Abstract
ObjectiveDetection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 ‘A’s Test (4AT) is a short (<2 minutes) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection.MethodsWe searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model.ResultsSeventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8–32.1%; range 10.5–61.9%). The pooled sensitivity was 0.88 (95% CI 0.80–0.93) and the pooled specificity was 0.88 (95% CI 0.82–0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77–0.92) and the pooled specificity was 0.89 (95% CI 0.83–0.93). The methodological quality of studies varied but was moderate to good overall.ConclusionsThe 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection.PROSPERO Registration numberCRD42019133702.
Highlights
Delirium is a serious acute neuropsychiatric disorder of consciousness, attention and cognition triggered by general medical conditions, drugs, surgery, or a combination of causes
Inclusion criteria were: older adults (≥65y); diagnostic accuracy study of the 4 ‘A’s Test (4AT) index test when compared to delirium reference standard
The overall prevalence of delirium was 24.2%
Summary
Delirium is a serious acute neuropsychiatric disorder of consciousness, attention and cognition triggered by general medical conditions, drugs, surgery, or a combination of causes. It manifests through acute and fluctuating cognitive, psychomotor and perceptual disturbances which develop over hours to days. Delirium is common in hospitalised older adults, with a recent meta-analysis of 33 studies of medical inpatients finding an overall delirium occurrence of 23% (95% CI 19-26%) [1] It is common in surgical patients, in care homes and palliative care settings [2]. Categories of tools include: those intended for episodic use at first presentation or at other points when delirium is suspected; regular use (that is, daily or more frequently) in monitoring for new onset delirium in inpatients; ‘ultra-brief’ screening tools; intensive care unit tools; measurement of delirium severity; informant-based; and detailed phenomenological assessment
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