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Received 7 December 2016; editorial decision 12 July 2017

Age and Ageing 2018; 47: 131–137 © The Author 2017. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi: 10.1093/ageing/afx133 All rights reserved. For permissions, please email: journals.permissions@oup.com
Published electronically 9 August 2017

Development of an international undergraduate

curriculum for delirium using a modified delphi
process
CLAIRE COPELAND1, JAMES FISHER2, ANDREW TEODORCZUK3
1
Department of Ageing & Health, Forth Valley Royal Hospital, NHS Forth Valley, UK
2
Department of Geriatric Medicine, Northumbria Healthcare NHS Foundation Trust, UK
3
School of Medicine, Griffith University, Queensland, Australia
Address correspondence to: C. Copeland. Tel: (+44) 01324 56600. Email: clairecopeland@nhs.net

Abstract

Background: delirium is a medical emergency affecting approximately 30% of hospitalised older patients. Recent work
examining UK undergraduate medical curricula highlighted inconsistencies in the delivery of teaching on delirium. The aim
of this project was to develop consensus agreement on a delirium curriculum for medical undergraduates.

131
C. Copeland et al.

Methods: a modified Delphi process was used to determine consensus amongst experts in an iterative manner. Experts at
the European Delirium Association Conference (London, 2015) were invited to participate. Participants were asked to con-
sider: (i) What should be taught? (ii) How should teaching be delivered? (iii) Who should deliver the teaching? (iv) Where
should the teaching be delivered? (v) When should the teaching be delivered? Delphi rounds continued until consensus on
curriculum content (defined as 80% agreement) was achieved.
Results: consensus was reached after three rounds. A recurrent theme was the need to involve patients, families and carers
to help drive attitudinal change. The final curriculum, along with data pertaining to agreement with each curriculum item
during the Delphi process, is presented.
Conclusion: this Delphi process enabled an international group of experts from a broad range of specialties, to reach con-
sensus agreement on the components of an undergraduate curriculum for delirium. The curriculum represents an important
step in the development of delirium education within medical training. Despite competing demands of increasingly crowded
undergraduate curricula, delirium, given its relevance to 21st century healthcare, must be prioritised. We call on Medical

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Schools to consider integrating this delirium curriculum into their degree programmes.

Keywords: delirium, education, curriculum, training, geriatric medicine teaching, older people

Background
Delirium is a neuropsychiatric syndrome characterised by acute
and fluctuating inattention, in addition to cognitive and percep-
tual deficits. Delirium is a common medical emergency affecting
up to 30% of hospitalised older patients [1] and is associated
with increased rates of mortality and institutionalisation [2]. The
long-term sequalae of delirium are increasingly recognised—
delirium accelerates cognitive decline [3, 4] and may result in sig-
nificant psychological distress for the sufferer and carer [3].
Delirium is also a costly condition for health services; its com-
plications are estimated to result in additional costs of £13,000
per admission [4]. Delirium is preventable [5], yet the condition
is frequently missed by hospital staff [6] and junior doctors have
been shown to lack basic knowledge about the condition [7, 8].
It is vital that healthcare systems get delirium care right.
The condition is recognised as being ‘core business’ for 21st
century hospitals [9] and its prevalence will only rise further as
the population ages. Education is at the heart of driving up
standards of care; evidence shows that educational interven-
tions on delirium improve recognition of the condition [10],
reduce its severity [11] and reduce length of hospital stay [12].
Recent work examining UK undergraduate medical curricula
on delirium highlighted that whilst the condition was widely
taught, there were inconsistencies in the delivery of teaching
and widespread failure to address attitudinal learning outcomes
[13]. Given the heterogeneity of delirium education provision
identified by this survey, arguably there would be great value in
clearly defining what tomorrows’ doctors ought to know about
delirium and determining the optimal methods for delivering
this teaching. The aim of this project was therefore to develop
a consensus agreement amongst global delirium educators on a
curriculum for undergraduate medical education on delirium.
Methods
A modified Delphi process was used. The Delphi technique
is a robust education research approach for determining the
extent to which experts agree on a given issue [14] and has
previously been employed in multi-national curricular
research in geriatric medicine [15]. The purpose of the
Delphi process is to determine consensus amongst experts
in an iterative manner; a series of rounds are used to clarify,
refine, and to ultimately achieve agreement on the content
under discussion. Ethical approval was not required as
determined by the UK NHS Health Research Authority
online decision tool.
Expert panel members
Experts at the European Delirium Association Annual
Conference (London, 2015) who attended a workshop on
delirium education were invited to participate. This confer-
ence is the largest international meeting for delirium specia-
lists and attracts an international, multidisciplinary audience
that includes experts in the fields of delirium research and
clinical practice. In line with previously published work [16],
an expert was considered to be a registered clinician with
>5 years of experience of working with older people, or a
researcher who had obtained a higher degree in the field of
delirium. The workshop began with a brief plenary during
which an overview of previous relevant educational
research literature was presented (identified from knowl-
edge in the field rather than via a formal, systematic review)
and the need to develop a consensus curriculum was high-
lighted. Delegates were then asked to consider the five fol-
lowing questions relating to undergraduate delirium
education: What should be taught? How should teaching be
delivered? Who should deliver the teaching? Where should
the teaching be delivered? When should the teaching be
delivered? Thereafter, through small group exercises and
facilitated whole-group discussion, an initial draft curric-
ulum was developed. Twenty participants attended the ses-
sion and were invited to participate in the Delphi process;
all fulfilled criteria for expert panel members. Six additional
participants, who were unable to attend the workshop, were

132
 Development of an international undergraduate curriculum
thereafter recruited by the research team; these participants
were recognised as being delirium field leaders within
Geriatrics and Old Age Psychiatry. Specialists working in
both primary and critical care were included to ensure a
broad spread of viewpoints were represented.
Delphi process
First delphi round
Participants were contacted by email and invited to partici-
pate in the Delphi process. Those who agreed to participate
were provided with a link to an online questionnaire. All
draft curriculum items generated by the workshop were
included within the questionnaire. For each curriculum item
panel members were asked to rate each item as essential,
desirable, less desirable or not applicable. Panel members
were invited to provide additional free-text responses if
they had suggestions or amendments to any curriculum
item or if there was additional content they wanted to pro-
pose. The questionnaire was accessible for a one month
period and participants were sent weekly reminders to com-
plete it. Emails were sent individually and the use of an
online questionnaire system ensured anonymity was pre-
served. The number of rounds was not predefined before
starting.
Analysis of first delphi round
In response to participants’ suggestions curriculum items
were modified in a variety of ways that included: adjusting
wording of items to improve clarity, readability and achiev-
ability of learning outcomes; addition of further details to
increase the complexity or conversely, removal of content
to lower the difficulty. This process of redrafting and refin-
ing curriculum items was undertaken by the education
research team through a series of meetings.
Second delphi round
An e-mail invitation to the second Delphi round. Those
who wished to continue participating were given access to a
second online questionnaire containing the updated curric-
ulum. For each curriculum item, panel members were again
asked to rate each item as essential, desirable, less desirable
or not applicable. Additional free-text responses were
invited. The questionnaire was accessible for a one month
period and participants were sent weekly reminders to com-
plete it. The same procedure for analysis was used as in the
first Delphi round, except with this round, a priori decision
was made that curriculum items would be dropped from
the draft curriculum if they failed to achieve greater than
80% agreement (ie inclusion required 80% of participants
to indicate that the item ought to be included in the curric-
ulum). A disagreement was defined as a respondent who
indicated that the curriculum item was either not applicable
or less desirable.
Third delphi round
Panel members were sent an e-mail invitation to the third
Delphi round. Those continuing were advised that the
revised curriculum was the final draft. Panel members were
asked if they agreed with the proposed version, or if they
disagreed with any component of it. If any further disagree-
ments were to arise at this stage, a further Delphi round
would be undertaken.
Results
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The initial panel of Delphi participants consisted of 17 con-
sultants, 7 specialist trainees, 1 research fellow and 1 post-
graduate medical student. All participants fulfilled criteria
for ‘expert’ status, as outlined in the methods above. The
panel possessed significant experience in medical education;
some with formal qualifications, all were actively involved
in medical education. To ensure inclusitivioty, however, no
formal definition of education expertise was applied.
About 25 participants completed the first Delphi round;
one participant was un-contactable and thus was withdrawn
from the Delphi process. About 24 participants completed
the second Delphi round; one previous participant declined
further involvement due to constraints on their time. No
participants withdrew from the Delphi process thereafter.
The number of agreements/disagreements for each
stage of the Delphi process is shown in Table 1. After the
second round of the Delphi process seven items were
dropped from the draft curriculum due to failure to achieve
>80% agreement on their inclusion. These items can be
viewed in Supplementary data are, Appendix 1, available in
Age and Ageing online. Free text feedback did not suggest
that their rejection was due to poorly defined or described
items. Consensus on the curriculum and its constituent
parts was achieved after three Delphi rounds. The final
undergraduate curriculum for delirium is shown in Tables 2
and 3.
Discussion
This is the first Delphi process in which an international
group of experts, drawn from a broad range of specialties,
reached consensus on the components of an undergraduate
curriculum for delirium. Involvement of experts working
across three different continents added a unique inter-
national perspective to the work and enhances the likeli-
hood that its findings will be relevant and applicable to
medical schools globally. The high response rate and level
of agreement add robustness to the findings.
A further strength of this work is that it goes beyond
what should be taught to provide expert consensus on how
best this teaching can and should be delivered (i.e. the
‘how’, ‘who’, ‘where’ and ‘when’). Such an approach is
coherent with the true definition of a curriculum—that is,
not just what ought to be learnt but ‘a planned educational
experience that encompasses behavioural goals,
133
C. Copeland et al.

Table 1. Results of agreement/disagreement after three Delphi Rounds

Curriculum content Number of agreements N (%)
Round 1 (n = 25) Round 2 (n = 24) Round 3 (n = 24)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What should be taught?
Recall data pertaining to the incidence and prevalence of delirium 22 (88.0%) 21 (87.5%) 24 (100%)
Describe the risk factors for delirium 25 (100%) 24 (100%) 24 (100%)
List the common precipitants of delirium 24 (96.0%) 23 (95.8%) 24 (100%)
Understand current theories for the pathophysiology of delirium 17 (68.0%) 21 (87.5%) 24 (100%)
Understand the concept of vulnerability to different stressors in the development of delirium 24 (96.0%) 24 (100%) 24 (100%)
Understand that delirium accelerates cognitive decline 24 (96.0%) 24 (100%) 24 (100%)
Understand there is a link between delirium and frailty 23 (92.0%) 21 (87.5%) 24 (100%)

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Define delirium as a clinical condition based on validated criteria and consensus definitions, 14 (56.0%) 22 (91.7%) 24 (100%)
such as the DSM-V criteria
Recognise delirium in different clinical settings e.g. emergency department, intensive care, 21 (84.0%) 24 (100%) 24 (100%)
post-operatively and paediatrics
Know the subtypes: hyperactive, hypoactive and mixed 23 (92.0%) 24 (100%) 24 (100%)
Recall other clinical conditions that include confusion as a symptom 24 (96.0%) 21 (87.5%) 24 (100%)
Have a working knowledge of delirium detection tools e.g. 4AT and CAM 25 (100%) 21 (87.5%) 24 (100%)
Know that delirium is preventable 25 (100%) 22 (91.7%) 24 (100%)
Know that delirium is treatable 24 (96.0%) 23 (95.8%) 24 (100%)
Appreciate the role of interdisciplinary management of delirium 25 (100%) 24 (100%) 24 (100%)
Appreciate the role of non-pharmacological management of delirium 25 (100%) 22 (91.7%) 24 (100%)
Appreciate the role of drug treatment (within the current evidence base) in the management of 21 (84.0%) 23 (95.8%) 24 (100%)
delirium
Demonstrate the legislation in place to protect the delirious person relevant to your clinical area 22 (88.0%) 20 (83.3%) 24 (100%)
Recognise that negative attitudes towards patients with delirium exist amongst some healthcare 23 (92.0%) 23 (95.8%) 24 (100%)
professionals
Appreciate the importance of speaking to families/carers about delirium 25 (100%) 22 (91.7%) 24 (100%)
How should delirium be taught?
Where possible, patients, families and carers should be involved in the design of delirium teaching 22 (88.0%) 23 (95.8%) 24 (100%)
Built into each educational session should be time for reflection 24 (96.0%) 21 (87.5%) 24 (100%)
Case-based discussion 24 (96.0%) 24 (100%) 24 (100%)
Simulation 23 (92.0%) 23 (95.8%) 24 (100%)
Videos e.g. patient/care experience 23 (92.0%) 24 (100%) 24 (100%)
Interdisciplinary workshops 22 (88.0%) 24 (100%) 24 (100%)
Online learning resources e.g. web-based videos and e-learning modules 16 (64.0%) 20 (83.3%) 24 (100%)
Who should provide delirium teaching?
Geriatricians 25 (100%) 23 (95.8%) 24 (100%)
Old age psychiatrists 23 (92.0%) 24 (100%) 24 (100%)
Nurses 22 (88.0%) 24 (100%) 24 (100%)
Patients, families and carers 22 (88.0%) 20 (83.3%) 24 (100%)
Where should delirium teaching occur?
Acute settings e.g. emergency departments and hospital wards 25 (100%) 23 (95.8%) 24 (100%)
Long-term care homes 21 (84.0%) 24 (100%) 24 (100%)
When should delirium be taught?
Early in the patient journey e.g. community, emergency department and admissions ward 25 (100%) 23 (95.8%) 24 (100%)
In the early years of an undergraduate curriculum 19 (76.0%) 24 (100%) 24 (100%)
Exposure to longitudinal follow up of patients with delirium should be facilitated where possible 24 (96.0%) 23 (95.8%) 24 (100%)

instructional methods and actual experiences of the lear-
ners’ [17]. We contend that this rigorous, educational
research approach to curriculum development will ultim-
ately facilitate implementation of the curriculum into degree
programmes.
The three-stage iterative nature of the Delphi process
itself was a further strength of this work. The staged
approach introduced by multiple rounds encouraged reflec-
tion amongst participants as the process ensued and thus
facilitated consensus. The use of online questionnaire soft-
ware ensured respondents remained anonymous and thus
avoided problems such as group conformity, the potentially
stifling influence of dominant personalities and potential
reticence to participate due to perceived prestige or power
imbalance within the group [18]. It also facilitated collection
of responses and analysis, despite panel members being so
geographically disparate. This convenience may in part
account for the exceedingly low dropout rate amongst panel
members during the process. Involving participants from a
multitude of different countries brought other challenges;
for example, variation between the legal and ethical frame-
works in different countries may account for the failure to
achieve consensus on the item pertaining to the ‘capability’
of a patient.

134
 Development of an international undergraduate curriculum

Table 2. The consensus curriculum on undergraduate medical delirium education

Aetiology, epidemiology and pathophysiology
□ Outline data pertaining to the incidence and prevalence of delirium
□ Describe the risk factors for delirium
□ List the common precipitants of delirium
□ Understand current theories for the pathophysiology of delirium
□ Understand the concept of vulnerability to different stressors in the development of delirium
□ Understand that delirium accelerates cognitive decline
□ Understand there is a link between delirium and frailty
Diagnostics
□ Define delirium as a clinical condition based on validated criteria and consensus definitions, such as the DSM-V criteria
□ Recognise delirium in different clinical settings e.g. emergency department, intensive care, post-operatively and paediatrics
□ Know the subtypes: hyperactive, hypoactive and mixed

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□ Recall other clinical conditions that include confusion as a symptom
□ Have a working knowledge of delirium detection tools e.g. 4AT and CAM
Management
□ Know that delirium is preventable
□ Know that delirium is treatable
□ Appreciate the essential role of interdisciplinary working in the management of delirium
□ Appreciate the role of non-pharmacological strategies in the management of delirium
□ Appreciate the role of pharmacological treatment (within the current evidence base) in the management of delirium
□ Demonstrate appropriate implementation of the legislation in place to protect the delirious person (relevant to your clinical area)
□ Recognise that negative attitudes towards patients with delirium exist amongst some healthcare professionals
□ Appreciate the importance of speaking to families/carers about delirium

Table 3. How, by whom, where and when should undergraduate medical delirium teaching be delivered?
How should delirium be taught?
□ Where possible, patients, families and carers should be involved in the design of delirium teaching
□ Built into each educational session should be time for reflection
□ Case-based discussion
□ Simulation
□ Videos e.g. patient/care experience
□ Interdisciplinary workshops
□ Online learning resources
Who should provide delirium teaching?
□ Geriatricians
□ Old age psychiatrists
□ Nurses
□ Patients, families and carers
Where should delirium teaching occur?
□ Acute settings e.g. emergency departments and hospital wards
□ Long-term care homes
When should delirium be taught?
□ Early in the patient journey e.g. community, emergency department and admissions ward
□ In the early years of an undergraduate curriculum
□ Exposure to longitudinal follow up should be facilitated where possible

The inclusion of attitudinal competencies is a notable
finding in this curriculum. There is previous evidence
showing that improving knowledge and skills alone is inef-
fective at increasing detection rates of delirium [13]. It is
recognised that negative attitudes towards patients suffering
delirium, and a lack of ‘ownership’ for such patients, do
exist amongst healthcare professionals [19]. This may be
compounded by a paucity of attitudinal learning outcomes
relating to delirium in undergraduate curricula [13].
Challenging such attitudes at an early stage in training is
important and this curriculum provides a framework for
doing so.
Involvement of families and carers in teaching on delir-
ium is a recurring feature within the curriculum, the bene-
fits of which are likely to be manifold. First, in many cases
of delirium it is the family member or carer that alerts
healthcare professionals to an acute change in a person’s
cognition and thus the possibility of a delirium. Despite
this, ‘collateral’ history taking is often poorly done, or even
entirely neglected [20]. Our aspiration is that implementa-
tion of this curriculum will increase the emphasis placed on
this vital component of the medical consultation and may
ultimately help to increase recognition of delirium. Second,
it is recognised that involvement of patients and the public

135
C. Copeland et al.
within medical training can act as a potent driver for attitu-
dinal change [21]. Third, the traditional model of bedside
teaching, involving just medical students and a patient, is
flawed in delirium [22]. This curriculum provides a Medical
School road-map for the provision of longitudinal contact
between students, patients, families and carers. The accom-
panying insight that such longitudinal interactions provide
into carers’ needs has been shown to result in students feel-
ing better prepared to react to ethical challenges that they
encounter [23].
Also notable within the curriculum is the inclusion of
technology-enhanced learning, such as online learning and
simulation. Simulated clinical interactions with delirious
patients have been shown to improve student knowledge
on delirium and can provide a potent stimulus for reflective
practice [24]. It is notable that lectures, a far more trad-
itional teaching method, were rejected from the curriculum
(see Supplementary data, Appendix 1, available at Age and
Ageing online). It is critical that the learning outcomes being
taught in a given session determine the teaching method
the tutor opts to employ—placing ‘pedagogy before tech-
nology’ may help to ensure more rational application of
technologies within teaching practice [25].
It is worth highlighting that the curriculum’s guidance
on who should provide teaching on delirium is by no
means definitive. During the Delphi process a number of
specialties were removed from the ‘who’ component of the
curriculum due to a failure to achieve consensus in this
area: intensive care, palliative care and paediatrics.
The incidence of delirium is known to be extremely high
[26, 27] and thus these environments, and the specialists
working in them, are a valuable potential source of learning
on delirium for students. We also acknowledge that given
the multidisciplinary, patient centred nature of gold stand-
ard delirium care, the absence of nursing colleagues, carers
and patients from the Delphi process is suboptimal; how-
ever, the importance of their involvement in delirium edu-
cation is recognised through their inclusion as suggested
groups who ought to be involved with delivery of teaching.
We would encourage involvement of multiple disciplines
and professions in delirium teaching, since inter-
professional improves patient outcomes in delirium [28].
A potential limitation to the Delphi technique itself is
the influence of researchers on the formulation of the initial
statements. To minimise this risk initial statements were
entirely informed by the collaborative working of panel
members with the workshop. As highlighted recently, there
is no consensus in the literature about what defines a
Delphi study or how consensus is judged [29]. Percentage
agreement is the most commonly used definition for con-
sensus but that there is marked heterogeneity [14]. We
chose a threshold of 80% agreement as we were aiming for
a high degree of consensus. Whilst high, it is not dissimilar
to that highlighted in the recent systematic review (75%).
We also acknowledge the challenge of integrating this work
into what are increasingly crowded undergraduate curricula.
However, given the high prevalence, morbidity, mortality
136
and financial costs associated with delirium we contend that
delirium ought to be considered ‘core business’ for the
training of tomorrows’ doctors [9].
Conclusions
This Delphi study enabled the development of an inter-
national medical undergraduate curriculum for delirium.
The curriculum represents an important step in the devel-
opment of effective delirium education within medical train-
ing, which is essential given the condition’s increasing
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relevance to 21st century healthcare. The curriculum pro-
vides medical schools with an overview of the skills
required to train tomorrows’ doctors to be competent in
the delivery of delirium care, along with a framework for
how this education might be delivered. This work will also
facilitate benchmarking in delirium education. We call on
Medical Schools undergoing curricular reviews to consider
integrating this state of the science delirium curriculum into
their degree programmes. Future research might seek to
evaluate the impact within schools that do so.
Key points
• Delirium is poorly managed and under-detected; hence
there is an urgent need to educate clinicians about delir-
ium at an early stage.
• Previous research has identified inconsistencies in the
delivery at undergraduate level.
• Using a modified Delphi process an international panel of
experts reached consensus agreement on the components
of an undergraduate curriculum for delirium.
• Involvement of patients, families and carers in the delivery
of delirium education is highlighted to drive attitudinal
change that is essential to best delirium practice.
Supplementary data
Supplementary data are available at Age and Ageing online.
Acknowledgements
The following people contributed to the Delphi process
and were agreeable to their contribution being acknowl-
edged here (in alphabetical order): O. Akintade, P. Braude,
A. Byrne, H. Chamberlain, R. Field, J. Harrison, D. Hogg,
R. Lawes, S. Leung, A. MacLullich, A. Macharouthu,
C. Potter, S. Richardson, L. Shields, S. Sockalingam,
D. Thomas, S. Timmons, S. Todd, M. Whitsey, S. Wishart,
J. Yeo and A. Ziakowski.
Conflict of interest
None declared.
 Development of an international undergraduate curriculum
Funding
Costs relating to the online questionnaire system were pro-
vided by the European Delirium Association.
Ethical approval
None required. The UK NHS Health Research Authority
online decision tool was used to determine whether this
study required formal ethical approval—this deemed that
formal review by a research ethics committee was not
required.
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Received 1 April 2017; editorial decision 29 June 2017
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