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

From the Departments of Clinical Psychology and Geriatric Medicine (JFMdJ, KJK, RV, MGK, TvdP), Medical Center Alkmaar, Alkmaar, The Netherlands; Van Foreestcentrum (MD), GGZ Noord-Holland Noord, The Netherlands; the Department of Clinical Neuropsychology (HvD), University of Amsterdam, The Netherlands; the Department of Psychiatry (PE), Academic Medical Center, University of Amsterdam and Free University of Amsterdam, Department of Psychiatry, Amsterdam, The Netherlands; and the Department of Neurology (WAvG), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.

Objectives: The authors investigated prodromal delirium symptoms in elderly patients undergoing hip surgery.

Methods: 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.

Results: 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.

Conclusions: 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.

Key Words: Early symptoms • prodromal • delirium • DRS-R-98 • elderly • orthopedic surgery • risk factors

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