Early Symptoms in the Prodromal Phase of Delirium: A Prospective Cohort Study in Elderly Patients Undergoing Hip Surgery

Department of Clinical Psychology, Medical Center Alkmaar, Alkmaar, The Netherlands.
American Journal of Geriatric Psychiatry (Impact Factor: 4.24). 03/2007; 15(2):112-21. DOI: 10.1097/01.JGP.0000241002.86410.c2
Source: PubMed


The authors investigated prodromal delirium symptoms in elderly patients undergoing hip surgery.
This was a prospective cohort study in the setting of a large medical school-affiliated general hospital in Alkmaar, The Netherlands. Participants were patients undergoing hip surgery aged 70 and older at risk for delirium. Before surgery, patients were randomized to low-dose prophylactic haloperidol treatment or placebo. Daily assessments were based on patient interviews with the Mini-Mental State Examination and Digit Span test. The Delirium Rating Scale-Revised (DRS-R-98) was used to measure early symptoms during the prodromal phase before the onset of delirium.
Data of 66 patients with delirium were compared with those of 35 at-risk patients who did not develop delirium: 14 of 66 patients (21%) had delirium on the day of surgery or early the day after, 32 of 66 (48%) on the second day, 14 of 66 on the third, and six of 66 (9%) on the fourth. The average DRS-R-98 total scores on day -4 to day -1 before delirium were 1.9 for the comparison group patients and 5.0, 4.3, 5.8, and 10.7 for patients with postoperative delirium. Multivariate analysis showed that the early symptoms memory impairments, incoherence, disorientation, and underlying somatic illness predict delirium.
Most elderly patients undergoing hip surgery with postoperative delirium already have early symptoms in the prodromal phase of delirium. These findings are potentially useful for screening purposes and for optimizing prevention strategies targeted at reducing the incidence of postoperative delirium.

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Available from: Jos F M de Jonghe, Sep 29, 2015
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    • "The temporal onset of symptoms and the existence of physical symptoms, diagnostic items for delirium, could support the phenomenological symptoms shown during the prodromal stage of delirium as ground items for diagnosis of delirium later. Duppils et al.25 reported anxiety and disorientation during the prodromal stage of delirium in elderly patients who developed delirium after undergoing hip joint surgery, and de Jonghe et al.7 reported memory disorder, incoherence, and disorientation as prodromal symptoms of delirium. Our results were generally consistent with the results of previous studies except for the addition of affective instability, which can be seen as a difference. "
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    ABSTRACT: This study is intended to identify predictive factors of delirium, including risk factors and prodromal symptoms. This study included sixty-five patients aged 65 years or older who had undergone hip surgery. Baseline assessments included age; gender; admission type (acute/elective); reason for surgery (fracture/replacement); C-reactive protein (CRP); Acute Physiology, Age, Chronic Health Evaluation (APACHE III); and the Mini-Mental State Examination (MMSE). The Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98) was used to assess prodromal symptoms daily before the onset of delirium. Almost 28% (n=18) of the 65 patients developed delirium after surgery. Delirium in elderly patients after hip surgery was observed more often in older patients and those with acute admission, hip fracture, higher APACHE III score, lower MMSE score, and higher CRP levels within early days after the operation. Sleep-wake cycle disturbances, thought process abnormalities, orientation, and long-term memory in symptom items of K-DRS-98 were showed significant difference on 4 days before delirium, lability of affect on 3 days before, perceptual disturbances and hallucination, and visuo-spatial ability on 2 days before, and delusion, motor agitation, and short-term memory on the day before the occurrence of delirium. CRP levels within 24 hours and 72 hours after hospitalization were significantly higher in the delirium group. Medical professionals must pay attention to behavioral, cognitive changes and risk factors in elderly patients undergoing hip surgery and to the prodromal phase of delirium. K-DRS-98 may help in identifying the prodromal symptoms of delirium in elderly patients after hip surgery.
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