Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people

Giuseppe Bellelli, Alessandro Morandi, Daniel H J Davis, Paolo Mazzola, Renato Turco, Simona Gentile, Tracy Ryan, Helen Cash, Fabio Guerini, Tiziana Torpilliesi, Francesco Del Santo, Marco Trabucchi, Giorgio Annoni, Alasdair M J MacLullich, Giuseppe Bellelli, Alessandro Morandi, Daniel H J Davis, Paolo Mazzola, Renato Turco, Simona Gentile, Tracy Ryan, Helen Cash, Fabio Guerini, Tiziana Torpilliesi, Francesco Del Santo, Marco Trabucchi, Giorgio Annoni, Alasdair M J MacLullich

Abstract

Objective: to evaluate the performance of the 4 'A's Test (4AT) in screening for delirium in older patients. The 4AT is a new test for rapid screening of delirium in routine clinical practice.

Design: : prospective study of consecutively admitted elderly patients with independent 4AT and reference standard assessments.

Setting: : an acute geriatrics ward and a department of rehabilitation.

Participants: two hundred and thirty-six patients (aged ≥70 years) consecutively admitted over a period of 4 months.

Measurements: in each centre, the 4AT was administered by a geriatrician to eligible patients within 24 h of admission. Reference standard delirium diagnosis (DSM-IV-TR criteria) was obtained within 30 min by a different geriatrician who was blind to the 4AT score. The presence of dementia was assessed using the Alzheimer's Questionnaire and the informant section of the Clinical Dementia Rating scale. The main outcome measure was the accuracy of the 4AT in diagnosing delirium.

Results: patients were 83.9 ± 6.1 years old, and the majority were women (64%). Delirium was detected in 12.3% (n = 29), dementia in 31.2% (n = 74) and a combination of both in 7.2% (n = 17). The 4AT had a sensitivity of 89.7% and specificity 84.1% for delirium. The areas under the receiver operating characteristic curves for delirium diagnosis were 0.93 in the whole population, 0.92 in patients without dementia and 0.89 in patients with dementia.

Conclusions: the 4AT is a sensitive and specific method of screening for delirium in hospitalised older people. Its brevity and simplicity support its use in routine clinical practice.

Keywords: cognitive impairment; delirium; delirium detection; dementia; diagnostic accuracy; geriatrics; older people; screening; validation.

© The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society.

Figures

Figure 1.
Figure 1.
ROC comparison curve for the 4AT versus the diagnosis of delirium (DSM IV-TR criteria) in the whole population and in subgroups of patients with and without dementia.

References

    1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Washington, DC: American Psychiatric Association; 2000.
    1. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006;35:350–64.
    1. Witlox J, Eurelings LSM, de Jonghe JFM. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010;304:443–51.
    1. Bellelli G, Magnifico F, Trabucchi M. Outcomes at 12 months in a population of elderly patients discharged from a rehabilitation unit. J Am Med Dir Assoc. 2008;9:55–64.
    1. Partridge JS, Martin FC, Harari D, Dhesi JK. The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this? Int J Geriatr Psychiatry. 2012 .
    1. Rockwood K. Educational interventions in delirium. Dement Geriatr Cogn Disord. 1999;10:426–9.
    1. Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and detection of delirium in elderly emergency department patients. CMAJ. 2000;163:977–81.
    1. Inouye SK, Foreman MD, Mion LC, Katz KH, Cooney LM., Jr Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med. 2001;161:2467–73.
    1. Collins N, Blanchard MR, Tookman A, Sampson EL. Detection of delirium in the acute hospital. Age Ageing. 2010;39:131–5.
    1. Bellelli G, Mazzola P, Corsi M, et al. The combined effect of ADL impairment and delay in time from fracture to surgery on 12-month mortality: an observational study in orthogeriatric patients. J Am Med Dir Assoc. 2012;13:664e9–e14.
    1. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS) JAMA. 2003;289:2983–91.
    1. Chester JG, Beth Harrington M, Rudolph JL. Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening. J Hosp Med. 2012;7:450–3.
    1. Schofield I, Stott DJ, Tolson D, McFadyen A, Monaghan J, Nelson D. Screening for cognitive impairment in older people attending accident and emergency using the 4-item Abbreviated Mental Test. Eur J Emerg Med. 2010;17:340–2.
    1. Katzman R, Brown T, Fuld P, Peck A, Schechter R, Schimmel H. Validation of a short orientation-memory-concentration test of cognitive impairment. Am J Psychiatry. 1983;140:734–9.
    1. Malek-Ahmadi M, Davis K, Belden C, et al. Validation and diagnostic accuracy of the Alzheimer's questionnaire. Age Ageing. 2012;41:396–9.
    1. Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for the staging of dementia. Br J Psychiatry. 1982;140:566–72.
    1. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.
    1. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941–8.
    1. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) JAMA. 2001;286:2703–10.
    1. Kean J, Ryan K. Delirium detection in clinical practice and research: critique of current tools and suggestions for future development. J Psychosom Res. 2008;65:255–9.
    1. Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient have delirium? Value of bedside instruments. JAMA. 2010;304:779–86.
    1. Young RS, Arseven A. Diagnosing delirium. JAMA. 2010;304:2125–6.
    1. Hall RJ, Meagher DJ, MacLullich AM. Delirium detection and monitoring outside the ICU. Best Pract Res Clin Anaesthesiol. 2012;26:367–83.
    1. Morandi A, McCurley J, Vasilevskis EE, et al. Tools to detect delirium superimposed on dementia: a systematic review. J Am Geriatr Soc. 2012;60:2005–13.
    1. Ryan DJ, O'Regan NA, Caoimh RO, et al. Delirium in an adult acute hospital population: predictors, prevalence and detection. BMJ Open. 2013;3 .
    1. Brown LJ, Fordyce C, Zaghdani H, Starr JM, MacLullich AM. Detecting deficits of sustained visual attention in delirium. J Neurol Neurosurg Psychiatry. 2011;82:1334–40.

Source: PubMed

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