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{{About|the medical scale for delirium|the Australian radio station|ABC Far North}} |
{{About|the medical scale for delirium|the Australian radio station|ABC Far North}} |
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{{Copy edit|date=May 2020}} |
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| ⚫ | The '''4 'A's Test''' ('''4AT''') is a bedside medical [[Scale (social sciences)|scale]] used to help determine if a person has [[delirium]].<ref>[http://www.symptomfind.com/symptoms/confusion/ ''Delirium''], Symptom Finder online.</ref> |
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| ⚫ | The '''4 'A's Test''' ('''4AT''') is a bedside medical [[Scale (social sciences)|scale]] used to help determine if a person has positive signs for [[delirium]].<ref>[http://www.symptomfind.com/symptoms/confusion/ ''Delirium''], Symptom Finder online.</ref> The test is designed to be used as a diagnostic tool in the general [[Medicine|clinical settings]] or inpatient hospital setting outside of the [[Intensive care unit|Intensive Care Unit]] (ICU). This procedure is intended to be used by [[Health care practitioner|healthcare practitioners]] without the need for special training, and it takes around two minutes to complete.<ref name=":12">{{cite web |title=4AT – RAPID CLINICAL TEST FOR DELIRIUM |url=https://www.the4AT.com |accessdate=14 May 2020}}</ref> The test was first published online in 2011.<ref name=":12" /> |
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| ⚫ | The 4AT has been evaluated in multiple [[diagnostic test]] |
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| ⚫ | The 4AT has been evaluated in multiple studies for accuracy in [[diagnostic test|diagnostic tests]], <ref name=":0">{{Cite journal|last=Tieges|first=Zoë|last2=MacLullich|first2=Alasdair M. J.|last3=Anand|first3=Atul|last4=Brookes|first4=Claire|last5=Cassarino|first5=Marica|last6=O'Connor|first6=Margaret|last7=Ryan|first7=Damien|last8=Saller|first8=Thomas|last9=Arora|first9=Rakesh C.|last10=Chang|first10=Yue|last11=Agarwal|first11=Kathryn|date=2020-06-12|title=Diagnostic Accuracy of the 4AT for delirium detection: systematic review and meta-analysis.|url=https://www.medrxiv.org/content/10.1101/2020.06.11.20128280v1|journal=medRxiv|language=en|pages=2020.06.11.20128280|doi=10.1101/2020.06.11.20128280}}</ref> and it is useful in both [[Clinic|clinical practice]]<ref>{{cite web |title=National Audit of Dementia Reports and Resources |url=https://www.rcpsych.ac.uk/improving-care/ccqi/national-clinical-audits/national-audit-of-dementia/nad-reports-and-resources#faq-accoridon-collapse89597b1a-7138-4c31-bd9c-4f1796c836ee |website=RC PSYCH ROYAL COLLEGE OF PSYCHIATRISTS |accessdate=14 May 2020 |language=en}}</ref><ref>{{cite web |title=National Hip Fracture Database: Annual Report 2019 |url=https://www.nhfd.co.uk/files/2019ReportFiles/NHFD_2019_Annual_Report_v101.pdf |website=National Hip Fracture Database |accessdate=14 May 2020}}</ref><ref>{{cite journal |last1=MacLullich |first1=AM |last2=Shenkin |first2=SD |last3=Goodacre |first3=S |last4=Godfrey |first4=M |last5=Hanley |first5=J |last6=Stíobhairt |first6=A |last7=Lavender |first7=E |last8=Boyd |first8=J |last9=Stephen |first9=J |last10=Weir |first10=C |last11=MacRaild |first11=A |last12=Steven |first12=J |last13=Black |first13=P |last14=Diernberger |first14=K |last15=Hall |first15=P |last16=Tieges |first16=Z |last17=Fox |first17=C |last18=Anand |first18=A |last19=Young |first19=J |last20=Siddiqi |first20=N |last21=Gray |first21=A |title=The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. |journal=Health Technology Assessment (Winchester, England) |date=August 2019 |volume=23 |issue=40 |pages=1–194 |doi=10.3310/hta23400 |pmid=31397263|pmc=6709509 }}</ref><ref>{{cite journal |last1=Dormandy |first1=L |last2=Mufti |first2=S |last3=Higgins |first3=E |last4=Bailey |first4=C |last5=Dixon |first5=M |title=Shifting the focus: A QI project to improve the management of delirium in patients with hip fracture. |journal=Future Healthcare Journal |date=October 2019 |volume=6 |issue=3 |pages=215–219 |doi=10.7861/fhj.2019-0006 |pmid=31660529|pmc=6798014 }}</ref><ref>{{cite journal |last1=Bearn |first1=A |last2=Lea |first2=W |last3=Kusznir |first3=J |title=Improving the identification of patients with delirium using the 4AT assessment. |journal=Nursing Older People |date=29 November 2018 |volume=30 |issue=7 |pages=18–27 |doi=10.7748/nop.2018.e1060 |pmid=30426731}}</ref><ref>{{Cite journal|title=Use of a Digital Delirium Pathway and Quality Improvement to Improve Delirium Detection in the Emergency Department and Outcomes in an Acute Hospital|last=E|first=Vardy|last2=N|first2=Collins|date=2020-05-16|language=en|pmid=32417926|last3=U|first3=Grover|last4=R|first4=Thompson|last5=A|first5=Bagnall|last6=G|first6=Clarke|last7=S|first7=Heywood|last8=B|first8=Thompson|last9=L|first9=Wintle|journal=Age and Ageing|doi=10.1093/ageing/afaa069}}</ref> and research.<ref>{{cite journal |last1=Casey |first1=P |last2=Cross |first2=W |last3=Mart |first3=MW |last4=Baldwin |first4=C |last5=Riddell |first5=K |last6=Dārziņš |first6=P |title=Hospital discharge data under-reports delirium occurrence: results from a point prevalence survey of delirium in a major Australian health service. |journal=Internal Medicine Journal |date=March 2019 |volume=49 |issue=3 |pages=338–344 |doi=10.1111/imj.14066 |pmid=30091294}}</ref><ref>{{cite journal |last1=Bellelli |first1=PG |last2=Biotto |first2=M |last3=Morandi |first3=A |last4=Meagher |first4=D |last5=Cesari |first5=M |last6=Mazzola |first6=P |last7=Annoni |first7=G |last8=Zambon |first8=A |title=The relationship among frailty, delirium and attentional tests to detect delirium: a cohort study. |journal=European Journal of Internal Medicine |date=December 2019 |volume=70 |pages=33–38 |doi=10.1016/j.ejim.2019.09.008 |pmid=31761505}}</ref><ref>{{cite journal |last1=Bellelli |first1=G |last2=Morandi |first2=A |last3=Di Santo |first3=SG |last4=Mazzone |first4=A |last5=Cherubini |first5=A |last6=Mossello |first6=E |last7=Bo |first7=M |last8=Bianchetti |first8=A |last9=Rozzini |first9=R |last10=Zanetti |first10=E |last11=Musicco |first11=M |last12=Ferrari |first12=A |last13=Ferrara |first13=N |last14=Trabucchi |first14=M |last15=Italian Study Group on Delirium |first15=(ISGoD). |title="Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. |journal=BMC Medicine |date=18 July 2016 |volume=14 |pages=106 |doi=10.1186/s12916-016-0649-8 |pmid=27430902|pmc=4950237 }}</ref><ref>{{cite journal |last1=Davis |first1=D |last2=Richardson |first2=S |last3=Hornby |first3=J |last4=Bowden |first4=H |last5=Hoffmann |first5=K |last6=Weston-Clarke |first6=M |last7=Green |first7=F |last8=Chaturvedi |first8=N |last9=Hughes |first9=A |last10=Kuh |first10=D |last11=Sampson |first11=E |last12=Mizoguchi |first12=R |last13=Cheah |first13=KL |last14=Romain |first14=M |last15=Sinha |first15=A |last16=Jenkin |first16=R |last17=Brayne |first17=C |last18=MacLullich |first18=A |title=The delirium and population health informatics cohort study protocol: ascertaining the determinants and outcomes from delirium in a whole population. |journal=BMC Geriatrics |date=9 February 2018 |volume=18 |issue=1 |pages=45 |doi=10.1186/s12877-018-0742-2 |pmid=29426299|pmc=5807842 }}</ref> It has been included in clinical guidlines and policy documents.<ref>{{cite web |title=SIGN 157 Delirium: Risk reduction and management of delirium |url=https://www.sign.ac.uk/sign-157-delirium |website=www.sign.ac.uk |accessdate=14 May 2020}}</ref><ref>{{cite web |title=Delirium Clinical Care Standard |url=https://www.safetyandquality.gov.au/sites/default/files/migrated/Delirium-CCS_Indicators-PDF.pdf |website=Australian Commission on Safety and Quality in Health Care |accessdate=14 May 2020}}</ref><ref>{{Cite web|title=National Early Warning Score (NEWS) 2. Standardising the assessment of acute-illness severity in the NHS. Additional Implemenation Guidance March 2020|url=https://www.rcplondon.ac.uk/file/20716/download|last=|first=|date=|website=|url-status=live|archive-url=|archive-date=|access-date=2 June 2020}}</ref> |
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==Summary of the test== |
==Summary of the test== |
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!colspan="3"|Full 4AT scale |
!colspan="3"|Full 4AT scale |
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! colspan="2" |<big> |
! colspan="2" |<big>Parameters and scoring</big> |
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!<big>Points</big> |
!<big>Points</big> |
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<small>''This includes patients who may be markedly [[drowsy]] (eg. difficult to rouse''</small> |
<small>''This includes patients who may be markedly [[drowsy]] (eg. difficult to rouse''</small> |
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<small>''and/or obviously sleepy''</small> <small>''during assessment) or agitated/hyperactive.''</small> |
<small>''and/or obviously sleepy''</small> <small>''during assessment) or [[Psychomotor agitation| |
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agitated]]/hyperactive.''</small> |
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<small>''Observe the patient. If asleep, attempt to wake with''</small> <small>''speech or a gentle touch''</small> |
<small>''Observe the patient. If asleep, attempt to wake with''</small> <small>''speech or a gentle touch''</small> |
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'''<small>0: delirium or severe cognitive impairment unlikely</small>''' |
'''<small>0: delirium or severe cognitive impairment unlikely</small>''' |
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'''<small>( |
'''<small>(Delirium still possible if [4] information incomplete)</small>''' |
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The 4AT has 4 |
The 4AT has 4 parameters: [1] '''[[Alertness|Alertness]]''', [2] '''[[Abbreviated mental test score|Abbreviated Mental Test-4]] (AMT4)''', [3] '''[[Attention|Attention]] (Months Backwards test)''', and [4] '''[[Acute Change or Fluctuating Course]]''' (see table). The score range is 0–12, with scores of 4 or more suggesting possible delirium. Scores of 1-3 suggest possible [[Cognitive deficit|cognitive impairment]]. |
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There are several |
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 both altered arousal and acute change in mental functioning are highly specific indicators of delirium.<ref>{{Cite journal|last=Inouye|first=S. K.|last2=van Dyck|first2=C. H.|last3=Alessi|first3=C. A.|last4=Balkin|first4=S.|last5=Siegal|first5=A. P.|last6=Horwitz|first6=R. I.|date=1990-12-15|title=Clarifying confusion: the confusion assessment method. A new method for detection of delirium|journal=Annals of Internal Medicine|volume=113|issue=12|pages=941–948|doi=10.7326/0003-4819-113-12-941|issn=0003-4819|pmid=2240918}}</ref><ref>{{Cite journal|last=Tieges|first=Zoë|last2=McGrath|first2=Aisling|last3=Hall|first3=Roanna J.|last4=Maclullich|first4=Alasdair M. J.|date=December 2013|title=Abnormal level of arousal as a predictor of delirium and inattention: an exploratory study|journal=The American Journal of Geriatric Psychiatry|volume=21|issue=12|pages=1244–1253|doi=10.1016/j.jagp.2013.05.003|issn=1545-7214|pmid=24080383}}</ref><ref>{{Cite journal|last=Chester|first=Jennifer G.|last2=Beth Harrington|first2=Mary|last3=Rudolph|first3=James L.|last4=VA Delirium Working Group|date=May 2012|title=Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening|journal=Journal of Hospital Medicine|volume=7|issue=5|pages=450–453|doi=10.1002/jhm.1003|issn=1553-5606|pmc=4880479|pmid=22173963}}</ref><ref name="European Delirium Association 141">{{Cite journal|last=European Delirium Association|last2=American Delirium Society|date=2014-10-08|title=The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer|journal=BMC Medicine|volume=12|pages=141|doi=10.1186/s12916-014-0141-2|issn=1741-7015|pmc=4177077|pmid=25300023}}</ref> |
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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 un-testability to trigger an outcome of possible delirium is many people with delirium are too drowsy or inattentive to undergo cognitive testing or [[interview]].<ref>{{Cite journal|last=Yates|first=Catherine|last2=Stanley|first2=Neil|last3=Cerejeira|first3=Joaquim M.|last4=Jay|first4=Roger|last5=Mukaetova-Ladinska|first5=Elizabeta B.|date=March 2009|title=Screening instruments for delirium in older people with an acute medical illness|journal=Age and Ageing|volume=38|issue=2|pages=235–237|doi=10.1093/ageing/afn285|issn=1468-2834|pmid=19110484}}</ref><ref name="European Delirium Association 141" /> These scoring options additionally allow the 4AT to be completed in patients who are unable to provide verbal responses. |
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== Psychometric properties == |
== Psychometric properties == |
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A [[systematic review]] and [[meta-analysis]] of data to 2019 involving 17 studies with a total of 3721 observations reported a pooled sensitivity of 88% and a pooled specificity of 88% for delirium diagnosis.<ref name=":0" /> The current range of studies spans emergency department, medical, surgical and community settings. |
A [[systematic review]] and [[meta-analysis]] of data to 2019 involving 17 studies with a total of 3721 observations reported a pooled [[Sensitivity and specificity#Sensitivity|sensitivity]] of 88% and a pooled [[Sensitivity and specificity#Specificity|specificity]] of 88% for delirium diagnosis.<ref name=":0" /> The current range of studies spans emergency department, medical, surgical and community settings. |
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== Recommended use in clinical practice == |
== Recommended use in clinical practice == |
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The 4AT is intended to be used to assess for delirium on |
The 4AT is intended to be used to assess for delirium on initial presentation with the patient, in transitions of care, and when delirium is suspected.<ref name=":11"/>It is not intended to be routinely performed multiple times per day. The orientation and attention cognitive tests are not designed to be used repeatedly and it increases burdens to staff and patients. |
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The 4AT is not intended to be performed multiple times per day in [[inpatient]]s to monitor for new delirium occurring after hospital admission. This is because the orientation and attention cognitive tests are not designed to be used repeatedly in this way, because of staff and patient burden, and practice effects. |
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Shorter tests such as the National [[Early warning score|Early Warning Score]] - 2 (NEWS2), RADAR,<ref>{{Cite journal|last=Voyer|first=Philippe|last2=Champoux|first2=Nathalie|last3=Desrosiers|first3=Johanne|last4=Landreville|first4=Philippe|last5=McCusker|first5=Jane|last6=Monette|first6=Johanne|last7=Savoie|first7=Maryse|last8=Richard|first8=Sylvie|last9=Carmichael|first9=Pierre-Hugues|date=2015|title=Recognizing acute delirium as part of your routine [RADAR]: a validation study|journal=BMC Nursing|volume=14|pages=19|doi=10.1186/s12912-015-0070-1|issn=1472-6955|pmc=4384313|pmid=25844067}}</ref> the Single Question in Delirium (SQiD),<ref>{{Cite journal|last=Sands|first=M. B.|last2=Dantoc|first2=B. P.|last3=Hartshorn|first3=A.|last4=Ryan|first4=C. J.|last5=Lujic|first5=S.|date=September 2010|title=Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale|journal=Palliative Medicine|volume=24|issue=6|pages=561–565|doi=10.1177/0269216310371556|issn=1477-030X|pmid=20837733}}</ref> or the Nursing Delirium Screening Scale (Nu-DESC)<ref>{{Cite journal|last=Hargrave|first=Anita|last2=Bastiaens|first2=Jesse|last3=Bourgeois|first3=James A.|last4=Neuhaus|first4=John|last5=Josephson|first5=S. Andrew|last6=Chinn|first6=Julia|last7=Lee|first7=Melissa|last8=Leung|first8=Jacqueline|last9=Douglas|first9=Vanja|date=November 2017|title=Validation of a Nurse-Based Delirium-Screening Tool for Hospitalized Patients|journal=Psychosomatics|volume=58|issue=6|pages=594–603|doi=10.1016/j.psym.2017.05.005|issn=1545-7206|pmc=5798858|pmid=28750835}}</ref> may be more suitable for ongoing |
Shorter tests such as the National [[Early warning score|Early Warning Score]] - 2 (NEWS2), [[RADAR tool|RADAR]],<ref>{{Cite journal|last=Voyer|first=Philippe|last2=Champoux|first2=Nathalie|last3=Desrosiers|first3=Johanne|last4=Landreville|first4=Philippe|last5=McCusker|first5=Jane|last6=Monette|first6=Johanne|last7=Savoie|first7=Maryse|last8=Richard|first8=Sylvie|last9=Carmichael|first9=Pierre-Hugues|date=2015|title=Recognizing acute delirium as part of your routine [RADAR]: a validation study|journal=BMC Nursing|volume=14|pages=19|doi=10.1186/s12912-015-0070-1|issn=1472-6955|pmc=4384313|pmid=25844067}}</ref> the [[Single Question in Delirium tool|(Single Question in Delirium (SQiD)]],<ref>{{Cite journal|last=Sands|first=M. B.|last2=Dantoc|first2=B. P.|last3=Hartshorn|first3=A.|last4=Ryan|first4=C. J.|last5=Lujic|first5=S.|date=September 2010|title=Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale|journal=Palliative Medicine|volume=24|issue=6|pages=561–565|doi=10.1177/0269216310371556|issn=1477-030X|pmid=20837733}}</ref> or the [[Nursing Delirium Screening Scale|Nursing Delirium Screening Scale (Nu-DESC)]]<ref>{{Cite journal|last=Hargrave|first=Anita|last2=Bastiaens|first2=Jesse|last3=Bourgeois|first3=James A.|last4=Neuhaus|first4=John|last5=Josephson|first5=S. Andrew|last6=Chinn|first6=Julia|last7=Lee|first7=Melissa|last8=Leung|first8=Jacqueline|last9=Douglas|first9=Vanja|date=November 2017|title=Validation of a Nurse-Based Delirium-Screening Tool for Hospitalized Patients|journal=Psychosomatics|volume=58|issue=6|pages=594–603|doi=10.1016/j.psym.2017.05.005|issn=1545-7206|pmc=5798858|pmid=28750835}}</ref> may be more suitable for ongoing routine monitoring for new delirium after admission to hospital (or in long-term care settings). A positive assesment in those tests generally require a more detailed assessment with a tool like the 4AT. This is an area of delirium practice which requires additional research. |
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The 4AT in one of several other delirium assessment tools in the literature. Each varies in its intended use (research, severity grading, very brief screening, etc.), completion time, need for training, and [[Psychometrics|psychometric]] characteristics.<ref>{{cite journal|last1=De|first1=J|last2=Wand|first2=AP|date=December 2015|title=Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients.|journal=The Gerontologist|volume=55|issue=6|pages=1079–99|doi=10.1093/geront/gnv100|pmid=26543179}}</ref><ref>{{cite journal|last1=Pérez-Ros|first1=P|last2=Martínez-Arnau|first2=FM|date=30 January 2019|title=Delirium Assessment in Older People in Emergency Departments. A Literature Review.|journal=Diseases (Basel, Switzerland)|volume=7|issue=1|page=14|doi=10.3390/diseases7010014|pmid=30704024|pmc=6473718}}</ref><ref>{{cite journal|last1=Rieck|first1=KM|last2=Pagali|first2=S|last3=Miller|first3=DM|date=March 2020|title=Delirium in hospitalized older adults.|journal=Hospital Practice (1995)|volume=48|issue=sup1|pages=3–16|doi=10.1080/21548331.2019.1709359|pmid=31874064}}</ref><ref>{{cite web|title=Adult Delirium Measurement Info Cards – NIDUS|url=https://deliriumnetwork.org/measurement/adult-delirium-info-cards/|accessdate=14 May 2020}}</ref> |
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== Languages == |
== Languages == |
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Revision as of 19:55, 16 June 2020
 | This article is currently undergoing a major edit by the Guild of Copy Editors. As a courtesy, please do not edit this page while this message is displayed. The copy editor who added this notice is listed in the page history. This page was last revised at 19:55, 16 June 2020 (UTC) (4 years ago) by Firedogbme (talk · contribs) (). Please remove {{GOCEinuse}} from this page as this page has not been edited for at least 24 hours. If you have any questions or concerns, please direct them to the Guild of Copy Editors' talk page. Thank you for your patience. |
The 4 'A's Test (4AT) is a bedside medical scale used to help determine if a person has positive signs for delirium.[1] The test is designed to be used as a diagnostic tool in the general clinical settings or inpatient hospital setting outside of the Intensive Care Unit (ICU). This procedure is intended to be used by healthcare practitioners without the need for special training, and it takes around two minutes to complete.[2] The test was first published online in 2011.[2]
The 4AT has been evaluated in multiple studies for accuracy in diagnostic tests, [3] and it is useful in both clinical practice[4][5][6][7][8][9] and research.[10][11][12][13] It has been included in clinical guidlines and policy documents.[14][15][16]
Summary of the test
| 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
1 2 | |
| [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), and [4] Acute Change or Fluctuating Course (see table). 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 both altered arousal and acute change in mental functioning are highly specific indicators of delirium.[17][18][19][20]
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 un-testability to trigger an outcome of possible delirium is many people with delirium are too drowsy or inattentive to undergo cognitive testing or interview.[21][20] These scoring options additionally allow the 4AT to be completed in patients who are unable to provide verbal responses.
Psychometric properties
A systematic review and meta-analysis of data to 2019 involving 17 studies with a total of 3721 observations reported a pooled sensitivity of 88% and a pooled specificity of 88% for delirium diagnosis.[3] The current range of studies spans emergency department, medical, surgical and community settings.
Recommended use in clinical practice
The 4AT is intended to be used to assess for delirium on initial presentation with the patient, in transitions of care, and when delirium is suspected.[22]It is not intended to be routinely performed multiple times per day. The orientation and attention cognitive tests are not designed to be used repeatedly and it increases burdens to staff and patients.
Shorter tests such as the National Early Warning Score - 2 (NEWS2), RADAR,[23] the (Single Question in Delirium (SQiD),[24] or the Nursing Delirium Screening Scale (Nu-DESC)[25] may be more suitable for ongoing routine monitoring for new delirium after admission to hospital (or in long-term care settings). A positive assesment in those tests generally require a more detailed assessment with a tool like the 4AT. This is an area of delirium practice which requires additional research.
The 4AT in one of several other delirium assessment tools in the literature. Each varies in its intended use (research, severity grading, very brief screening, etc.), completion time, need for training, and psychometric characteristics.[26][27][28][29]
Languages
The 4AT has to date been translated into German, French, Italian, Spanish, Danish, Finnish, Turkish, Arabic, Norwegian, Thai, Cantonese, Putonghua, Russian, Korean and Icelandic.[22]
References
- ^ Delirium, Symptom Finder online.
- ^ a b "4AT – RAPID CLINICAL TEST FOR DELIRIUM". Retrieved 14 May 2020.
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