[New tool to detect delirium and cognitive impairment]

Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis: a prospective cohort study

Aim

To study delirium screening upon Emergency Department admission among patients admitted with suspected sepsis.

Findings

Delirium screening upon Emergency Department admission, using 4AT, was useful among patients aged ≥65 years admitted with suspected sepsis. Two out of three patients had at least one feature of delirium upon admission.

Message

This study suggest increased awareness of delirium among older patients with suspected sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00558-5.

Purpose

We aimed to study the use of The 4 ‘A’s test (4AT), a rapid delirium screening tool, performed upon Emergency Department (ED) admission, and to characterize older patients admitted to the ED with and without sepsis in terms of delirium features.

Methods

In this prospective cohort study, we included patients aged ≥ 65 years, admitted to the ED with suspected sepsis. ED nurses and doctors performed delirium screening with 4AT within two hours after ED admission, and registered the time spent on the screening in each case. Sepsis and delirium during the hospital stay were diagnosed retrospectively, according to recommended diagnosis criteria.

Results

Out of the 196 patients included (mean age 81 years, 60% men), 100 patients fulfilled the sepsis diagnosis criteria. The mean 4AT screening time was 2.5 Minutes. In total, 114 patients (58%) had a 4AT score ≥ 1, indicating cognitive impairment, upon ED admission. Sepsis patients more often had a 4AT score ≥ 4, indicating delirium, than patients without sepsis (40% vs. 26%, p < 0.05). Out of the 100 patients with sepsis, 68 (68%) had delirium during the hospital stay, as compared to 34 out of 96 patients (35%) without sepsis (p < 0.05).

Conclusion

Delirium screening upon ED admission, using 4AT, was feasible among patients aged ≥ 65 years admitted with suspected sepsis. Two out of three patients had at least one feature of delirium upon admission. The prevalence of delirium during the hospital stay was high, particularly in patients with sepsis.

Graphic abstract

The delirium screening tool 4AT in routine clinical practice: prediction of mortality, sensitivity and specificity

Aim

Investigate if 4AT score predicts 1 year mortality and explore the sensitivity and specificity of the 4AT when applied as part of a clinical routine.

Findings

4AT score is one of several clinical characteristics predicting 1 year mortality. The 4AT has reasonable sensitivity and specificity to detect delirium in a clinical routine setting.

Message

The 4AT seems to be a useful tool for delirium screening and may predict mortality.

Purpose

Delirium is common and associated with poor outcomes, partly due to underdetection. We investigated if the delirium screening tool 4 A’s test (4AT) score predicts 1 year mortality and explored the sensitivity and specificity of the 4AT when applied as part of a clinical routine.

Methods

Secondary analyses of a prospective study of 228 patients acutely admitted to a Medical Geriatric Ward. Physicians without formal training conducted the index test (the 4AT); a predefined cut-off ≥ 4 suggested delirium. Reference standard was delirium diagnosed by two geriatricians using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). We calculated hazard ratios (HR) using Cox regression based on the groups 4AT = 0, 1–3, 4–7 and ≥ 8, first unadjusted, then adjusted for the covariates age, comorbidity, and personal activities of daily living. We calculated sensitivity, specificity, and the area under the receiver operating curve (AUC).

Results

Mean age of patients was 86.6 years, 139 (61.0%) were female, 78 (34.2%) had DSM-5 delirium; of these, 56 had 4AT-delirium. 1 year mortality was 27.6% (63 patients). Compared to 4AT score 0, the group 4AT ≥ 8 had increased 1 year mortality (HR 2.86, 95% confidence interval 1.28–6.37, p = 0.010). The effect was reduced in multiadjusted analyses (HR 1.69, 95% confidence interval 0.70–4.07, p = 0.24). Sensitivity, specificity, and AUC were 0.72, 0.84, and 0.88, respectively.

Conclusions

4AT ≥ 8 indicates increased mortality, but the effect was reduced in multiadjusted analyses. 4AT had acceptable sensitivity and specificity when applied as a clinical routine.