Improving therapy-led delirium screening to reduce hospital-associated deconditioning in older adults

Introduction

A pilot audit of older adults admitted to hospital and receiving a comprehensive geriatric assessment found that 73% of patients who received a therapy assessment had experienced functional decline requiring increased support. All patients in this group also presented with delirium. Despite this, delirium screening was not routinely included in therapy assessments for older adults.

This quality improvement project aimed to increase delirium assessment by therapists and reduce associated deconditioning among older adults admitted to hospital.

Method     

A single PDSA cycle was carried out across the acute medical unit and inpatient wards from November 2025 to March 2026. The periods of pre-intervention and intervention data collection each lasted three weeks.   

Primary outcome measures were length of stay and NHS England’s discharge pathway. Process measures included the amount of 4 A’s Tests (4AT) completed by occupational therapy or physiotherapy.

The main intervention was to increase completion rates of the 4AT by a physiotherapist or occupational therapist.

Results

The number of patients receiving at least one 4AT by a therapist increased by 93%.

Length of stay reduced from 16 days to 12.5 days following the intervention. Average NHS England discharge pathways reduced from 1.4 to 0.9.

The project indicated that increased delirium screening and therapy interventions were associated with shorter lengths of hospital stay and reduced dependence at discharge. These outcomes are clinically important because prolonged admission can contribute to further deconditioning, adverse outcomes and loss of independence. 

Conclusion

The findings were shared with the therapy team, with plans to embed regular delirium assessment using the 4AT throughout patients’ hospital stays. 

Further iterative cycles are recommended to test sustainability and explore therapy-led delirium recognition on patient outcomes. Future projects should consider increasing therapy-led reorientation for older adults with delirium.