Abstract
BackgroundDelirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 ‘A’s Test (4AT, www.the4AT.com) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM).MethodsThis was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0–12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment.ResultsEight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84–0.96). The 4AT had a sensitivity of 76% (95% CI 61–87%) and a specificity of 94% (95% CI 92–97%). The CAM had a sensitivity of 40% (95% CI 26–57%) and a specificity of 100% (95% CI 98–100%).ConclusionsThe 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care.Trial registrationInternational standard randomised controlled trial number (ISRCTN) 53388093. Date applied 30/05/2014; date assigned 02/06/2014.
Highlights
Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care
We reported the area under the receiver operating characteristic (ROC) curve and its 95% confidence interval (CI) for the 4 ‘A’s Test (4AT)
This study found that the 4AT had a sensitivity of 76% and a specificity of 94% for delirium as assessed independently by a reference standard
Summary
Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. Delirium is important because as well as being highly prevalent in hospitalised patients, it strongly predicts poor outcomes such as falls, other medical complications, new institutionalisation, and mortality [1, 6, 9,10,11,12,13]. It is associated with patient and carer distress [14,15,16]. Two assessment tools extensively used in clinical practice are the 4 ‘A’s Test (4AT) and the short form of the Confusion Assessment Method (CAM)
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