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Prodrome of delirium among long-term care residents: what clinical changes can be observed in the two weeks preceding a full-blown episode of delirium?

  • Philippe Voyer (a1) (a2), Jane McCusker (a3) (a4), Martin G. Cole (a5) (a6), Johanne Monette (a7) (a8), Nathalie Champoux (a9), Antonio Ciampi (a3) (a4), Eric Belzile (a3) and Sylvie Richard (a2)...


Background: Delirium among long-term care (LTC) residents is frequent and is associated with increased morbidity and mortality. Identification of clinical changes during the prodromal phase of delirium could lead to prevention of a full-blown episode and perhaps limit the deleterious consequences of this syndrome. The aim of the present study was to identify clinical changes observable in the 2-week period prior to the onset of full-blown delirium.

Methods: Long-term care (LTC) residents aged 65 years and over, with or without dementia were eligible for this nested case-control study. Delirium was assessed weekly over a 6-month period using the Confusion Assessment Method. Cases with incident delirium were matched by time since enrolment to one or more controls without delirium.

Results: When compared to the controls, LTC residents who developed delirium (cases = 85) were more likely to have new-onset perceptual disturbances (OR = 4.75; 95% CI 1.65–13.66) and disorganized thinking (OR = 3.09; 95% CI 1.33–7.19) and a worsening of the Mini-Mental State Examination (MMSE) item measuring registration (OR = 2.59; 95% CI 1.24–5.41) during the preceding 2 weeks. However, the frequency of these changes was low. Residents with at least 3 clinical changes were more likely to develop delirium than those without any clinical change (OR = 2.52; 95% CI 1.08–5.87).

Conclusions: This study provides evidence of clinical changes during the prodromal phase of delirium among LTC residents. More studies are needed to further explore the role and relevance of these clinical changes as warning signs of imminent delirium.


Corresponding author

Correspondence should be addressed to: Dr. Philippe Voyer, RN, PhD, Faculty of Nursing Sciences, Laval University, Pavillon Ferdinand-Vandry, Room 3445, 1050, rue de la Médecine, Quebec, QC, Canada, G1V 0A6. Phone: +1 418 656 2131; ext: 8799; Fax: +1 418 656 7747. Email:


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American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Washington, DC: American Psychiatric Association.
Boller, F., Verny, M., Hugonot-Diener, L. and Saxton, J. (2002). Clinical features and assessment of severe dementia. A review. European Journal of Neurology, 9 (2), 125136.
Bravo, G., Dubois, M. F., Hebert, R., De Wals, P. and Messier, L. (2002). A prospective evaluation of the Charlson Comorbidity Index for use in long-term care patients. Journal of the American Geriatrics Society, 50 (4), 740745.
Breslow, N. and Day, N. (1980). Statistical Methods in Cancer Research. Volume 1-The analysis of Case-control studies. Lyon: IARC Scientific Publication.
Buntinx, F., Niclaes, L., Suetens, C., Jans, B., Mertens, R. and Van den Akker, M. (2002). Evaluation of Charlson's comorbidity index in elderly living in nursing homes. Journal of Clinical Epidemiology, 55 (11), 11441147.
Charlson, M. E., Pompei, P., Ales, K. L. and MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of Chronic Diseases, 40 (5), 373383.
Cole, M. G. and Dastoor, D. P. (1987). A new hierarchic approach to the measurement of dementia. Accurate results within 15 to 30 minutes. Psychosomatics, 28 (6), 298301, 304.
Cole, M. G., McCusker, J., Dendukuri, N. and Han, L. (2002). Symptoms of delirium among elderly medical inpatients with or without dementia. The Journal of Neuropsychiatry and Clinical Neurosciences, 14 (2), 167175.
Culp, K. et al. (1997). Screening for acute confusion in elderly long-term care residents. The Journal of Neuroscience Nursing, 29 (2), 8688, 95100.
de Jonghe, J. F. et al. (2007). Early symptoms in the prodromal phase of delirium: a prospective cohort study in elderly patients undergoing hip surgery. American Journal of Geriatric Psychiatry, 15 (2), 112121.
Duppils, G. S. and Wikblad, K. (2004). Delirium: behavioural changes before and during the prodromal phase. Journal of Clinical Nursing, 13 (5), 609616.
Fick, D. M., Agostini, J. V. and Inouye, S. K. (2002). Delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society, 50 (10), 17231732.
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). “Mini-Mental State.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12 (3), 189198.
Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P. and Horwitz, R. I. (1990). Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113 (12), 941948.
Inouye, S. K. et al. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. The New England Journal of Medicine, 340 (9), 669676.
Kafonek, S., Ettinger, W. H., Roca, R., Kittner, S., Taylor, N. and German, P. S. (1989). Instruments for screening for depression and dementia in a long-term care facility. Journal of the American Geriatrics Society, 37 (1), 2934.
Levkoff, S. E. et al. (1992). Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients. Archives of Internal Medicine, 152 (2), 334340.
Levkoff, S. E. et al. (1994). Progression and resolution of delirium in elderly patients hospitalized for acute care. The American Journal of Geriatric Psychiatry, 2 (3), 230238.
Lubin, J. H. and Gail, M. H. (1984). Biased selection of controls for case-control analyses of cohort studies. Biometrics, 40 (1), 6375.
Mahoney, F. I. and Barthel, D. W. (1965). Functional Evaluation: the Barthel Index. Maryland State Medical Journal, 14, 6165.
Marcantonio, E. R., Flacker, J. M., Wright, R. J. and Resnick, N. M. (2001). Reducing delirium after hip fracture: a randomized trial. Journal of the American Geriatrics Society, 49 (5), 516522.
Matsushima, E., Nakajima, K., Moriya, H., Matsuura, M., Motomiya, T. and Kojima, T. (1997). A psychophysiological study of the development of delirium in coronary care units. Biological Psychiatry, 41 (12), 12111217.
McCusker, J. et al. (2011). Prevalence and incidence of delirium in long-term care. International Journal of Geriatric Psychiatry, 26 (11), 11521161.
Richardson, D. B. (2004). An incidence density sampling program for nested case-control analyses. Occupational and Environmental Medicine, 61 (12), e59.
Ronnberg, L. and Ericsson, K. (1994). Reliability and validity of the Hierarchic Dementia Scale. International Psychogeriatrics/IPA, 6 (1), 8794.
Shah, S., Vanclay, F. and Cooper, B. (1989). Improving the sensitivity of the Barthel Index for stroke rehabilitation. Journal of Clinical Epidemiology, 42 (8), 703709.
Tombaugh, T. N. and McIntyre, N. J. (1992). The Mini-Mental State Examination: a comprehensive review. Journal of the American Geriatrics Society, 40 (9), 922935.
Voyer, P., Richard, S., Doucet, L. and Carmichael, P. H. (2009). Detecting delirium and subsyndromal delirium using different diagnostic criteria among demented long-term care residents. Journal of the American Medical Directors Association, 10 (3), 181188.
Wei, L. A., Fearing, M. A., Sternberg, E. J. and Inouye, S. K. (2008). The Confusion Assessment Method: a systematic review of current usage. Journal of the American Geriatrics Society, 56 (5), 823830.
Zou, Y., Cole, M. G., Primeau, F. J., McCusker, J., Bellavance, F. and Laplante, J. (1998). Detection and diagnosis of delirium in the elderly: psychiatrist diagnosis, confusion assessment method, or consensus diagnosis? International Psychogeriatrics/IPA, 10 (3), 303308.


Prodrome of delirium among long-term care residents: what clinical changes can be observed in the two weeks preceding a full-blown episode of delirium?

  • Philippe Voyer (a1) (a2), Jane McCusker (a3) (a4), Martin G. Cole (a5) (a6), Johanne Monette (a7) (a8), Nathalie Champoux (a9), Antonio Ciampi (a3) (a4), Eric Belzile (a3) and Sylvie Richard (a2)...


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