Documentation: Delirium in the Hospitalized Older Adult

Background: Delirium is a common, life threatening and preventable geriatric syndrome. Because this condition is frequently addressed by administering dangerous antipsychotic drugs, it is imperative that accurate systematic assessments are charted to determine the actual need for these medications. The purpose of the study was to describe medical record documentation of a systematic assessment of delirium in older adults who had been administered an antipsychotic medication. Methods: A descriptive correlational retrospective design was used for this medical record data based study. The setting was a 107 bed acute care community hospital located in southern California. Inclusion criteria were medical records of patients who were 65 years or older, admitted to a medical/surgical/telemetry unit and had received lorazepam or haloperidol. Descriptive and inferential statistics were conducted using SPSS version 18. Results: For the total participant cases (N=70), age 65 to 97 years, and 60% female, there was no documentation of a systematic delirium assessment. Therefore, associations between a documented systematic assessment and other select variables could not be determined. However, antipsychotic medications were prescribed more often to females than males (p=.003). Conclusions: This study examined the documentation of a systematic assessment for delirium in hospitalized older adult patients who had been medicated with select antipsychotic medications. Documentation of a systematic assessment of delirium is important so causative factors can be remedied and appropriate interventions put into place to not only keep the patient safe, but hopefully improve the outcomes of hospitalized older adults