GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium.

objectivesThis portion of the Geriatric Emergency Department (GED) Guidelines 2.0 focuses on delirium in the emergency department (ED).

methodsA multidisciplinary group applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and develop recommendations related to older ED patients with possible delirium.

resultsThe GED Guidelines 2.0 Delirium Work Group derived six evidence-based recommendations for risk stratification, diagnosis, and brain imaging. To reduce universal screening, the Delirium Risk Score may be used to identify older adults at low risk for delirium, though the evidence certainty is very low. In adults over 65 admitted to ED observation units, Zucchelli's risk assessment tool (threshold ≥ 4) may stratify delirium risk, also with very low certainty. For adults over 75, the REDEEM Score may be used to identify low- or high-risk individuals, again with very low certainty. For diagnosis, 4AT, bCAM, CAM-ICU, mCAM, AMT-4, or RASS may be used to rule delirium in or out, based on very low certainty. The Delirium Triage Screen (DTS) may be used to rule out, but not to rule in, delirium, also with very low certainty. For diagnostic imaging, there is very low certainty of evidence to recommend for or against obtaining a head CT as part of the evaluation for older ED patients with delirium. All recommendations are conditional, reflecting very low certainty of evidence due to the lack of high-quality ED-based studies and comparative effectiveness research.

conclusionRigorous ED-based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.