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Objective: To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality., Design: Systematic literature search for formal guidelines (in English or French) with focus on delirium assessment and/or management in adults (≥18 years), guideline summary papers and evaluation studies.Full appraisal of delirium guidelines published between 2008 and 2013 and obtaining a 'Rigour of Development' domain screening score cut-off of >40% using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument., Data Sources: Multiple bibliographic databases, guideline organisation databases, complemented by a grey literature search., Results: 3327 database citations and 83 grey literature links were identified. A total of 118 retrieved delirium guidelines and related documents underwent full-text screening. A final 21 delirium guidelines (with 10 being >5 years old), 12 guideline summary papers and 3 evaluation studies were included. For 11 delirium guidelines published between 2008 and 2013, the screening AGREE II 'Rigour' scores ranged from 3% to 91%, with seven meeting the cut-off score of >40%. Overall, the highest rating AGREE II domains were 'Scope and Purpose' (mean 80.1%, range 64-100%) and 'Clarity and Presentation' (mean 76.7%, range 38-97%). The lowest rating domains were 'Applicability' (mean 48.7%, range 8-81%) and 'Editorial Independence' (mean 53%, range 2-90%). The three highest rating guidelines in the 'Applicability' domain incorporated monitoring criteria or audit and costing templates, and/or implementation strategies., Conclusions: Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Context: Delirium often presents difficult management challenges in the context of goals of care in palliative care settings., Objectives: The aim was to formulate an analytical framework for further research on delirium in palliative care settings, prioritize the associated research questions, discuss the inherent methodological challenges associated with relevant studies, and outline the next steps in a program of delirium research., Methods: We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting, relevant literature searches, focused input of epidemiologic expertise, and a meeting participant and coauthor survey to formulate a conceptual research framework and prioritize research questions., Results: Our proposed framework incorporates three main groups of research questions: the first was predominantly epidemiologic, such as delirium occurrence rates, risk factor evaluation, screening, and diagnosis; the second covers pragmatic management questions; and the third relates to the development of predictive models for delirium outcomes. Based on aggregated survey responses to each research question or domain, the combined modal ratings of "very" or "extremely" important confirmed their priority., Conclusion: Using an analytical framework to represent the full clinical care pathway of delirium in palliative care settings, we identified multiple knowledge gaps in relation to the occurrence rates, assessment, management, and outcome prediction of delirium in this population. The knowledge synthesis generated from adequately powered, multicenter studies to answer the framework's research questions will inform decision making and policy development regarding delirium detection and management and thus help to achieve better outcomes for patients in palliative care settings., (Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Despite the high prevalence of delirium in palliative care settings, this diagnosis is frequently missed, particularly in patients with hypoactive delirium. These patients are also commonly misdiagnosed with depression because of the overlap in symptoms between the two diagnoses. Failure to promptly diagnose delirium can have significant ramifications in terms of delirium reversal, subsequent patient involvement in end-of-life decision making, and the recognition and treatment of other symptoms., Method: We report a case of a 63-year-old French-speaking woman admitted to our inpatient palliative care unit with colorectal cancer and a history of depression. This case report highlights the major challenges associated with making the diagnosis of delirium in a patient with a complex medical history, including depression., Results: The patient presented with symptoms of depressed mood and fluctuation in psychomotor activity, but failed to respond to an increase in her fluoxetine treatment in addition to methylphenidate and treatment of her hypothyroidism. A psychiatric assessment in her own language detected features of inattention and confirmed a diagnosis of delirium that was multifactorial, secondary to a combination of posterior reversible encephalopathy syndrome (PRES), hypothyroidism, hepatic dysfunction, and medication., Significance of Results: Subsyndromal delirium may present with mood lability, and as delirium and depression can coexist, clinicians should perform a delirium screen for all patients presenting with symptoms of depression, preferably in the patient's first language. Cognitive testing can be particularly helpful in distinguishing delirium, especially hypoactive delirium, from depression.