Improving Delirium Recognition in Older Adults: A Closed-Loop Audit of 4AT and PINCH-ME Implementation

Abstract Background Delirium is a common, serious, and often under-recognised condition affecting up to 31% of hospitalised older adults. It is associated with increased mortality, prolonged length of stay, and higher care needs post-discharge. Despite national guidelines recommending routine cognitive screening and non-pharmacological management, adherence remains variable. This closed-loop audit aimed to evaluate the impact of a targeted intervention on the early recognition and management of delirium in older medical inpatients. Methods We conducted a retrospective chart review of patients aged ≥65 admitted to two general medical wards in an Irish Model 3 hospital. The audit assessed whether a 4AT cognitive screen was performed within 24 hours, if it was abnormal, whether delirium was formally diagnosed, and whether risk factors were identified and addressed using the PINCH-ME framework. Documentation of conservative (non-pharmacological) management was also reviewed. Following baseline data collection (n=47), an intervention was introduced: a bedside “Delirium Tool” incorporating the 4AT and PINCH-ME prompts, accompanied by regular education sessions. A re-audit was conducted post-intervention (n=52). Results Following the intervention, 4AT screening within 24 hours improved from 34% to 44%. The proportion of patients formally diagnosed with delirium rose from 8.5% to 25%, aligning with expected prevalence in older inpatients. Identification of delirium risk factors increased from 8.5% to 21%, while documentation of risk factor management and non-pharmacological strategies both improved from 8.5% to 17%. Conclusion This closed-loop audit demonstrates that a structured bedside tool and staff education significantly improved the recognition and initial management of delirium. The observed post-intervention diagnosis rate reflects improved clinical awareness and documentation. Sustained use of structured tools may further enhance care quality for older adults at risk of delirium.