Medicine:4AT

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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 test is designed to be used as a detection tool in general clinical settings, inpatient hospital setting 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.[3] The test was first published online in 2011; the 4AT website provides downloads, and a guide to the test along with case examples.[3] The 4AT is also available on the Android and iOS platforms, and as an online calculator.

The 4AT has been evaluated in multiple diagnostic test accuracy studies[4][5] and it is used internationally in both clinical practice[6][7][8][9][10][11] and research.[12][13][14][15] It has been included in clinical guidelines and policy documents.[16][17][18][19][20][21]

Summary

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.[22][23][24][25]

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.[26][25] These scoring options additionally allow the 4AT to be completed in patients who are unable to provide verbal responses.

Psychometric properties

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.[4] The current range of studies spans emergency department, medical, surgical and community settings.

Recommended use

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.[27] Using the 4AT multiple times per day for monitoring for new onset delirium is not recommended because of the burden of repeated cognitive testing on patients and staff.[28] 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.

Shorter, largely observational tests such as the National Early Warning Score - 2 (NEWS2),[29] RADAR,[30] the Delirium Observation Scale (DOS),[31] the (Single Question in Delirium (SQiD),[32] or the Nursing Delirium Screening Scale (Nu-DESC)[33] are more suitable for ongoing routine monitoring for new delirium after admission to hospital (or in long-term care settings).[34] 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.[35] Each varies in its intended use (research, severity grading, very brief screening, etc.), completion time, need for training, and psychometric characteristics.[36][37][38][39][40]

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.[27]

References

  1. ↑ Delirium , Symptom Finder online.
  2. ↑ 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. PMID 33184265. https://pubmed.ncbi.nlm.nih.gov/33184265. 
  3. ↑ 3.0 3.1 "4AT – RAPID CLINICAL TEST FOR DELIRIUM". https://www.the4AT.com. 
  4. ↑ 4.0 4.1 Tieges, Zoë; Maclullich, Alasdair M. J.; Anand, Atul; Brookes, Claire; Cassarino, Marica; O'connor, Margaret; Ryan, Damien; Saller, Thomas et al. (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. PMID 33196813. https://pubmed.ncbi.nlm.nih.gov/33196813. 
  5. ↑ Shenkin, Susan D.; Fox, Christopher; Godfrey, Mary; Siddiqi, Najma; Goodacre, Steve; Young, John; Anand, Atul; Gray, Alasdair et al. (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. PMID 31337404. PMC 6651960. https://pubmed.ncbi.nlm.nih.gov/31337404. 
  6. ↑ "National Audit of Dementia Reports and Resources" (in en). 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. 
  7. ↑ "National Hip Fracture Database: Annual Report 2019". https://www.nhfd.co.uk/files/2019ReportFiles/NHFD_2019_Annual_Report_v101.pdf. 
  8. ↑ MacLullich, AM; Shenkin, SD; Goodacre, S; Godfrey, M; Hanley, J; Stíobhairt, A; Lavender, E; Boyd, J et al. (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. PMID 31397263. 
  9. ↑ 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. PMID 31660529. 
  10. ↑ 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. 
  11. ↑ E, Vardy; N, Collins; U, Grover; R, Thompson; A, Bagnall; G, Clarke; S, Heywood; B, Thompson et al. (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" (in en). Age and Ageing 49 (4): 672–678. doi:10.1093/ageing/afaa069. PMID 32417926. 
  12. ↑ 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. 
  13. ↑ 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. 
  14. ↑ Bellelli, G; Morandi, A; Di Santo, SG; Mazzone, A; Cherubini, A; Mossello, E; Bo, M; Bianchetti, A et al. (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. PMID 27430902. 
  15. ↑ Davis, D; Richardson, S; Hornby, J; Bowden, H; Hoffmann, K; Weston-Clarke, M; Green, F; Chaturvedi, N et al. (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. PMID 29426299. 
  16. ↑ "SIGN 157 Delirium: Risk reduction and management of delirium". https://www.sign.ac.uk/sign-157-delirium. 
  17. ↑ "Delirium Clinical Care Standard". https://www.safetyandquality.gov.au/sites/default/files/migrated/Delirium-CCS_Indicators-PDF.pdf. 
  18. ↑ "National Early Warning Score (NEWS) 2. Standardising the assessment of acute-illness severity in the NHS. Additional Implemenation Guidance March 2020". https://www.rcplondon.ac.uk/file/20716/download. 
  19. ↑ "Delirium Quality Standard: Tools for Implementation" (in en-US). https://quorum.hqontario.ca/en/Home/Posts/Delirium-Quality-Standard-Tools-for-Implementation. 
  20. ↑ "Integrated Care Pathways and Delirium Algorithms" (in en). https://dementiapathways.ie/care-pathways/acute-hospital-care/integrated-care-pathways-and-delirium-algorithms. 
  21. ↑ "4AT calculator". https://www.signdecisionsupport.uk/risk-reduction-and-management-of-delirium/4at-calculator/. 
  22. ↑ 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. 
  23. ↑ 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. 
  24. ↑ 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. PMID 22173963. 
  25. ↑ 25.0 25.1 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. PMID 25300023. 
  26. ↑ 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. ISSN 1468-2834. PMID 19110484. 
  27. ↑ 27.0 27.1 "4AT – RAPID CLINICAL TEST FOR DELIRIUM" (in en-GB). https://www.the4at.com/. 
  28. ↑ "Delirium detection in routine clinical care: two basic processes" (in en-GB). https://www.deliriumwords.com/delirium-words-1/delirium-detection-in-routine-clinical-care-two-basic-processes. 
  29. ↑ "NEWS2: Additional implementation guidance". 2020-04-06. https://www.rcplondon.ac.uk/projects/outputs/news2-additional-implementation-guidance. 
  30. ↑ Voyer, Philippe; Champoux, Nathalie; Desrosiers, Johanne; Landreville, Philippe; McCusker, Jane; Monette, Johanne; Savoie, Maryse; Richard, Sylvie et al. (2015). "Recognizing acute delirium as part of your routine [RADAR: a validation study"]. BMC Nursing 14: 19. doi:10.1186/s12912-015-0070-1. ISSN 1472-6955. PMID 25844067. 
  31. ↑ Schuurmans, Marieke J.; Shortridge-Baggett, Lillie M.; Duursma, Sijmen A. (2003). "The Delirium Observation Screening Scale: a screening instrument for delirium". Research and Theory for Nursing Practice 17 (1): 31–50. doi:10.1891/rtnp.17.1.31.53169. ISSN 1541-6577. PMID 12751884. 
  32. ↑ Sands, M. B.; Dantoc, B. P.; Hartshorn, A.; Ryan, C. J.; Lujic, S. (September 2010). "Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale". Palliative Medicine 24 (6): 561–565. doi:10.1177/0269216310371556. ISSN 1477-030X. PMID 20837733. 
  33. ↑ Hargrave, Anita; Bastiaens, Jesse; Bourgeois, James A.; Neuhaus, John; Josephson, S. Andrew; Chinn, Julia; Lee, Melissa; Leung, Jacqueline et al. (November 2017). "Validation of a Nurse-Based Delirium-Screening Tool for Hospitalized Patients". Psychosomatics 58 (6): 594–603. doi:10.1016/j.psym.2017.05.005. ISSN 1545-7206. PMID 28750835. 
  34. ↑ "Delirium detection in routine clinical care: two basic processes" (in en-GB). https://www.deliriumwords.com/delirium-words-1/delirium-detection-in-routine-clinical-care-two-basic-processes. 
  35. ↑ "A classification of delirium assessment tools" (in en-GB). https://www.deliriumwords.com/delirium-words-1/a-classification-of-delirium-assessment-tools. 
  36. ↑ De, J; Wand, AP (December 2015). "Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients.". The Gerontologist 55 (6): 1079–99. doi:10.1093/geront/gnv100. PMID 26543179. 
  37. ↑ Pérez-Ros, P; Martínez-Arnau, FM (30 January 2019). "Delirium Assessment in Older People in Emergency Departments. A Literature Review.". Diseases 7 (1): 14. doi:10.3390/diseases7010014. PMID 30704024. 
  38. ↑ Rieck, KM; Pagali, S; Miller, DM (March 2020). "Delirium in hospitalized older adults.". Hospital Practice (1995) 48 (sup1): 3–16. doi:10.1080/21548331.2019.1709359. PMID 31874064. 
  39. ↑ "Adult Delirium Measurement Info Cards – NIDUS". https://deliriumnetwork.org/measurement/adult-delirium-info-cards/. 
  40. ↑ 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. PMID 33184265. https://pubmed.ncbi.nlm.nih.gov/33184265. 

External links




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