Delirium: behavioural changes before and during the prodromal phase

Background. Delirium is an important form of psychopathology in older people and is associated with increased morbidity and functional decline. In the prodromal phase of delirium early symptoms occur, before all criteria have been met. Aim. The aim of this study was to delineate behavioural changes before and during the prodromal phase of delirium. That was considered to include the time from the first behavioural change up to the point when all DSM-IV criteria for delirium were met. Design. Prospective and descriptive observation study. Methods. One hundred and three hip surgery patients (hip fracture and hip replacement) aged greater than or equal to 80 years participated in this study. On admission none of them was delirious or had severe cognitive decline, but 32 patients met the DSM-IV criteria for delirium during the hospital stay. Frequent observations were performed up to delirium onset or 48 hours postoperatively. The observations included 37 items on the patient's state of mind, cognition, activity and behaviour. The first observation on admission was used as a reference and behavioural changes were defined as deviations from this first observation. Results. Twenty-one patients out of the 32 who met the DSM-IV criteria (62%, D group) demonstrated behavioural changes before delirium onset, as did 34 (48%, R group) out of the remaining 71 patients. The D group had different and more numerous behavioural changes than the R group. Anxiety was common in both groups. Disorientation and urgent calls for attention were the most frequent changes in the D group. The D group presented a pattern of behavioural changes and early symptoms of the approaching delirium. Six hours immediately before the onset of delirium, the behavioural changes were more numerous and evident. Conclusions and relevance to clinical practice. It is necessary to pay attention to each behavioural change in the patients and to be aware of the prodromal phase of delirium in order to prevent its onset and to maintain the patient's well-being.