4 A’s Test for Delirium Screening

4AT
Alertness
AMT4 (Age, DOB, Place, Year)
Attention (Months Backwards)
Acute Change or Fluctuating Course
4AT Score:0
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Diagnoses delirium in older patients.

Why Use

Delirium is misdiagnosed, missed, or diagnosed late in over 60% of cases ( Collins 2010 ). A simple screening tool can help identify these patients. Can be used in patients deemed “untestable” by other tests.

When to Use

Patients admitted to geriatric wards, to screen for delirium.

Formula

Addition of the selected points: Alertness Normal 0 Mild sleepiness for <10 seconds after waking, then normal 0 Clearly abnormal 4 AMT 4 Age, date of birth, place (name of hospital or building), current year No mistakes 0 1 mistake 1 ≥2 mistakes or untestable 2 Attention* Lists ≥7 months correctly 0 Starts but lists <7 months, or refuses to start 1 Untestable (cannot start because unwell, drowsy, inattentive) 2 Acute change or fluctuating course** No 0 Yes 4 *Instruct patient to list months in reverse order, starting at December. **Evidence of significant change or fluctuation in mental status within the last 2 weeks and still persisting in the last 24 hours.

Pearls / Pitfalls

Screens with higher sensitivity in patients without dementia. No consensus exists for the assessment of inattention. Limited external validation in some small populations, including the acute stroke setting. Validated in non-English speaking patients with 91% sensitivity ( De 2016 ).

Advice

If delirium is diagnosed, identify and treat underlying cause.

More Information

Interpretation: 4AT Score Level of impairment ≥4 Possible delirium and/or cognitive impairment 1–3 Possible cognitive impairment 0 Delirium or severe cognitive impairment unlikely (but delirium still possible if “acute change or fluctuating course” information is incomplete)

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