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This article is about the medical scale for delirium. For the Australian radio station, see ABC Far North.

The 4 'A's Test (4AT) is a bedside medical scale used to help determine if a person has positive signs for delirium.[1][2] The 4AT also includes cognitive test items, making it suitable also for use as a rapid test for cognitive impairment.[3]

The 4AT is designed to be used as a delirium detection tool in general clinical settings, inpatient hospital settings outside of the Intensive Care Unit (ICU), or in the community. The 4AT is intended to be used by healthcare practitioners without the need for special training, and it takes around two minutes to complete.[4] The test was first published online in 2011; the 4AT website provides downloads, and a guide to the test along with case examples.[4] The 4AT is also available as a standalone app on the Android and iOS platforms, and as an online calculator.

The 4AT has the most published diagnostic test accuracy data of any delirium tool, with 31 published studies involving >6000 patients.[5] It has been evaluated in multiple areas of practice including in the emergency department (ED), medical, surgical, community and palliative care settings.[6][7][8] The 4AT is used internationally in both clinical practice[9][10][11][12][13][14] and research.[15][16][17][18] It is recommended in clinical guidelines, including the UK NICE Guidelines on Delirium, and policy documents.[19][20][21][22][23][24]

Some evidence shows that the 4AT can be implemented at scale in real-world clinical practice and that it shows positive score rates at comparable levels to the expected delirium prevalence rates.[25][26]

A 2022 two-center study in real-world clinical populations (total N=82,770) found that 4AT positive scores were aligned with expected delirium rates, and also were strongly linked with important outcomes including 30-day mortality, one-year mortality, hospital length of stay, and days at home in the year following hospital admission. Notably, the 4AT was completed as part of usual care by a large number of different staff (mostly doctors and nurses) who had not received special training in use of the 4AT. This study therefore showed that the 4AT is feasible in large-scale practice and that it provides real-time delirium ascertainment with positive scores being linked to important short and longer-term outcomes.[26]

Summary

[edit]
Full 4AT scale
Parameters and scoring Points
[1] Alertness

This includes patients who may be markedly drowsy (eg. difficult to rouse

and/or obviously sleepy during assessment) or agitated/hyperactive.

Observe the patient. If asleep, attempt to wake with speech or a gentle touch

on the shoulder. Ask the patient to state their name and address to assist rating.

Normal (fully alert, but not agitated, throughout assessment)

Mild sleepiness for <10 seconds after waking, then normal

Clearly abnormal

0

0

4

[2] AMT4

Age, date of birth, place (name of the hospital or building), current year.

No mistakes

1 mistake

2 or more mistakes/untestable

0

1

2

[3] Attention

Ask the patient: "Please tell me the months of the year in backwards order,

starting at December."To assist initial understanding one prompt of "what is

the month before December?" is permitted.

Achieves 7 months or more correctly

Starts but scores <7 months / refuses to start

Untestable (cannot start because unwell, drowsy, inattentive)

0

1

2

[4] Acute change or fluctuating course

Evidence of significant change or fluctuation in alertness, cognition, other

mental function (eg. paranoia, hallucinations) arising over the last 2 weeks

and still evident in the last 24hrs

No

Yes

0

4

4AT TOTAL SCORE
SCORING KEY

4 or above: possible delirium +/- cognitive impairment

1-3: possible cognitive impairment

0: delirium or severe cognitive impairment unlikely

(Delirium still possible if [4] information incomplete)

The 4AT has 4 parameters:

  1. Alertness
  2. Abbreviated mental test-4 (AMT4)
  3. Attention (months backwards test)
  4. Acute change or fluctuating course

The score range is 0–12, with scores of 4 or more suggesting possible delirium. Scores of 1-3 suggest possible cognitive impairment.

There are several indications of a positive score of 4 or more. Parameters [1] and [4] can each individually trigger a positive score. The rationale is that both altered arousal and acute change in mental functioning are highly specific indicators of delirium.[27][28][29][30]

Parameters [2] and [3] provide embedded cognitive testing. These parameters can also yield an overall positive score for the 4AT: if [2] scores as 2 or more mistakes or if the patient is untestable, and with [3] the patient is untestable, then the combined score is 4, suggesting possible delirium. The rationale for allowing untestability to trigger an outcome of possible delirium is that many people with delirium are too drowsy or inattentive to undergo cognitive testing or interview.[31][30] These scoring options additionally allow the 4AT to be completed in patients who are unable to provide verbal responses.

Psychometric properties

[edit]

A review of data to December 2019 involving 17 studies reported a pooled sensitivity of 88% and a pooled specificity of 88% for delirium diagnosis.[6] Since then, several additional validation studies have been published.[32][33][34][35][36][37]

A large, high quality (STARD-compliant) diagnostic randomized controlled trial comparing the 4AT and the Confusion Assessment Method (CAM) found that the 4AT had higher sensitivity and similar specificity to the CAM.[38]

[edit]

The 4AT is intended to be used to assess for delirium on initial presentation with the patient, in transitions of care, in periods of high risk such as post-operatively and when delirium is suspected.[39] Using the 4AT multiple times per day for monitoring for new onset delirium for prolonged periods (weeks or more) is not recommended because of the burden of repeated cognitive testing on patients and staff.[40] However, it can be used 1-2 times per day for specified periods, e.g. peri-operatively. Additionally the 4AT is commonly used to monitor for recovery from active delirium. The 4AT is thus considered an episodic delirium test rather than a monitoring test. Use of the 4AT multiple times per day may be associated with lower compliance and overall performance because of the burden on staff and patients caused by performing several face to face interviews and cognitive testing per day.[34][41]

Shorter, largely observational tests such as the National Early Warning Score - 2 (NEWS2),[42] RADAR,[43] the Delirium Observation Scale (DOS),[44] the (Single Question in Delirium (SQiD)),[45] or the Nursing Delirium Screening Scale (Nu-DESC)[46] are more suitable for ongoing routine monitoring for new delirium after admission to hospital (or in long-term care settings).[47] A positive score in those tests generally then requires a more detailed assessment with a tool like the 4AT. This is an area of delirium practice which requires additional research.

The 4AT is one of several other delirium assessment tools in the literature.[48] Each varies in its intended use (research, severity grading, very brief screening, etc.), completion time, need for training, and psychometric characteristics.[49][50][51][52][2]

Languages

[edit]

The 4AT has to date been translated into German, French, Italian, Spanish, Portuguese, Danish, Finnish, Swedish, Turkish, Arabic, Norwegian, Thai, Cantonese, Putonghua, Russian, Korean, Japanese, and Icelandic.[39]

References

[edit]
  1. ^ Delirium Archived 2019-05-13 at the Wayback Machine, Symptom Finder online.
  2. ^ a b Wilson, Jo Ellen; Mart, Matthew F.; Cunningham, Colm; Shehabi, Yahya; Girard, Timothy D.; MacLullich, Alasdair M. J.; Slooter, Arjen J. C.; Ely, E. Wesley (2020-11-12). "Delirium". Nature Reviews. Disease Primers. 6 (1): 90. doi:10.1038/s41572-020-00223-4. ISSN 2056-676X. PMC 9012267. PMID 33184265.
  3. ^ Calf, Agneta H.; Pouw, Maaike A.; van Munster, Barbara C.; Burgerhof, Johannes G. M.; de Rooij, Sophia E.; Smidt, Nynke (2021-01-08). "Screening instruments for cognitive impairment in older patients in the Emergency Department: a systematic review and meta-analysis". Age and Ageing. 50 (1): 105–112. doi:10.1093/ageing/afaa183. ISSN 1468-2834. PMC 7793600. PMID 33009909.
  4. ^ a b "4AT – RAPID CLINICAL TEST FOR DELIRIUM". Retrieved 14 May 2020.
  5. ^ "References". 4AT - RAPID CLINICAL TEST FOR DELIRIUM. Retrieved 2022-02-26.
  6. ^ a b Tieges, Zoë; Maclullich, Alasdair M. J.; Anand, Atul; Brookes, Claire; Cassarino, Marica; O'connor, Margaret; Ryan, Damien; Saller, Thomas; Arora, Rakesh C.; Chang, Yue; Agarwal, Kathryn (2020-11-11). "Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis". Age and Ageing. 50 (3): 733–743. doi:10.1093/ageing/afaa224. ISSN 1468-2834. PMC 8099016. PMID 33196813.
  7. ^ Shenkin, Susan D.; Fox, Christopher; Godfrey, Mary; Siddiqi, Najma; Goodacre, Steve; Young, John; Anand, Atul; Gray, Alasdair; Hanley, Janet; MacRaild, Allan; Steven, Jill (2019-07-24). "Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method". BMC Medicine. 17 (1): 138. doi:10.1186/s12916-019-1367-9. ISSN 1741-7015. PMC 6651960. PMID 31337404.
  8. ^ Arnold, Elizabeth; Finucane, Anne M; Taylor, Stacey; Spiller, Juliet A; O’Rourke, Siobhan; Spenceley, Julie; Carduff, Emma; Tieges, Zoë; MacLullich, Alasdair MJ (May 2024). "The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study". Palliative Medicine. 38 (5): 535–545. doi:10.1177/02692163241242648. ISSN 0269-2163. PMC 11170929.
  9. ^ "National Audit of Dementia Reports and Resources". RC PSYCH ROYAL COLLEGE OF PSYCHIATRISTS. Retrieved 14 May 2020.
  10. ^ "National Hip Fracture Database: Annual Report 2019" (PDF). National Hip Fracture Database. Retrieved 14 May 2020.
  11. ^ MacLullich, AM; Shenkin, SD; Goodacre, S; Godfrey, M; Hanley, J; Stíobhairt, A; Lavender, E; Boyd, J; Stephen, J; Weir, C; MacRaild, A; Steven, J; Black, P; Diernberger, K; Hall, P; Tieges, Z; Fox, C; Anand, A; Young, J; Siddiqi, N; Gray, A (August 2019). "The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study". Health Technology Assessment. 23 (40): 1–194. doi:10.3310/hta23400. PMC 6709509. PMID 31397263.
  12. ^ Dormandy, L; Mufti, S; Higgins, E; Bailey, C; Dixon, M (October 2019). "Shifting the focus: A QI project to improve the management of delirium in patients with hip fracture". Future Healthcare Journal. 6 (3): 215–219. doi:10.7861/fhj.2019-0006. PMC 6798014. PMID 31660529.
  13. ^ Bearn, A; Lea, W; Kusznir, J (29 November 2018). "Improving the identification of patients with delirium using the 4AT assessment". Nursing Older People. 30 (7): 18–27. doi:10.7748/nop.2018.e1060. PMID 30426731. S2CID 53303149.
  14. ^ E, Vardy; N, Collins; U, Grover; R, Thompson; A, Bagnall; G, Clarke; S, Heywood; B, Thompson; L, Wintle (2020-05-16). "Use of a Digital Delirium Pathway and Quality Improvement to Improve Delirium Detection in the Emergency Department and Outcomes in an Acute Hospital". Age and Ageing. 49 (4): 672–678. doi:10.1093/ageing/afaa069. PMID 32417926.
  15. ^ Casey, P; Cross, W; Mart, MW; Baldwin, C; Riddell, K; Dārziņš, P (March 2019). "Hospital discharge data under-reports delirium occurrence: results from a point prevalence survey of delirium in a major Australian health service". Internal Medicine Journal. 49 (3): 338–344. doi:10.1111/imj.14066. PMID 30091294. S2CID 205209486.
  16. ^ Bellelli, PG; Biotto, M; Morandi, A; Meagher, D; Cesari, M; Mazzola, P; Annoni, G; Zambon, A (December 2019). "The relationship among frailty, delirium and attentional tests to detect delirium: a cohort study". European Journal of Internal Medicine. 70: 33–38. doi:10.1016/j.ejim.2019.09.008. PMID 31761505. S2CID 208277203.
  17. ^ Bellelli, G; Morandi, A; Di Santo, SG; Mazzone, A; Cherubini, A; Mossello, E; Bo, M; Bianchetti, A; Rozzini, R; Zanetti, E; Musicco, M; Ferrari, A; Ferrara, N; Trabucchi, M; Italian Study Group on Delirium, (ISGoD). (18 July 2016). ""Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool". BMC Medicine. 14: 106. doi:10.1186/s12916-016-0649-8. PMC 4950237. PMID 27430902.
  18. ^ Davis, D; Richardson, S; Hornby, J; Bowden, H; Hoffmann, K; Weston-Clarke, M; Green, F; Chaturvedi, N; Hughes, A; Kuh, D; Sampson, E; Mizoguchi, R; Cheah, KL; Romain, M; Sinha, A; Jenkin, R; Brayne, C; MacLullich, A (9 February 2018). "The delirium and population health informatics cohort study protocol: ascertaining the determinants and outcomes from delirium in a whole population". BMC Geriatrics. 18 (1): 45. doi:10.1186/s12877-018-0742-2. PMC 5807842. PMID 29426299.
  19. ^ "SIGN 157 Delirium: Risk reduction and management of delirium". www.sign.ac.uk. Retrieved 14 May 2020.
  20. ^ "Delirium Clinical Care Standard" (PDF). Australian Commission on Safety and Quality in Health Care. Retrieved 14 May 2020.
  21. ^ "National Early Warning Score (NEWS) 2. Standardising the assessment of acute-illness severity in the NHS. Additional Implementation Guidance March 2020". Retrieved 2 June 2020.
  22. ^ "Delirium Quality Standard: Tools for Implementation". Quorum. Retrieved 2021-05-13.
  23. ^ "Integrated Care Pathways and Delirium Algorithms". dementiapathways.ie. Retrieved 2021-05-13.
  24. ^ "4AT calculator". www.signdecisionsupport.uk. Retrieved 2021-05-13.
  25. ^ Penfold, Rose S.; Squires, Charlotte; Angus, Alisa; Shenkin, Susan D.; Ibitoye, Temi; Tieges, Zoë; Neufeld, Karin J.; Avelino‐Silva, Thiago J.; Davis, Daniel; Anand, Atul; Duckworth, Andrew D.; Guthrie, Bruce; MacLullich, Alasdair M. J. (2024-01-19). "Delirium detection tools show varying completion rates and positive score rates when used at scale in routine practice in general hospital settings: A systematic review". Journal of the American Geriatrics Society. doi:10.1111/jgs.18751. ISSN 0002-8614.
  26. ^ a b Anand, Atul; Cheng, Michael; Ibitoye, Temi; Maclullich, Alasdair M J; Vardy, Emma R L C (2022-03-01). "Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and home time: two-centre study of 82,770 emergency admissions". Age and Ageing. 51 (3): afac051. doi:10.1093/ageing/afac051. ISSN 0002-0729. PMC 8923813. PMID 35292792.
  27. ^ Inouye, S. K.; van Dyck, C. H.; Alessi, C. A.; Balkin, S.; Siegal, A. P.; Horwitz, R. I. (1990-12-15). "Clarifying confusion: the confusion assessment method. A new method for detection of delirium". Annals of Internal Medicine. 113 (12): 941–948. doi:10.7326/0003-4819-113-12-941. ISSN 0003-4819. PMID 2240918.
  28. ^ Tieges, Zoë; McGrath, Aisling; Hall, Roanna J.; Maclullich, Alasdair M. J. (December 2013). "Abnormal level of arousal as a predictor of delirium and inattention: an exploratory study". The American Journal of Geriatric Psychiatry. 21 (12): 1244–1253. doi:10.1016/j.jagp.2013.05.003. ISSN 1545-7214. PMID 24080383.
  29. ^ Chester, Jennifer G.; Beth Harrington, Mary; Rudolph, James L.; VA Delirium Working Group (May 2012). "Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening". Journal of Hospital Medicine. 7 (5): 450–453. doi:10.1002/jhm.1003. ISSN 1553-5606. PMC 4880479. PMID 22173963.
  30. ^ a b European Delirium Association; American Delirium Society (2014-10-08). "The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer". BMC Medicine. 12: 141. doi:10.1186/s12916-014-0141-2. ISSN 1741-7015. PMC 4177077. PMID 25300023.
  31. ^ Yates, Catherine; Stanley, Neil; Cerejeira, Joaquim M.; Jay, Roger; Mukaetova-Ladinska, Elizabeta B. (March 2009). "Screening instruments for delirium in older people with an acute medical illness". Age and Ageing. 38 (2): 235–237. doi:10.1093/ageing/afn285. hdl:10400.4/1170. ISSN 1468-2834. PMID 19110484.
  32. ^ Hasegawa, Tadashi; Seo, Tomomi; Kubota, Yoko; Sudo, Tomoko; Yokota, Kumi; Miyazaki, Nao; Muranaka, Akira; Hirano, Shigeki; Yamauchi, Atsushi; Nagashima, Kengo; Iyo, Masaomi (January 2022). "Reliability and validity of the Japanese version of the 4A's Test for delirium screening in the elderly patient". Asian Journal of Psychiatry. 67: 102918. doi:10.1016/j.ajp.2021.102918. ISSN 1876-2026. PMID 34798384. S2CID 243841870.
  33. ^ Johansson, Yvonne A.; Tsevis, Theofanis; Nasic, Salmir; Gillsjö, Catharina; Johansson, Linda; Bogdanovic, Nenad; Kenne Sarenmalm, Elisabeth (2021-10-18). "Diagnostic accuracy and clinical applicability of the Swedish version of the 4AT assessment test for delirium detection, in a mixed patient population and setting". BMC Geriatrics. 21 (1): 568. doi:10.1186/s12877-021-02493-3. ISSN 1471-2318. PMC 8522056. PMID 34663229.
  34. ^ a b Chang, Yue; Ragheb, Sandra M.; Oravec, Nebojsa; Kent, David; Nugent, Kristina; Cornick, Alexandra; Hiebert, Brett; Rudolph, James L.; MacLullich, Alasdair M. J.; Arora, Rakesh C. (2021-06-01). "Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward". The Journal of Thoracic and Cardiovascular Surgery. 165 (3): S0022–5223(21)00876–X. doi:10.1016/j.jtcvs.2021.05.031. hdl:20.500.11820/a4b90ba6-dd24-428b-b038-df1670781523. ISSN 1097-685X. PMID 34243932. S2CID 235786438.
  35. ^ Delgado-Parada, E.; Morillo-Cuadrado, D.; Saiz-Ruiz, J; Cebollada-Gracia, A.; Ayuso-Mateos, J. L.; Cruz-Jentoft, A. J. (2022-02-10). "Diagnostic accuracy of the Spanish version of the 4AT scale (4AT-ES) for delirium screening in older inpatients". The European Journal of Psychiatry. 36 (3): 182–190. doi:10.1016/j.ejpsy.2022.01.003. ISSN 0213-6163. S2CID 246767623.
  36. ^ Evensen, Sigurd; Hylen Ranhoff, Anette; Lydersen, Stian; Saltvedt, Ingvild (August 2021). "The delirium screening tool 4AT in routine clinical practice: prediction of mortality, sensitivity and specificity". European Geriatric Medicine. 12 (4): 793–800. doi:10.1007/s41999-021-00489-1. ISSN 1878-7649. PMC 8321971. PMID 33813725.
  37. ^ Sepúlveda, Esteban; Bermúdez, Ester; González, Dulce; Cotino, Paula; Viñuelas, Eva; Palma, José; Ciutat, Marta; Grau, Imma; Vilella, Elisabet; Trzepacz, Paula T.; Franco, José G. (May 2021). "Validation of the Delirium Diagnostic Tool-Provisional (DDT-Pro) in a skilled nursing facility and comparison to the 4 'A's test (4AT)". General Hospital Psychiatry. 70: 116–123. doi:10.1016/j.genhosppsych.2021.03.010. ISSN 1873-7714. PMID 33813146. S2CID 233029095.
  38. ^ Shenkin, Susan D.; Fox, Christopher; Godfrey, Mary; Siddiqi, Najma; Goodacre, Steve; Young, John; Anand, Atul; Gray, Alasdair; Hanley, Janet; MacRaild, Allan; Steven, Jill (2019-07-24). "Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method". BMC Medicine. 17 (1): 138. doi:10.1186/s12916-019-1367-9. ISSN 1741-7015. PMC 6651960. PMID 31337404.
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