adaptation), mapping consensus/disagreement areas, and gaps on various topics, and by exploring contextual factors such as ethics and feasibility which could play a role in formulating recommendations24.

Study objective

The objectives of this scoping review are to (i) identify national or major regional delirium CPGs for the adult population; (ii) appraise the methodological rigour and transparency of each guideline’s development process; (iii) map the topics covered by the guidelines and identify the gaps in current guidelines.

The specific research questions are:

  • 1. What CPGs exist for delirium in an adult population?

  • 2. How rigorous and transparent was each guideline’s development process?

  • 3. What gaps and areas of consensus/disagreement exist across the guidelines?

Methods

The study will utilise the Levac et al. methodology25, an enhanced version of the Arksey & O’Malley methodology for scoping reviews26. A scoping review was chosen over a systematic review as the aim is to map the existing literature on CPGs for delirium, providing a broad overview of their scope, quality, and thematic emphasis, rather than answering specific questions which would be better addressed by a systematic review27. Reporting will comply with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist28. The expected study duration is August to December 2025. This scoping review protocol was registered with Open Science Framework (https://osf.io/kfh3m).

Search strategy

A systematic literature search will be undertaken by researchers with the necessary skills to identify applicable guidelines. Search terms were derived from the research questions and modified as necessary for the various data sources. Four academic databases will be searched: Medline Ovid, Embase, CINAHL and PsycInfo. As prior studies have shown the importance of grey literature searches in sourcing clinical guidelines22,29, 19 grey literature sources will include databases (TRIP, Google, Google Scholar), guideline repositories, delirium organisation websites and other sources (Table 1). The reference lists of all included articles will be examined for additional sources. The search period will cover guidelines published from 1 January 2010 to 26 August 2025.

Table 1. Search terms and databases.

Literature resourceSearch term
Academic databases
‘Delirium’ search filter taken from page 65 of NICE (2023) Delirium: prevention, diagnosis and management [A] Evidence review for
diagnostic accuracy of tests to identify delirium; modified as necessary to suit platform(s): https://www.nice.org.uk/guidance/cg103/evidence/a-diagnostic-accuracy-of-tests-to-identify-delirium-pdf-11320715486
‘Guideline’ search filter taken from: Canada's Drug Agency (2025) Guidelines - Standard; modified as necessary to suit platform(s):
https://searchfilters.cda-amc.ca/
Medline via Ovid1 exp Delirium/
2 Confusion/
3 deliri*.tw.
4 (confus* adj3 state*).tw.
5 (acute* adj3 (confus* or "brain syndrome" or "brain failure")).tw.
6 organic psychosyndrome.tw.
7 psychoorganic syndrome.tw.
8 psycho-organic syndrome.tw.
9 toxic confusion*.tw.
10 toxic psychosis.tw.
11 or/1-10
12 (guideline or practice guideline or consensus development conference or consensus development conference, NIH).pt.
13 (guideline* or standards or consensus* or recommendat*).ti.
14 (practice parameter* or position statement* or policy statement* or CPG or CPGs or best practice*).ti.
15 (care adj2 (path or paths or pathway or pathways or map or maps or plan or plans or standard)).ti.
16 ((critical or clinical or practice) adj2 (path or paths or pathway or pathways or protocol*)).ti.
17 (algorithm* and (pharmacotherap* or chemotherap* or chemotreatment* or therap* or treatment* or intervention*)).ti.
18 (algorithm* and (screening or examination or test or tested or testing or assessment* or diagnosis or diagnoses or diagnosed or diagnosing)).ti.
19 (guideline* or standards or consensus* or recommendat*).au.
20 (guideline* or standards or consensus* or recommendat*).ca.
21 systematic review.ti,pt,kf,sh. and (practice guideline* or treatment guideline* or clinical guideline* or guideline recommendation*).ti,ab,kf.
22 or/12-21
23 11 and 22
24 limit 23 to yr="2010 - Current"
Embase1 delirium assessment
2 deliri*.tw.
3 ‘delirium’/ OR ‘emergence agitation’/ OR ‘hyperactive delirium’/ OR ‘hypoactive delirium’/ OR ‘postoperative delirium’/
4 (confus* adj3 state*).tw.
5 (acute* adj3 (confus* or "brain syndrome" or "brain failure")).tw.
6 organic psychosyndrome.tw.
7 psychoorganic syndrome.tw.
8 psycho-organic syndrome.tw.
9 toxic confusion*.tw.
10 toxic psychosis.tw.
11 or/2-10
12 (guideline or practice guideline or consensus development conference or consensus development conference, NIH).pt.
13 (guideline* or standards or consensus* or recommendat*).ti.
14 (practice parameter* or position statement* or policy statement* or CPG or CPGs or best practice*).ti.
15 (care adj2 (path or paths or pathway or pathways or map or maps or plan or plans or standard)).ti.
16 ((critical or clinical or practice) adj2 (path or paths or pathway or pathways or protocol*)).ti.
17 (algorithm* and (pharmacotherap* or chemotherap* or chemotreatment* or therap* or treatment* or intervention*)).ti.
18 (algorithm* and (screening or examination or test or tested or testing or assessment* or diagnosis or diagnoses or diagnosed or diagnosing)).ti.
19 (guideline* or standards or consensus* or recommendat*).au.
20 (guideline* or standards or consensus* or recommendat*).co.
21 (guideline* or standards or consensus* or recommendat*).ca.
22 ‘systematic review’:ti,it,kw and (‘practice guideline*’ or ‘treatment guideline*’ or ‘clinical guideline*’ or ‘guideline recommendation*’):ti,ab,kw
23 or/12-22
24 11 and 23
25 limit 24 to yr="2010 - Current"
26 25 AND ([adult]/lim OR [young adult]/lim OR [middle aged]/lim OR [aged]/lim OR [very elderly/lim)
CINAHL via EBSCOS1 delirium/
S2 mental confusion/
S3 deliri*
S4 (confus* N3 state*)
S5 acute* N3 (confus* OR "brain syndrome" OR brain failure)
S6 organic psychosyndrome
S7 psychoorganic syndrome
S8 psycho-organic syndrome
S9 toxic confusion*
S10 toxic psychosis
S11: S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10
S21 PT (guideline OR "practice guideline" OR "consensus development conference" OR "consensus development conference, NIH")
S12 TI (guideline* OR standards OR consensus* OR recommendat*)
S13 TI (practice parameter* or position statement* or policy statement* or CPG or CPGs or best practice*)
S14 TI (care N2 (path or paths or pathway or pathways or map or maps or plan or plans or standard))
S15 TI ((critical or clinical or practice) N2 (path or paths or pathway or pathways or protocol*))
S16 (algorithm* and (pharmacotherap* or chemotherap* or chemotreatment* or therap* or treatment* or intervention*))
S17 (algorithm* and (screening or examination or test or tested or testing or assessment* or diagnosis or diagnoses or diagnosed or diagnosing))
S18 AU (guideline* or standards or consensus* or recommendat*)
S19 CA (guideline* or standards or consensus* or recommendat*)
S20 (TI "systematic review" OR PT "systematic review" OR SU "systematic review" OR KW "systematic review") AND (TI (practice guideline* OR treatment guideline* OR clinical guideline* OR guideline recommendation*) OR AB (practice guideline* OR treatment guideline* OR clinical guideline* OR guideline recommendation*) OR KW (practice guideline* OR treatment guideline* OR clinical guideline* OR guideline recommendation*))
S22: S12…S21
S23: S11 AND S22
S24: Filter 2010 to current
PsycInfo via EBSCO1 delirium
2 mental confusion
3 deliri*
4 (confus* N3 state*)
5 acute* N3 (confus* or "brain syndrome" or "brain failure")
6 organic psychosyndrome
7 psychoorganic syndrome
8 psycho-organic syndrome
9 toxic confusion*
10 toxic psychosis
11 or/1-10
12 (guideline or practice guideline or consensus development conference or consensus development conference, NIH).pt.
13 (guideline* or standards or consensus* or recommendat*).ti.
14 (practice parameter* or position statement* or policy statement* or CPG or CPGs or best practice*).ti.
15 (care adj2 (path or paths or pathway or pathways or map or maps or plan or plans or standard)).ti.
16 ((critical or clinical or practice) adj2 (path or paths or pathway or pathways or protocol*)).ti.
17 (algorithm* and (pharmacotherap* or chemotherap* or chemotreatment* or therap* or treatment* or intervention*)).ti.
18 (algorithm* and (screening or examination or test or tested or testing or assessment* or diagnosis or diagnoses or diagnosed or diagnosing)).ti.
19 (guideline* or standards or consensus* or recommendat*).au.
20 (guideline* or standards or consensus* or recommendat*).co.
21 (guideline* or standards or consensus* or recommendat*).ca.
22 systematic review.ti,pt,kf,sh. and (practice guideline* or treatment guideline* or clinical guideline* or guideline recommendation*).ti,ab,kf.
23 or/12-22
24 11 and 23
25 limit 24 to yr="2010 - Current"
Grey literature: databases
TRIP(delirium OR confusion OR deliri* OR "confus* state*" OR "acute confusion" OR "brain syndrome" OR "brain failure" OR "organic psychosyndrome" OR "psychoorganic syndrome" OR "toxic confusion" OR "toxic psychosis") AND (guideline OR "practice guideline" OR "clinical guideline" OR "treatment guideline" OR "consensus development" OR "consensus statement" OR "recommendation" OR "position statement" OR "policy statement" OR "care pathway" OR "clinical pathway" OR "best practice" OR "practice parameter" OR "screening algorithm" OR "diagnostic algorithm" OR "treatment algorithm") from_date:2010 to_date:2025
Google Scholar (first 200)("delirium" OR "confusion" OR "delirious state" OR "acute confusion" OR "brain syndrome" OR "brain failure" OR "organic psychosyndrome" OR "psychoorganic syndrome" OR "psycho-organic syndrome" OR "toxic confusion" OR "toxic psychosis") AND ("clinical guideline" OR "practice guideline" OR "consensus statement" OR "consensus development conference" OR "NIH consensus" OR "position statement" OR "policy statement" OR "CPG" OR "CPGs" OR "best practice" OR "care pathway" OR "clinical pathway" OR "care plan" OR "critical path" OR "treatment algorithm" OR "screening algorithm" OR "diagnostic algorithm")
Custom range 2010 – 2025
Google (first 200)(delirium OR confusion OR "delirious state" OR "acute confusion" OR "brain syndrome" OR "brain failure" OR "organic psychosyndrome" OR "psychoorganic syndrome" OR "psycho-organic syndrome" OR "toxic confusion" OR "toxic psychosis") AND ("clinical guideline" OR "practice guideline" OR "consensus statement" OR "consensus development conference" OR "position statement" OR "policy statement" OR "best practice" OR "care pathway" OR "clinical pathway" OR "treatment algorithm" OR "screening algorithm" OR "diagnostic algorithm") AND ("2010..2025")
Grey literature: websites and repositories
If appropriate (i.e. website has an advanced search function), the Google search filter outlined above will be used.In other cases, to keep the search broad, search terms using the webpage’s search function will focus on ‘delirium’ or ‘delirium guideline/s’; this will be combined with a search of relevant webpages (e.g. Resources section). Results will be cross-checked against a Google Advanced search (e.g., site:www.xxx.com/ delirium).
RNAOhttps://rnao.ca/
AHRQhttps://www.ahrq.gov/
NICEhttps://www.nice.org.uk/
SIGNhttps://www.sign.ac.uk/our-guidelines/
ECRI Guidelines Trusthttps://guidelines.ecri.org/
Guideline Centralhttps://www.guidelinecentral.com/
Canada’s Drug Agency, aka CADTHhttps://www.cda-amc.ca/
Canadian Medical Association, CMAhttps://www.cma.ca/
Cochrane Libraryhttps://www.cochranelibrary.com/
GINhttps://guidelines.ebmportal.com/
New Zealand Guidelines Grouphttps://anz-guideline-network.webnode.page/anz-guidelines/
Australian NHMRChttps://www.nhmrc.gov.au/
American Delirium Societyhttps://americandeliriumsociety.org/healthcare-professionals/essential-readings/
European Delirium Associationhttps://www.europeandeliriumassociation.org/
Australasian Delirium Associationhttps://www.delirium.org.au/
Alzheimer’s Associationhttps://www.alz.org/

Source of evidence selection

Article selection will be based on the pre-defined criteria in this protocol. Inclusion criteria are: a national or major regional guideline or guidance or clinical pathway, or clinical care standards or practice statements on delirium; including recommendations relating to adults 18 years of age or older; in hospitals, primary care settings, long term care homes, private residences; including emergency departments, acute medicine, elective and emergency surgery, palliative care, or rehabilitation; published since 1st January 2010 and published in any language. Exclusion criteria are: local level guideline or guidance (e.g. hospital or hospital group level, or equivalent in other settings); delirium guidelines specific to alcohol or drug intoxication or withdrawal only; delirium guidelines specific to COVID-19 only; paediatric delirium (under 18 years of age); guidelines focussed on the Intensive Care Unit (ICU) setting; guidelines published before 1st January 2010. A PRISMA flow diagram will be used to record the number of records identified, included, and excluded, along with reasons for exclusions.

Zotero (Version 7.0.16), Rayyan, Excel (Microsoft 365 Version 2509) and OneDrive will be used to manage the results. After removing duplicates, the titles and abstracts of potential guidelines will be screened by two researchers. Following this, guidelines that meet the pre-defined inclusion criteria will be read in full by two researchers to determine eligibility. Disagreements at either screening stage will be resolved by consensus meetings, or if necessary, by the decision of a third (senior) reviewer.

Guideline quality appraisal

The quality and validity of the guidelines will be assessed using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II), a 23-item tool for evaluating CPGs, with items grouped into six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence30,31. The CPGs will be independently assessed by two appraisers, with each appraiser scoring each guideline on 23 items using the recommended seven-point scale. The guideline item scores will be taken as the average item score of the two appraisers. Domain scores will be calculated by summing the averaged item scores per domain, then scaling the total as a percentage of the maximum possible score for that domain, as per the AGREE II instructions. Upon completing the scoring of the 23 items, both appraisers will give an overall assessment score on the quality of the guideline and confirm if they would recommend use of the guideline.

Data charting

Draft charting tables have been developed (Table 2–Table 4). These will be further refined and updated at review stage if required. Extracted information will include author(s); year of publication; title; number of pages; country of origin; language; setting; focus; basis for recommendations; AGREE II scores (overall and individual scores for the six domains); database source(s) of identified guidelines. AI tools will not be used for data extraction.

Table 2. Characteristics of included clinical practice guidelines on delirium.

AuthorYearTitleNo.
pages		Guideline
development
group		CountryLanguageSettingFocus (risk
stratification;
prevention;
screening;
assessment;
management)		Basis for
recommendation
(evidence
weighting
system used);
consensus
method		Other

Table 3. AGREE II scores for clinical practice guidelines on delirium.

AuthorTitle1: Scope
and
purpose		2: Stake-
holder
involvement		3: Rigour of
development		4: Clarity of
presentation		5:
Applicability		6: Editorial
independence		Overall
score
(average)		Overall
recommendation
for use

Table 4. Identified guideline mapped to database source.

Medline OvidEmbaseCINAHLPsycInfoGrey literature
source
Guideline #1Yes/NoYes/NoYes/NoYes/NoYes/No
Guideline #2Yes/NoYes/NoYes/NoYes/NoYes/No
Etc.

Discussion

Despite many recent advances in research, policy and advocacy, delirium remains a condition with a low profile which is often poorly managed14. By mapping the current national and major regional guidelines, we aim to identify areas of consensus and disagreement, as well as gaps that need to be addressed, which could help in the development of an international delirium guideline. We also aim to map the source of the guidelines in terms of websites and other grey literature versus academic journal databases, and the scope of the guidelines in terms of specific populations and settings.

Ethics and dissemination

Research ethics approval and consent is not required for this scoping review. The findings will be made available to health professionals, decision makers and the public via publication in relevant journals and dissemination at regional, national and international conferences.

Data availability

No data are associated with this article.

Acknowledgements

Thanks to Breeda Herlihy, UCC Library, for guidance on developing search filters.

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Faherty M, Harwood R, Bellelli G et al. Clinical Practice Guidelines on Delirium - Consensus and Gaps: A Scoping Review Protocol [version 1; peer review: awaiting peer review]. HRB Open Res 2025, 8:118 (https://doi.org/10.12688/hrbopenres.14269.1)
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Open Peer Review

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Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

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VERSION 1 PUBLISHED 07 Nov 2025
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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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