4AT

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 detection tool in the 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.[2] The test was first published online in 2011.[2]

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

The 4AT has been evaluated in multiple diagnostic test accuracy studies[3] and it is used in both clinical practice[4][5][6][7][8][9] and research.[10][11][12][13] It has been included in clinical guidelines 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

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), 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 that 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 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.[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 21 December 2019 involving 17 studies with a total of 3701 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.

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 because of the burden on staff and patients, and because of practice effects.[23] The 4AT is thus an episodic delirium test rather than monitoring test.

Shorter, largely observational tests such as the National Early Warning Score - 2 (NEWS2),[24] RADAR,[25] the Delirium Observation Scale (DOS),[26] the (Single Question in Delirium (SQiD),[27] or the Nursing Delirium Screening Scale (Nu-DESC)[28] are more suitable for ongoing routine monitoring for new delirium after admission to hospital (or in long-term care settings).[29] 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.[30] Each varies in its intended use (research, severity grading, very brief screening, etc.), completion time, need for training, and psychometric characteristics.[31][32][33][34][35]

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
  1. Delirium, Symptom Finder online.
  2. "4AT – RAPID CLINICAL TEST FOR DELIRIUM". Retrieved 14 May 2020.
  3. 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. doi:10.1093/ageing/afaa224. ISSN 1468-2834. PMID 33196813.
  4. "National Audit of Dementia Reports and Resources". RC PSYCH ROYAL COLLEGE OF PSYCHIATRISTS. Retrieved 14 May 2020.
  5. "National Hip Fracture Database: Annual Report 2019" (PDF). National Hip Fracture Database. Retrieved 14 May 2020.
  6. 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 (Winchester, England). 23 (40): 1–194. doi:10.3310/hta23400. PMC 6709509. PMID 31397263.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
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  16. "National Early Warning Score (NEWS) 2. Standardising the assessment of acute-illness severity in the NHS. Additional Implemenation Guidance March 2020". Retrieved 2 June 2020.
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  18. 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.
  19. 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.
  20. 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.
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  24. "NEWS2: Additional implementation guidance". RCP London. 2020-04-06. Retrieved 2020-06-18.
  25. Voyer, Philippe; Champoux, Nathalie; Desrosiers, Johanne; Landreville, Philippe; McCusker, Jane; Monette, Johanne; Savoie, Maryse; Richard, Sylvie; Carmichael, Pierre-Hugues (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. PMC 4384313. PMID 25844067.
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  34. "Adult Delirium Measurement Info Cards – NIDUS". Retrieved 14 May 2020.
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