Evaluation of a multidimensional occupational therapy environmental checklist for people experiencing delirium during hospital admission

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Environmental modifications in hospital wards are underexplored despite their potential to mitigate delirium’s effects. This study evaluated a multidimensional occupational therapy environmental checklist’s impact on functional and service outcomes for hospitalised delirium patients compared to standard care. Methods A quasi-experimental design was employed, collecting pre- and post-intervention data from 100 electronic medical records (50 control, 50 intervention) on the Geriatric Evaluation and Management ward in Melbourne, Australia. The Checklist, implemented by occupational therapists and allied health assistants, targeted orientation, object accessibility, daily routines, and safety. Outcomes included length of stay, adverse events (e.g., falls, pressure injuries), and Functional Independence Measure (FIM) scores. Descriptive statistics, t-tests, and chi-square tests were conducted using SPSS Statistics 28 (p<0.05). Results The intervention group showed a 27.3% reduction in total adverse events (control: n=37; intervention: n=27) and significantly higher FIM scores at discharge (motor: t=-2.38, p=0.02; cognitive: t=-2.62, p=0.01; total: t=-3.24, p=0.00). However, length of stay (control: M=28.2 days; intervention: M=29.36 days; t=-0.20, p=0.84) and adverse event rates (X2=1.48, p=0.22) did not differ significantly. The intervention group had a higher falls admission rate (36.0% vs. 2.0%; X2=20.38, p=0.00). Conclusion The Checklist enhances functional recovery in older adults with delirium, reducing adverse events. Larger, multi-site studies are needed to confirm efficacy and generalizability, supporting occupational therapy’s role in delirium management. Geriatrics & Gerontology Hospital Medicine Delirium occupational therapy environmental modification older adults functional outcomes hospital Figures Figure 1 Background Delirium is an acute medical emergency characterised by disturbed consciousness, cognition, attention, and perception, with rapid onset and fluctuating presentation. 1 It is linked to increased institutionalisation, morbidity, mortality, and substantial healthcare costs. 2 Kinchin et al. 3 estimate inpatient delirium costs the Australian healthcare system $806–$24,509 per patient. Individuals with delirium face elevated risks of pressure injuries, dementia, falls, and extended hospital stays. 4 Effective delirium management requires a coordinated response from healthcare professionals, including nurses, doctors, and allied health staff (ACSQHC, 2021). Evidence supports multicomponent interventions targeting risk factors such as immobility, disorientation, and sensory deficits, with strategies like early mobilisation, re-orientation, and reduced psychoactive drug use proving effective. 5 However, interventions explicitly addressing hospital ward environments are less common, despite their potential to mitigate delirium’s impact. Mudge et al. 4 implemented a multidisciplinary approach with occupational therapists and physiotherapists, introducing delirium bays, orientation boards, and appropriate lighting, resulting in shorter stays and reduced unresolved delirium. Similarly, Martinez et al. 6 engaged families in environmental strategies—clocks, familiar objects, and increased visitor time—lowering delirium incidence from 13.3% to 5.6%. Chong et al. 7-9 demonstrated the benefits of bright light therapy specifically, improving sleep and function in cohort studies. Occupational therapy has professional expertise in environmental modification, and the role of occupational therapists has been highlighted in recent studies. Sheard et al. 10 reported 25% reduction in delirium incidence with personalised orientation boards, while Harper et al. 11 found fewer readmissions after the implementation an occupational therapy led delirium pathway. However, Alvarez et al. 12 found individual occupational therapy sessions had little impact following surgery. These studies underscore the promise of environmental modifications in hospital environments, yet their specific contributions to multidisciplinary care remain unclear. Rigorous evaluation is lacking, with few studies including comparison groups to robustly assess the efficacy of these interventions. This study evaluated a multidimensional occupational therapy environmental checklist’s impact on functional and service outcomes for hospitalised delirium patients compared to standard care. The research question was how do length of stay, adverse events, and functional outcomes differ between intervention and standard care groups? Methods This study employed a quasi-experimental design, collecting pre and post intervention data from patients receiving and not receiving the environmental checklist intervention. Ethics approval was obtained via the health service’s negligible risk (QA2022.30_85975) and low risk (HREC/22/WH/87320) pathways and ratified by the partner university. Study Setting The study was conducted on the Geriatric Evaluation and Management (GEM) ward of a metropolitan hospital in Melbourne, Australia. The research team comprised four clinician researchers with 5–25 years of experience working with older people with delirium and a final-year occupational therapy student completing her honours degree. Two of the clinician researchers (Neale, Hitch) have led previous research about the role of occupational therapy in delirium management. Intervention The Checklist, designed by the occupational therapy team based on prior research and clinical experience, aims to create a delirium-friendly environment. Implemented by occupational therapists and Allied Health Assistants (AHAs) with multidisciplinary team support, it included interventions across multiple domains (Table 1). Training was provided to the multidisciplinary team prior to implementation and revisited regularly, given the crucial role of nursing colleagues in maintaining changes to the ward environment. Following referral to occupational therapy, AHAs used the Checklist to observe patients’ rooms, identifying whether each intervention was in place, required action, or was not present. They also made changes to the patients’ room to reinstate interventions when they had been changed or removed. Place Table 1 here Participants and Recruitment Data were collected in two phases via electronic medical record (eMR) audits to evaluate patient outcomes. Phase one (pre-implementation) audited retrospective data, and phase two (post-implementation) audited data after Checklist implementation. Consecutive purposive sampling identified eMR records for patients admitted to the GEM ward. Phase one inclusion criteria were a delirium diagnosis (medical or 4AT assessment) on admission to GEM prior to Environment Checklist implementation and aged over 18 years. Phase two criteria were a delirium diagnosis on admission to GEM, aged over 18 years, and exposure to the Environment Checklist. The 4AT assessment screens for delirium or cognitive impairment, with a score of 4 or above indicating possible delirium. However, the results of these tests are rarely recorded in eMR records and most delirium diagnosis is made via clinical observation by medical staff. The issue of inconsistent recording of delirium diagnoses is also often reported in international studies. 13, 14 Procedure and Data Collection Data extracted from eMRs focused on patient and service outcomes, including length of stay, pressure sore incidence, number of falls, Functional Independence Measure (FIM) scores (motor, cognitive, and total), and code grey (unarmed threats) and code black (armed threats) incidents. Delirium diagnoses were identified via medical records or 4AT assessments, with a score of 4 or above indicating possible delirium or cognitive impairment. Additional adverse event data, such as falls and behaviours of concern were sourced from the RiskMan platform, which record hospital incidents such as falls and behaviours of concern. The research team extracted data into a secure RedCAP platform for analysis and storage. Data Analysis Descriptive statistics, including frequencies, means, and standard deviations, were calculated using SPSS Statistics 28 to summarise demographic characteristics (age, gender, ethnicity, reason for admission, delirium diagnosis method, and delirium resolution at discharge) and clinical outcomes. Independent t-tests assessed differences in continuous variables (e.g., age, length of stay, FIM scores) between groups, while chi-square tests evaluated categorical variables (e.g., gender, ethnicity, adverse events, discharge destination). A significance threshold of p<0.05 was applied. Results Data were extracted from 50 eMR records prior to environmental checklist implementation and 50 eMR records following environmental checklist implementation. Sample Demographics Patient age did not different significantly between control records ( M 80.9, SD 7.5, Range 63-99) and intervention records ( M 81.6, SD 8.3, Range 56-96), t=-0.49, p=0.31. There were no significant differences between the groups for gender, ethnicity, method of delirium diagnosis and delirium resolution at discharge (Table 2). Place Table 2 here Clinical Outcomes As shown in Table 3, when comparing the number of patients experiencing any adverse event, there was no significant difference between the control and intervention groups (X2 = 1.48, p=0.22). However, there was a decrease of 27.3% in the total number of adverse events (n=27) in the Intervention Group in comparison to the Control Group (n=37). There was no significant difference between the groups for destination discharge when comparing home, residential aged care and other destinations (X2 0.80, p=0.67). There was also no significant difference for length of stay between the control group ( M 28.2 days, SD 36.2 days) and the intervention group ( M 29.36 SD 18.1), t=-0.20, p=0.84. Place Table 3 here FIM Scores As shown below in Figure 1, the Intervention Group had higher mean motor, cognitive and total FIM scores than the Control Group at both admission and discharge. Place Figure 1 here There were no significant differences in motor, cognitive or total FIM scores between the group at admission (Table 4). However, the Intervention Group achieved significantly higher motor, cognitive and total FIM scores by the time they were discharged. Place Table 4 here Discussion While there is growing and promising evidence to support targeted environmental interventions in hospital wards, their implementation and effectiveness remains an underexplored area in delirium management research. The findings of this study indicate the capacity of the multidimensional occupational therapy environmental checklist to improve functional outcomes in older adults with delirium. Implementing the checklist resulted in important improvements for both people with delirium via significantly enhanced function at discharge, and the organisation through fewer total adverse events. This study complements existing evidence about the potential of environmental modifications for supporting functional recovery for older adults with delirium. 4 , 5 The impacts of delirium on function can persist for months after hospitalisation 15 , and is less amenable to improvement than the functional impacts of other conditions such as depression. 16 Optimising function during hospital admission through targeted environmental strategies, such as the Checklist, may therefore be a protective strategy for reducing long-term functional decline for this vulnerable population. However, the lack of significant reductions in length of stay or the number of patients experiencing adverse events reflect the complex clinical presentations and contexts of delirium management. Advanced age and lower functional status are themselves risk factors for delirium 17 , and other confounding variables such as falls and co-morbidities make it challenging to isolate the specific impact of the Checklist. Future research could address these confounders by employing stratified analyses to examine the Checklist’s effects across subgroups defined by age, functional status, and fall history, or use propensity score matching to control for comorbidities in larger, multi-site studies. The Checklist’s structured approach offers a replicable, low-cost tool with potential for scaling across diverse settings to enhance delirium management for older adults. Its simplicity and affordability also support its accessibility for resource-constrained hospitals in the Australasian context, amidst rising demand from ageing populations. 18 However, participation in non-pharmacological delirium interventions can be thwarted by poor symptom control and inflexible hospital routines and practices. 19 To maximise the Checklist’s future use, hospitals will need to integrate it with symptom management protocols and be willing to adopt more flexible ward routines, both of which will support broader adoption and sustained impact. Strengths and Limitations The inclusion of a control group enhanced the rigour of this study, as the development of the Checklist by experienced occupational therapists familiar with the current evidence base. The focus on a GEM ward enabled the recruitment of a representative group of older adults in a setting with high delirium prevalence. However, the small sample size limits the ability to detect significant differences in outcomes like length of stay, and the generalisability of these findings. The single-site design also means these findings may not be relevant to other settings, such to contextual factors such as staffing levels or ward layout. Conclusions This study evaluated the impact of a multidimensional occupational therapy hospital environmental checklist (the Checklist) on functional and service outcomes for older people with delirium patients compared to standard care. It demonstrated the Checklist’s potential to enhance recovery, resulting in significantly higher functional scores at discharge and reduce total adverse events in the Intervention Group. However, length of stay and adverse event rates were not significantly different following Checklist implementation. These findings indicate the Checklist’s effectiveness in improving patient and organisational outcomes through targeted environmental modifications, particularly for older adults who are vulnerable to delirium related decline. Future research should prioritise larger, multi-site studies with extended follow-up periods to confirm the Checklist’s efficacy and generalisability across diverse healthcare settings, addressing the current single-site limitation. Incorporating retrospective comparison groups or advanced statistical methods, such as propensity score matching to control for confounders like falls, would strengthen the evidence base for this intervention. Including patient and family perspectives will be crucial to ensure the Checklist meets their needs and could potentially enhance its impact through co-designed modifications and improvements. The cultural validity of the Checklist should also be explored and developed, to better reflect the multicultural nature of Australasian communities. From a practical point of view, the Checklist will need to be integrated into routine care through staff training and implementation support and may require tailoring for specific ward contexts. Overall, this study contributes to knowledge and practice related to multidimensional interventions for delirium management by providing evidence of the value of structured environmental interventions. It also provides further evidence of the key, but often overlooked, role that occupational therapy could play in effective delirium management during hospital admissions. Declarations Ethics Statement This study was approved by the Western Health Human Research Ethics Committee under negligible risk (QA2022.30_85975) and low risk (HREC/22/WH/87320) pathways and was registered with Deakin University’s ethics committee. Conflicts of interest The authors have no competing interests to declare. Funding No specific funding was received for this study. Acknowledgments We acknowledge the traditional Wurundjeri custodians of the lands on which this project was completed, and pay our respects to their elders past, present, and emerging. We also gratefully acknowledge the support and assistance of our occupational therapy and multidisciplinary colleagues for checklist implementation. Authors' contributions Sharon Neale: Formulation or evolution of overarching research goals and aims (equal), data curation (equal), formal analysis (equal), investigation (equal), methodology (equal), project administration (contributor), resources (lead), supervision (contributor), validation (equal), writing – original draft preparation (contributor), writing – review & editing (equal). Erin McKnight: Formulation or evolution of overarching research goals and aims (equal), data curation (equal), formal analysis (equal), investigation (equal), methodology (equal), validation (equal), writing – original draft preparation (contributor), writing – review & editing (equal). Renee Dixon: Formulation or evolution of overarching research goals and aims (equal), formal analysis (contributor), methodology (equal), writing – original draft preparation (contributor), writing – review & editing (equal). Danielle Hitch: Formulation or evolution of overarching research goals and aims (equal), data curation (equal), formal analysis (equal), investigation (equal), methodology (equal), project administration (lead), resources (contributor), supervision (lead), validation (equal), visualisation (lead), writing – original draft preparation (lead), writing – review & editing (equal). Data availability statement Data is available from the authors upon reasonable request. References Strecker C and Hitch D. Perceptions of current occupational therapy practice with older adults experiencing delirium. Australasian Journal on Ageing 2020; 40. DOI: 10.1111/ajag.12882. Australian Commission on Safety and Quality in Health Care (ACSQHC). Delirium clinical care standard. Sydney: ACSQHC, 2021. Kinchin I, Mitchell E, Agar M and Trépel D. The economic cost of delirium: A systematic review and quality assessment. Alzheimers Dement 2021; 17: 1026-1041. 2021/01/23. DOI: 10.1002/alz.12262. Mudge AM, Maussen C, Duncan J and Denaro CP. Improving quality of delirium care in a general medical service with established interdisciplinary care: a controlled trial. Internal Medicine Journal 2012; 43: 270-277. DOI: https://doi.org/10.1111/j.1445-5994.2012.02840.x. Salvi F, Young J, Lucarelli M, et al. Non-pharmacological approaches in the prevention of delirium. European Geriatric Mdicine 2020; 11: 71-81. 20200102. DOI: 10.1007/s41999-019-00260-7. Martinez FT, Tobar C, Beddings CI, et al. Preventing delirium in an acute hospital using a non-pharmacological intervention. Age Ageing 2012; 41: 629-634. 2012/05/17. DOI: 10.1093/ageing/afs060. Chong MS, Chan M, Tay L and Ding YY. Outcomes of an innovative model of acute delirium care: the Geriatric Monitoring Unit (GMU). Clin Interv Aging 2014; 9: 603-612. 2014/04/22. DOI: 10.2147/cia.S60259. Chong MS, Chan MPC, Kang J, et al. A New Model of Delirium Care in the Acute Geriatric Setting: Geriatric Monitoring Unit. BMC Geriatrics 2011; 11: 41. DOI: 10.1186/1471-2318-11-41. Chong MS, Tan KT, Tay L, et al. Bright light therapy as part of a multicomponent management program improves sleep and functional outcomes in delirious older hospitalized adults. Clinical Interventions in Aging 2013; 565: https://doi.org/10.2147/cia.s44926. Sheard KL, Lape JE and Weissberg K. Occupational Therapy-Led Delirium Management in Long-Term Acute Care: a pilot. Physical and Occupational Therapy in Geriatrics 2022; 1. DOI: https://doi.org/10.1080/02703181.2022.2043983. Harper KJ, McAuliffe K, Williamson M, et al. An occupational therapy delirium pathway reduces hospital re-presentations in older adults with delirium: A before and after observational study. British Journal of Occupational Therapy 2023; 0: 03080226231197010. DOI: 10.1177/03080226231197010. Alvarez EA, Rojas VA, Caipo LI, et al. Non-pharmacological prevention of postoperative delirium by occupational therapy teams: A randomized clinical trial. Front Med (Lausanne) 2023; 10: 1099594. 2023/02/24. DOI: 10.3389/fmed.2023.1099594. Titlestad I, Haugarvoll K, Solvang S-EH, et al. Delirium is frequently underdiagnosed among older hospitalised patients despite available information in hospital medical records. Age and Ageing 2024; 53: afae006. DOI: 10.1093/ageing/afae006. Chuen VL, Chan ACH, Ma J, et al. The frequency and quality of delirium documentation in discharge summaries. BMC Geriatrics 2021; 21: 307. DOI: 10.1186/s12877-021-02245-3. Kaushik R, McAvay GJ, Murphy TE, et al. In-Hospital Delirium and Disability and Cognitive Impairment After COVID-19 Hospitalization. JAMA Network Open 2024; 7: e2419640-e2419640. DOI: 10.1001/jamanetworkopen.2024.19640. Weng C-F, Lin K-P, Lu F-P, et al. Effects of depression, dementia and delirium on activities of daily living in elderly patients after discharge. BMC Geriatrics 2019; 19: 261. DOI: 10.1186/s12877-019-1294-9. Gao Y, Gao R, Yang R and Gan X. Prevalence, risk factors, and outcomes of subsyndromal delirium in older adults in hospital or long-term care settings: A systematic review and meta-analysis. Geriatric Nursing 2022; 45: 9-17. DOI: https://doi.org/10.1016/j.gerinurse.2022.02.021. Reade MC. Delirium: one size does not fit all. Internal Medicine Journal 2019; 49: 1469-1471. DOI: https://doi.org/10.1111/imj.14656. Lee-Steere K, Liddle J, Mudge A, et al. "You've got to keep moving, keep going": Understanding older patients' experiences and perceptions of delirium and nonpharmacological delirium prevention strategies in the acute hospital setting. Journal of Clinical Nursing 2020; 29: 2363-2377. 20200413. DOI: 10.1111/jocn.15248. Tables Table 1: Summary of Checklist Interventions Domain Interventions Orientation Clock with correct time, day, date, month, year; updated bedside whiteboard; window blinds up/down for natural light; artificial light on at night or if low light; verbal orientation by clinicians. Objects Glasses, hearing aids, mobility aids, phone, call bell, water jug, and cup within reach; patient’s own clothes, photos, blankets, and personal items available. Daily Routine Personal timetable; family/friends encouraged to visit; engagement pack (e.g., crosswords, word searches, colouring) if able to participate. Other Clutter-free room; delirium-friendly environment sign on door; Sunflower tool (patient facts poster for conversation starters). Table 2: Demographic Characteristics Control Group n(%) Intervention Group n(%) X 2, p Gender Male 20 (40.0%) 28 (56.0%) 2.56, 0.11 Female 30 (60.0%) 22 (44.0%) Ethnicity Australian born & English speaking 13 (26.0%) 17 (34.0%) 1.64, 0.44 Overseas born & English speaking 14 (28.0%) 9 (18.0%) Overseas born & non-English speaking 23 (46.0%) 24 (48.0%) Reason for admission * Delirium 15 (30.0%) 10 (20.0%) 20.38, 0.00** Functional Goal Achievement and Discharge Planning (21) 21 (42.0%) 11 (22.0%) Medical Reasons 31 (62.0%) 17 (34.0%) Fractures or other musculoskeletal issues 7 (14.0%) 2 (4.0%) Neurological issues 5 (10.0%) 9 (18.0%) Cardiovascular issues 2 (4.0%) 2 (4.0%) Carer-related concerns 3 (6.0%) 0 (0.0%) Delirium Diagnosis 4AT Score prior to admission 4 (8.0%) 2 (4.0%) 1.81, 0.40 4AT during admission 5 (10.0%) 9 (18.0%) Medically diagnosed 41 (82.0%) 40 (80.0%) Yes 9 (18.0%) 20 (40.0%) No 26 (52.0%) 21 (42.0%) Delirium resolved at discharge Deceased 4 (8.0%) 2 (4.0%) 6.26, 0.10 Not documented 11 (22.0%) 7 (14.0%) Note: * More than one reason for admission was specified for most patients Table 3: Summary of Clinical Outcomes Control Group Intervention Group n of patients (%) n of incidents (%) n of patients (%) n of incidents (%) Adverse Events Pressure Injuries 7 (14.0%) 7 (14.0%) 2 (4.0%) 2 (4.0%) Inpatient Falls 13 (26.0%) 21 (42.0%) 12 (24.0%) 15 (30.0%) Planned Code Grey 3 (6.0%) 7 (14.0%) 1 (2%) 3 (6.0%) Unplanned Code Grey 2 (4.0%) 2 (4.0%) 3 (6.0%) 3 (6.0%) Code Black 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) No codes called 26 (52.0%) 32 (64.0%) Other adverse events 12 (24.0%) 16 (32.0%) 9 (18.0%) 13 (26.0%) Discharge destination Home 24 (48.0%) 27 (54%) Other hospital ward 5 (10.0%) 4 (8.0%) Residential aged care 16 (32.0%) 17 (34.0) Deceased 4 (8.0%) 2 (4.0%) Note: Code Black = Armed aggressive behaviour, Code Grey = Unarmed aggressive behaviour. Table 4: Summary of FIM Scores Control Group Mean (SD) Intervention Group Mean (SD) t score, p Admission Motor 30.62 (15.41) 34.24 (21.78) -0.96, 0.34 Cognitive 14.56 (6.93) 16.96 (8.49) -1.55, 0.12 Total 45.28 (20.37) 51.61 (28.07) -1.62, 0.11 Discharge Motor 32.20 (18.57) 41.88 (21.83) -2.38, 0.02* Cognitive 14.60 (8.33) 19.08 (8.74) -2.62, 0.01* Total 45.92 (25.99) 60.55 (28.63) -3.24, 0.00* Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7050389","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":480933600,"identity":"9e49bca5-09d2-4a88-98a7-8645ca11e889","order_by":0,"name":"Sharon Neale","email":"","orcid":"","institution":"Western Health","correspondingAuthor":false,"prefix":"","firstName":"Sharon","middleName":"","lastName":"Neale","suffix":""},{"id":480933601,"identity":"89c182ac-e691-4aa9-bac1-c379a2aea656","order_by":1,"name":"Erin McKnight","email":"","orcid":"","institution":"Deakin University","correspondingAuthor":false,"prefix":"","firstName":"Erin","middleName":"","lastName":"McKnight","suffix":""},{"id":480933602,"identity":"8958c55f-56d8-40c9-b05f-4ce8b3eaa8d6","order_by":2,"name":"Renee Dixon","email":"","orcid":"","institution":"Western Health","correspondingAuthor":false,"prefix":"","firstName":"Renee","middleName":"","lastName":"Dixon","suffix":""},{"id":480933603,"identity":"f6cad65c-5080-475f-956a-355d116e2d74","order_by":3,"name":"Daniele Hitch","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYDCCA0DE2CDBwCDBfABIJvCABCWI0SLBIMGWQLwWBsYGoCIJHgOQFgaCWviOnz14gHGHRR3/7J6PNz7UpMmYMzAfvM3DYJfYgEOL5Jm8hAOMZyQkJO6c3Ww541gOj2UDW7I1D0MyTi0GB3IMDjC2SUgYSORuk+Zhq+AxOMBjJs3DwIxby/k3MC05z6T//ANp4f8G1FKPW8sNuC05bNKMbTkgW9iAWg7j9ssNoC2JbRKSM26kGVv29qXxGBxmM7acY3DcGJcWvvM5xh8+ttXx889Ifnjjx7dke4PjzQ9vvKmolsWlBQwSUHjMYAfjUz8KRsEoGAWjgBAAAP4KVfZikm5tAAAAAElFTkSuQmCC","orcid":"","institution":"Deakin University","correspondingAuthor":true,"prefix":"","firstName":"Daniele","middleName":"","lastName":"Hitch","suffix":""}],"badges":[],"createdAt":"2025-07-05 04:26:17","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7050389/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7050389/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86759088,"identity":"748415ea-2941-4ef8-99b1-f8cc87239aad","added_by":"auto","created_at":"2025-07-15 09:55:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":139628,"visible":true,"origin":"","legend":"\u003cp\u003eFIM scores for Control and Intervention Group at Admission and Discharge\u003c/p\u003e","description":"","filename":"AJOAFig1.png","url":"https://assets-eu.researchsquare.com/files/rs-7050389/v1/ba25600489505e8d3d7228bd.png"},{"id":86759090,"identity":"6059a036-138c-405b-9cc6-d5dd379336d4","added_by":"auto","created_at":"2025-07-15 09:55:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":614381,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7050389/v1/b3a8c0e4-8f52-4fdf-9dfc-9ca6457d6a43.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eEvaluation of a multidimensional occupational therapy environmental checklist for people experiencing delirium during hospital admission\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eDelirium is an acute medical emergency characterised by disturbed consciousness, cognition, attention, and perception, with rapid onset and fluctuating presentation.\u003csup\u003e1\u003c/sup\u003e It is linked to increased institutionalisation, morbidity, mortality, and substantial healthcare costs.\u003csup\u003e2\u003c/sup\u003e Kinchin et al.\u003csup\u003e3\u003c/sup\u003e estimate inpatient delirium costs the Australian healthcare system $806\u0026ndash;$24,509 per patient. Individuals with delirium face elevated risks of pressure injuries, dementia, falls, and extended hospital stays.\u003csup\u003e4\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEffective delirium management requires a coordinated response from healthcare professionals, including nurses, doctors, and allied health staff (ACSQHC, 2021). Evidence supports multicomponent interventions targeting risk factors such as immobility, disorientation, and sensory deficits, with strategies like early mobilisation, re-orientation, and reduced psychoactive drug use proving effective. \u003csup\u003e5\u003c/sup\u003e However, interventions explicitly addressing hospital ward environments are less common, despite their potential to mitigate delirium\u0026rsquo;s impact. Mudge et al. \u003csup\u003e4\u003c/sup\u003e implemented a multidisciplinary approach with occupational therapists and physiotherapists, introducing delirium bays, orientation boards, and appropriate lighting, resulting in shorter stays and reduced unresolved delirium. Similarly, Martinez et al. \u003csup\u003e6\u003c/sup\u003e engaged families in environmental strategies\u0026mdash;clocks, familiar objects, and increased visitor time\u0026mdash;lowering delirium incidence from 13.3% to 5.6%. Chong et al. \u003csup\u003e7-9\u003c/sup\u003e demonstrated the benefits of bright light therapy specifically, improving sleep and function in cohort studies. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOccupational therapy has professional expertise in environmental modification, and the role of occupational therapists has been highlighted in recent studies. \u0026nbsp;Sheard et al. \u003csup\u003e10\u003c/sup\u003e reported 25% reduction in delirium incidence with personalised orientation boards, while Harper et al. \u003csup\u003e11\u003c/sup\u003e found fewer readmissions after the implementation an occupational therapy led delirium pathway. However, Alvarez et al. \u003csup\u003e12\u003c/sup\u003e found individual occupational therapy sessions had little impact following surgery. These studies underscore the promise of environmental modifications in hospital environments, yet their specific contributions to multidisciplinary care remain unclear. Rigorous evaluation is lacking, with few studies including comparison groups to robustly assess the efficacy of these interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study evaluated a multidimensional occupational therapy environmental checklist\u0026rsquo;s impact on functional and service outcomes for hospitalised delirium patients compared to standard care. The research question was how do length of stay, adverse events, and functional outcomes differ between intervention and standard care groups?\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employed a quasi-experimental design, collecting pre and post intervention data from patients receiving and not receiving the environmental checklist intervention. Ethics approval was obtained via the health service\u0026rsquo;s negligible risk (QA2022.30_85975) and low risk (HREC/22/WH/87320) pathways and ratified by the partner university.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy Setting\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted on the Geriatric Evaluation and Management (GEM) ward of a metropolitan hospital in Melbourne, Australia. The research team comprised four clinician researchers with 5\u0026ndash;25 years of experience working with older people with delirium and a final-year occupational therapy student completing her honours degree. Two of the clinician researchers (Neale, Hitch) have led previous research about the role of occupational therapy in delirium management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Checklist, designed by the occupational therapy team based on prior research and clinical experience, aims to create a delirium-friendly environment. Implemented by occupational therapists and Allied Health Assistants (AHAs) with multidisciplinary team support, it included interventions across multiple domains (Table 1). Training was provided to the multidisciplinary team prior to implementation and revisited regularly, given the crucial role of nursing colleagues in maintaining changes to the ward environment. Following referral to occupational therapy, AHAs used the Checklist to observe patients\u0026rsquo; rooms, identifying whether each intervention was in place, required action, or was not present. They also made changes to the patients\u0026rsquo; room to reinstate interventions when they had been changed or removed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePlace Table 1 here\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants and Recruitment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were collected in two phases via electronic medical record (eMR) audits to evaluate patient outcomes. Phase one (pre-implementation) audited retrospective data, and phase two (post-implementation) audited data after Checklist implementation. Consecutive purposive sampling identified eMR records for patients admitted to the GEM ward.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePhase one inclusion criteria were a delirium diagnosis (medical or 4AT assessment) on admission to GEM prior to Environment Checklist implementation and aged over 18 years. Phase two criteria were a delirium diagnosis on admission to GEM, aged over 18 years, and exposure to the Environment Checklist. The 4AT assessment screens for delirium or cognitive impairment, with a score of 4 or above indicating possible delirium. However, the results of these tests are rarely recorded in eMR records and most delirium diagnosis is made via clinical observation by medical staff. The issue of inconsistent recording of delirium diagnoses is also often reported in international studies.\u003csup\u003e13, 14\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eProcedure and Data Collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData extracted from eMRs focused on patient and service outcomes, including length of stay, pressure sore incidence, number of falls, Functional Independence Measure (FIM) scores (motor, cognitive, and total), and code grey (unarmed threats) and code black (armed threats) incidents. Delirium diagnoses were identified via medical records or 4AT assessments, with a score of 4 or above indicating possible delirium or cognitive impairment. Additional adverse event data, such as falls and behaviours of concern were sourced from the RiskMan platform, which record hospital incidents such as falls and behaviours of concern. The research team extracted data into a secure RedCAP platform for analysis and storage.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics, including frequencies, means, and standard deviations, were calculated using SPSS Statistics 28 to summarise demographic characteristics (age, gender, ethnicity, reason for admission, delirium diagnosis method, and delirium resolution at discharge) and clinical outcomes. Independent t-tests assessed differences in continuous variables (e.g., age, length of stay, FIM scores) between groups, while chi-square tests evaluated categorical variables (e.g., gender, ethnicity, adverse events, discharge destination). A significance threshold of p\u0026lt;0.05 was applied.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eData were extracted from 50 eMR records prior to environmental checklist implementation and 50 eMR records following environmental checklist implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSample Demographics\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatient age did not different significantly between control records (\u003cem\u003eM\u003c/em\u003e 80.9, \u003cem\u003eSD\u003c/em\u003e 7.5, \u003cem\u003eRange\u003c/em\u003e 63-99) and intervention records (\u003cem\u003eM\u003c/em\u003e 81.6, \u003cem\u003eSD\u003c/em\u003e 8.3, \u003cem\u003eRange\u003c/em\u003e 56-96), t=-0.49, p=0.31. There were no significant differences between the groups for gender, ethnicity, method of delirium diagnosis and delirium resolution at discharge (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePlace Table 2 here\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical Outcomes\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 3, when comparing the number of patients experiencing any adverse event, there was no significant difference between the control and intervention groups (X2 = 1.48, p=0.22). However, there was a decrease of 27.3% in the total number of adverse events (n=27) in the Intervention Group in comparison to the Control Group (n=37). There was no significant difference between the groups for destination discharge when comparing home, residential aged care and other destinations (X2 0.80, p=0.67). There was also no significant difference for length of stay between the control group (\u003cem\u003eM\u003c/em\u003e 28.2 days, \u003cem\u003eSD\u003c/em\u003e 36.2 days) and the intervention group (\u003cem\u003eM\u003c/em\u003e 29.36 \u003cem\u003eSD\u003c/em\u003e 18.1), t=-0.20, p=0.84.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePlace Table 3 here\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFIM Scores\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs shown below in Figure 1, the Intervention Group had higher mean motor, cognitive and total FIM scores than the Control Group at both admission and discharge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePlace Figure 1 here\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere were no significant differences in motor, cognitive or total FIM scores between the group at admission (Table 4). However, the Intervention Group achieved significantly higher motor, cognitive and total FIM scores by the time they were discharged.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePlace Table 4 here\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhile there is growing and promising evidence to support targeted environmental interventions in hospital wards, their implementation and effectiveness remains an underexplored area in delirium management research. The findings of this study indicate the capacity of the multidimensional occupational therapy environmental checklist to improve functional outcomes in older adults with delirium. Implementing the checklist resulted in important improvements for both people with delirium via significantly enhanced function at discharge, and the organisation through fewer total adverse events.\u003c/p\u003e\u003cp\u003eThis study complements existing evidence about the potential of environmental modifications for supporting functional recovery for older adults with delirium.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e The impacts of delirium on function can persist for months after hospitalisation\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, and is less amenable to improvement than the functional impacts of other conditions such as depression.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Optimising function during hospital admission through targeted environmental strategies, such as the Checklist, may therefore be a protective strategy for reducing long-term functional decline for this vulnerable population.\u003c/p\u003e\u003cp\u003eHowever, the lack of significant reductions in length of stay or the number of patients experiencing adverse events reflect the complex clinical presentations and contexts of delirium management. Advanced age and lower functional status are themselves risk factors for delirium\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, and other confounding variables such as falls and co-morbidities make it challenging to isolate the specific impact of the Checklist. Future research could address these confounders by employing stratified analyses to examine the Checklist\u0026rsquo;s effects across subgroups defined by age, functional status, and fall history, or use propensity score matching to control for comorbidities in larger, multi-site studies.\u003c/p\u003e\u003cp\u003eThe Checklist\u0026rsquo;s structured approach offers a replicable, low-cost tool with potential for scaling across diverse settings to enhance delirium management for older adults. Its simplicity and affordability also support its accessibility for resource-constrained hospitals in the Australasian context, amidst rising demand from ageing populations.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e However, participation in non-pharmacological delirium interventions can be thwarted by poor symptom control and inflexible hospital routines and practices.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e To maximise the Checklist\u0026rsquo;s future use, hospitals will need to integrate it with symptom management protocols and be willing to adopt more flexible ward routines, both of which will support broader adoption and sustained impact.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrengths and Limitations\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe inclusion of a control group enhanced the rigour of this study, as the development of the Checklist by experienced occupational therapists familiar with the current evidence base. The focus on a GEM ward enabled the recruitment of a representative group of older adults in a setting with high delirium prevalence. However, the small sample size limits the ability to detect significant differences in outcomes like length of stay, and the generalisability of these findings. The single-site design also means these findings may not be relevant to other settings, such to contextual factors such as staffing levels or ward layout.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study evaluated the impact of a multidimensional occupational therapy hospital environmental checklist (the Checklist) on functional and service outcomes for older people with delirium patients compared to standard care. It demonstrated the Checklist\u0026rsquo;s potential to enhance recovery, resulting in significantly higher functional scores at discharge and reduce total adverse events in the Intervention Group. However, length of stay and adverse event rates were not significantly different following Checklist implementation. These findings indicate the Checklist\u0026rsquo;s effectiveness in improving patient and organisational outcomes through targeted environmental modifications, particularly for older adults who are vulnerable to delirium related decline.\u003c/p\u003e\u003cp\u003eFuture research should prioritise larger, multi-site studies with extended follow-up periods to confirm the Checklist\u0026rsquo;s efficacy and generalisability across diverse healthcare settings, addressing the current single-site limitation. Incorporating retrospective comparison groups or advanced statistical methods, such as propensity score matching to control for confounders like falls, would strengthen the evidence base for this intervention. Including patient and family perspectives will be crucial to ensure the Checklist meets their needs and could potentially enhance its impact through co-designed modifications and improvements. The cultural validity of the Checklist should also be explored and developed, to better reflect the multicultural nature of Australasian communities. From a practical point of view, the Checklist will need to be integrated into routine care through staff training and implementation support and may require tailoring for specific ward contexts.\u003c/p\u003e\u003cp\u003eOverall, this study contributes to knowledge and practice related to multidimensional interventions for delirium management by providing evidence of the value of structured environmental interventions. It also provides further evidence of the key, but often overlooked, role that occupational therapy could play in effective delirium management during hospital admissions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Western Health Human Research Ethics Committee under negligible risk (QA2022.30_85975) and low risk (HREC/22/WH/87320) pathways and was registered with Deakin University\u0026rsquo;s ethics committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo specific funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the traditional Wurundjeri custodians of the lands on which this project was completed, and pay our respects to their elders past, present, and emerging. We also gratefully acknowledge the support and assistance of our occupational therapy and multidisciplinary colleagues for checklist implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSharon Neale: Formulation or evolution of overarching research goals and aims (equal), data curation (equal), formal analysis (equal), investigation (equal), methodology (equal), project administration (contributor), resources (lead), supervision (contributor), validation (equal), writing \u0026ndash; original draft preparation (contributor), writing \u0026ndash; review \u0026amp; editing (equal).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eErin McKnight: Formulation or evolution of overarching research goals and aims (equal), data curation (equal), formal analysis (equal), investigation (equal), methodology (equal), validation (equal), writing \u0026ndash; original draft preparation (contributor), writing \u0026ndash; review \u0026amp; editing (equal).\u003c/p\u003e\n\u003cp\u003eRenee Dixon: Formulation or evolution of overarching research goals and aims (equal), formal analysis (contributor), methodology (equal), writing \u0026ndash; original draft preparation (contributor), writing \u0026ndash; review \u0026amp; editing (equal).\u003c/p\u003e\n\u003cp\u003eDanielle Hitch: Formulation or evolution of overarching research goals and aims (equal), data curation (equal), formal analysis (equal), investigation (equal), methodology (equal), project administration (lead), resources (contributor), supervision (lead), validation (equal), visualisation (lead), writing \u0026ndash; original draft preparation (lead), writing \u0026ndash; review \u0026amp; editing (equal).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available from the authors upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStrecker C and Hitch D. Perceptions of current occupational therapy practice with older adults experiencing delirium. \u003cem\u003eAustralasian Journal on Ageing\u003c/em\u003e 2020; 40. DOI: 10.1111/ajag.12882.\u003c/li\u003e\n\u003cli\u003eAustralian Commission on Safety and Quality in Health Care (ACSQHC). Delirium clinical care standard. Sydney: ACSQHC, 2021.\u003c/li\u003e\n\u003cli\u003eKinchin I, Mitchell E, Agar M and Tr\u0026eacute;pel D. The economic cost of delirium: A systematic review and quality assessment. \u003cem\u003eAlzheimers Dement\u003c/em\u003e 2021; 17: 1026-1041. 2021/01/23. DOI: 10.1002/alz.12262.\u003c/li\u003e\n\u003cli\u003eMudge AM, Maussen C, Duncan J and Denaro CP. Improving quality of delirium care in a general medical service with established interdisciplinary care: a controlled trial. \u003cem\u003eInternal Medicine Journal\u003c/em\u003e 2012; 43: 270-277. DOI: https://doi.org/10.1111/j.1445-5994.2012.02840.x.\u003c/li\u003e\n\u003cli\u003eSalvi F, Young J, Lucarelli M, et al. Non-pharmacological approaches in the prevention of delirium. \u003cem\u003eEuropean Geriatric Mdicine\u003c/em\u003e 2020; 11: 71-81. 20200102. DOI: 10.1007/s41999-019-00260-7.\u003c/li\u003e\n\u003cli\u003eMartinez FT, Tobar C, Beddings CI, et al. Preventing delirium in an acute hospital using a non-pharmacological intervention. \u003cem\u003eAge Ageing\u003c/em\u003e 2012; 41: 629-634. 2012/05/17. DOI: 10.1093/ageing/afs060.\u003c/li\u003e\n\u003cli\u003eChong MS, Chan M, Tay L and Ding YY. Outcomes of an innovative model of acute delirium care: the Geriatric Monitoring Unit (GMU). \u003cem\u003eClin Interv Aging\u003c/em\u003e 2014; 9: 603-612. 2014/04/22. DOI: 10.2147/cia.S60259.\u003c/li\u003e\n\u003cli\u003eChong MS, Chan MPC, Kang J, et al. A New Model of Delirium Care in the Acute Geriatric Setting: Geriatric Monitoring Unit. \u003cem\u003eBMC Geriatrics\u003c/em\u003e 2011; 11: 41. DOI: 10.1186/1471-2318-11-41.\u003c/li\u003e\n\u003cli\u003eChong MS, Tan KT, Tay L, et al. Bright light therapy as part of a multicomponent management program improves sleep and functional outcomes in delirious older hospitalized adults. \u003cem\u003eClinical Interventions in Aging\u003c/em\u003e 2013; 565: https://doi.org/10.2147/cia.s44926.\u003c/li\u003e\n\u003cli\u003eSheard KL, Lape JE and Weissberg K. Occupational Therapy-Led Delirium Management in Long-Term Acute Care: a pilot. \u003cem\u003ePhysical and Occupational Therapy in Geriatrics\u003c/em\u003e 2022; 1. DOI: https://doi.org/10.1080/02703181.2022.2043983.\u003c/li\u003e\n\u003cli\u003eHarper KJ, McAuliffe K, Williamson M, et al. An occupational therapy delirium pathway reduces hospital re-presentations in older adults with delirium: A before and after observational study. \u003cem\u003eBritish Journal of Occupational Therapy\u003c/em\u003e 2023; 0: 03080226231197010. DOI: 10.1177/03080226231197010.\u003c/li\u003e\n\u003cli\u003eAlvarez EA, Rojas VA, Caipo LI, et al. Non-pharmacological prevention of postoperative delirium by occupational therapy teams: A randomized clinical trial. \u003cem\u003eFront Med (Lausanne)\u003c/em\u003e 2023; 10: 1099594. 2023/02/24. DOI: 10.3389/fmed.2023.1099594.\u003c/li\u003e\n\u003cli\u003eTitlestad I, Haugarvoll K, Solvang S-EH, et al. Delirium is frequently underdiagnosed among older hospitalised patients despite available information in hospital medical records. \u003cem\u003eAge and Ageing\u003c/em\u003e 2024; 53: afae006. DOI: 10.1093/ageing/afae006.\u003c/li\u003e\n\u003cli\u003eChuen VL, Chan ACH, Ma J, et al. The frequency and quality of delirium documentation in discharge summaries. \u003cem\u003eBMC Geriatrics\u003c/em\u003e 2021; 21: 307. DOI: 10.1186/s12877-021-02245-3.\u003c/li\u003e\n\u003cli\u003eKaushik R, McAvay GJ, Murphy TE, et al. In-Hospital Delirium and Disability and Cognitive Impairment After COVID-19 Hospitalization. \u003cem\u003eJAMA Network Open\u003c/em\u003e 2024; 7: e2419640-e2419640. DOI: 10.1001/jamanetworkopen.2024.19640.\u003c/li\u003e\n\u003cli\u003eWeng C-F, Lin K-P, Lu F-P, et al. Effects of depression, dementia and delirium on activities of daily living in elderly patients after discharge. \u003cem\u003eBMC Geriatrics\u003c/em\u003e 2019; 19: 261. DOI: 10.1186/s12877-019-1294-9.\u003c/li\u003e\n\u003cli\u003eGao Y, Gao R, Yang R and Gan X. Prevalence, risk factors, and outcomes of subsyndromal delirium in older adults in hospital or long-term care settings: A systematic review and meta-analysis. \u003cem\u003eGeriatric Nursing\u003c/em\u003e 2022; 45: 9-17. DOI: https://doi.org/10.1016/j.gerinurse.2022.02.021.\u003c/li\u003e\n\u003cli\u003eReade MC. Delirium: one size does not fit all. \u003cem\u003eInternal Medicine Journal\u003c/em\u003e 2019; 49: 1469-1471. DOI: https://doi.org/10.1111/imj.14656.\u003c/li\u003e\n\u003cli\u003eLee-Steere K, Liddle J, Mudge A, et al. \u0026quot;You\u0026apos;ve got to keep moving, keep going\u0026quot;: Understanding older patients\u0026apos; experiences and perceptions of delirium and nonpharmacological delirium prevention strategies in the acute hospital setting. \u003cem\u003eJournal of Clinical Nursing\u003c/em\u003e 2020; 29: 2363-2377. 20200413. DOI: 10.1111/jocn.15248.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Summary of Checklist Interventions\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4973%;\"\u003e\n \u003cp\u003eDomain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74.5027%;\"\u003e\n \u003cp\u003eInterventions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4973%;\"\u003e\n \u003cp\u003eOrientation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74.5027%;\"\u003e\n \u003cp\u003eClock with correct time, day, date, month, year; updated bedside whiteboard; window blinds up/down for natural light; artificial light on at night or if low light; verbal orientation by clinicians.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4973%;\"\u003e\n \u003cp\u003eObjects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74.5027%;\"\u003e\n \u003cp\u003eGlasses, hearing aids, mobility aids, phone, call bell, water jug, and cup within reach; patient\u0026rsquo;s own clothes, photos, blankets, and personal items available.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4973%;\"\u003e\n \u003cp\u003eDaily Routine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74.5027%;\"\u003e\n \u003cp\u003ePersonal timetable; family/friends encouraged to visit; engagement pack (e.g., crosswords, word searches, colouring) if able to participate.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4973%;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74.5027%;\"\u003e\n \u003cp\u003eClutter-free room; delirium-friendly environment sign on door; Sunflower tool (patient facts poster for conversation starters).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Demographic Characteristics \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eControl Group n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eIntervention Group n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eX\u003csub\u003e2,\u0026nbsp;\u003c/sub\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e20 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e28 (56.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2.56, 0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e30 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e22 (44.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eAustralian born \u0026amp; English speaking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e13 (26.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e17 (34.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.64, 0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eOverseas born \u0026amp; English speaking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e14 (28.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eOverseas born \u0026amp; non-English speaking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e23 (46.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e24 (48.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eReason for admission *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eDelirium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e15 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e10 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e20.38, 0.00**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eFunctional Goal Achievement and Discharge Planning (21)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e21 (42.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11 (22.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eMedical Reasons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e31 (62.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e17 (34.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eFractures or other musculoskeletal issues\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e7 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2 (4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eNeurological issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e5 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eCardiovascular issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e2 (4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2 (4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eCarer-related concerns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e3 (6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eDelirium Diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e4AT Score prior to admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e4 (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2 (4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.81, 0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e4AT during admission\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e5 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eMedically diagnosed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e41 (82.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e40 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e9 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e20 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e26 (52.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e21 (42.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eDelirium resolved at discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eDeceased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e4 (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2 (4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e6.26, 0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eNot documented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e11 (22.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e7 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: * More than one reason for admission was specified for most patients\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3: Summary of Clinical Outcomes\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eIntervention Group\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003en of patients (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003en of incidents (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003en of patients (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003en of incidents (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eAdverse\u003c/p\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003ePressure Injuries\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e7 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e7 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2 \u0026nbsp;(4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2 \u0026nbsp;(4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eInpatient Falls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e13 (26.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003cp\u003e(42.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e12 (24.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e(30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003ePlanned Code Grey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e3 (6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e7 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e(2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e(6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eUnplanned Code Grey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2 \u0026nbsp;(4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2 \u0026nbsp;(4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e(6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e(6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eCode Black\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eNo codes called\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e26 (52.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e32 (64.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eOther adverse events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e12 \u0026nbsp;(24.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e(32.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e9 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e13 (26.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eDischarge destination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eHome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003cp\u003e(48.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e27 (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eOther hospital ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e5 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e4 (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eResidential aged care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e16 (32.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e17 (34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eDeceased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e(8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2 (4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Code Black = Armed aggressive behaviour, Code Grey = Unarmed aggressive behaviour. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4: Summary of FIM Scores\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eIntervention Group\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003et score, p\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eAdmission\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMotor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e30.62 (15.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e34.24 (21.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-0.96, 0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eCognitive\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e14.56 (6.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e16.96 (8.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-1.55, 0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e45.28 (20.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e51.61 (28.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-1.62, 0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eDischarge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMotor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e32.20 (18.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e41.88 (21.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.38, 0.02*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eCognitive\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e14.60 (8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e19.08 (8.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.62, 0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTotal \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e45.92 (25.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e60.55 (28.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-3.24, 0.00*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Deakin University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Delirium, occupational therapy, environmental modification, older adults, functional outcomes, hospital","lastPublishedDoi":"10.21203/rs.3.rs-7050389/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7050389/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nDelirium, an acute medical emergency, significantly impacts older adults, increasing morbidity, mortality, and healthcare costs (estimated at $806–$24,509 per patient in Australia). Environmental modifications in hospital wards are underexplored despite their potential to mitigate delirium’s effects. This study evaluated a multidimensional occupational therapy environmental checklist’s impact on functional and service outcomes for hospitalised delirium patients compared to standard care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nA quasi-experimental design was employed, collecting pre- and post-intervention data from 100 electronic medical records (50 control, 50 intervention) on the Geriatric Evaluation and Management ward in Melbourne, Australia. The Checklist, implemented by occupational therapists and allied health assistants, targeted orientation, object accessibility, daily routines, and safety. Outcomes included length of stay, adverse events (e.g., falls, pressure injuries), and Functional Independence Measure (FIM) scores. Descriptive statistics, t-tests, and chi-square tests were conducted using SPSS Statistics 28 (p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nThe intervention group showed a 27.3% reduction in total adverse events (control: n=37; intervention: n=27) and significantly higher FIM scores at discharge (motor: t=-2.38, p=0.02; cognitive: t=-2.62, p=0.01; total: t=-3.24, p=0.00). However, length of stay (control: M=28.2 days; intervention: M=29.36 days; t=-0.20, p=0.84) and adverse event rates (X2=1.48, p=0.22) did not differ significantly. The intervention group had a higher falls admission rate (36.0% vs. 2.0%; X2=20.38, p=0.00).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cbr\u003e\nThe Checklist enhances functional recovery in older adults with delirium, reducing adverse events. Larger, multi-site studies are needed to confirm efficacy and generalizability, supporting occupational therapy’s role in delirium management.\u003c/p\u003e","manuscriptTitle":"Evaluation of a multidimensional occupational therapy environmental checklist for people experiencing delirium during hospital admission","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 09:39:19","doi":"10.21203/rs.3.rs-7050389/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"57d64ea8-ac1c-456d-8ed6-63ea54ea1e75","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":51552918,"name":"Geriatrics \u0026 Gerontology"},{"id":51552919,"name":"Hospital Medicine"}],"tags":[],"updatedAt":"2025-07-15T09:39:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 09:39:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7050389","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7050389","identity":"rs-7050389","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}