The 4AT is a rapid clinical instrument for delirium detection. It is a short and practical tool designed for use in busy areas where assessment for delirium is needed. This article looks at how to raise awareness of delirium in the hospital setting.
Delirium is a state of mental confusion that can happen if you become medically unwell. It is also known as an “acute confusional state.”1 It can be triggered by certain medications, surgical intervention or onset of an illness. Symptoms of delirium could start suddenly and settle as soon as the cause is identified and treated. This whole experience can be terrifying for a patient and their family, who are unable to comprehend the sudden change in the behaviour of their loved one.
Up to two-thirds of cases with delirium are missed or misdiagnosed by the initial assessing clinician.2 It is estimated that about 30% of patients seen in emergency departments have presented with an underlying delirium,3,4 whilst the estimate for hospitalised older patients to experience or develop delirium is about 11-42%.4,5 There is a notable increase in the tendency to develop delirium with age,6 based on cumulative statistics from studies, about 0.4% in those over 18 years of age, 1.1% in those over 55 years of age, 13.6% in those over 85 years of age.4,7
Following a SAMS (Senior Adult Medical Service) departmental meeting on the primary data outcome from our participation in a short national audit on delirium under the Royal Society of Psychiatry, we recognised the shortfall in early identification of patients presenting at our emergency department with delirium. Some of these patients were misdiagnosed to having dementia. In order to initiate prompt management to these patients, we had to improve on awareness and early recognition of delirium. Information on healthcare staff understanding of delirium was important. It was also in our objective to introduce the 4AT as a primary assessment tool since there was no definitive tool used in our trust.
The 4AT has a sensitivity of 89.7% and a specificity of 84.1%.8,9 It can be easily done by both medical and nursing staff. The objective was to ensure all patients admitted under medicine, over the age of 75 were assessed for delirium on their time of arrival or within 24 hours.6
This robust approach would eradicate the sporadic documentation of “patient is confused” without the use of a validated assessment tool like the 4AT. Our aim is to keep re-auditing beside promotional activities until we achieve compliance above 80%.
Random data of 25 patients were collected through review of our standardised medical admission clerking proforma between April 2017 and July 2017, with a view to collect a larger pool of data one year later for comparison, following implementation to drive a change.
- For training purpose, a generic PowerPoint was created to suit all level of staffing following a collaborative work by geriatricians, old age psychiatric consultants, dementia specialist occupational therapist, acute physicians and senior nurses. This PowerPoint was used in teachings at junior doctors and induction programmes within the trust. It was also used on presentations on mandatory training days, as well as on off-site departmental bonding day out. We made it a priority to target emergency department (ED) staff, as they were the first point of contact for most patients, followed by older person’s wards and the medical assessment unit.
- Short video clips on delirium were put on the trust website, as part of the awareness campaign.
- Staff members who were unable to attend face to face teaching/training sessions were able to complete their training, through the use of the mandatory online training tracker on delirium was encouraged.
- A pocket-sized delirium knowledge card was created which had the 4AT and on the reverse of the card, a simplified table highlighting the difference between delirium and dementia
- The inclusion of the 4AT into the medical clerking proforma, the discharge to access scheme (DACS), and the trust digital care flow were implemented.
- Mass production and dissemination of a delirium leaflet at key areas throughout the trust targeted at staff, visitors and patients. Also, posters were put out within the trust to raise awareness.
The positive feedback of our work on delirium awareness within the trust led to the extension of our teaching into the local community hubs, as well as in meetings with care home managers.
Pre-intervention: April - July 2017
Post-intervention July 2018
Average age: 86.12 years
Female: male ratio: 17:8
4AT outcome: 36%
Average age: 88.63 years
Female: male ratio: 139:112
4AT outcome: 51%
A robust awareness campaign by a dedicated team and various implementation strategies have shown improved adherence in the use of the 4AT. Early recognition and prompt management of patients with delirium are important. A reduced length of hospitalisation has been reported with the early recognition and management of delirium.10,11 As staff members adapt to this new initiative, there will be further increased chance of compliance with the 4AT use.
P. Enwere, J. Jenkinson, R. Mahmood, D. Sills, A. Aranda-Martinez, A. Manzoor, K. Soliman, E. Wilkinson, K. Yeong, R. Lisk.
Ashford and St Peter's Hospital.
- https://www.rcpsych.ac.uk/healthadvice/problemsanddisorders/delirium.aspx Authors: Dr Hilary Gordon, Professor George Ikkos, Dr Susie Lingwood and Dr Jim Bolton. Updated October 2015
- Collins et al. Age Aging 2010; 39(1): 131-135
- Vidal EI, Villas Boas PJ, Valle AP, et al; Delirium in older adults. BMJ 2013: f2031. doi: 10.1136/bmj.f2031.
- https://patient.info/doctor/delirium-pro Author Dr Laurence Knott, 26 Aug.2015, Document ID: 1714 (v24)
- Young J, Inouye SK. Delirium in older people. BMJ 2007; 334: 842-846
- McCusker J, Cole M, Dendukuri N, et al. The course of delirium in older medical inpatients: a prospective study. J Gen Intern Med 2003; 18(9): 696-704
- Burns A, Gallagley A, Byrne J. Delirium. J Neurol Neurosurg Psychiatry. 2004; 75(3): 362-7
- Shenkin SD, Fox C, Godfrey M, et al. Protocol for validation of the 4AT, a rapid screening tool for delirium: a multicentre prospective diagnostic test accuracy study. BMJ Open 2018; 8: e015572. doi: 10.1136/bmjopen-2016-015572
- Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 2014; 43: 496–502.doi:10.1093/ageing/afu021
- McCusker J, Cole MG, Dendukuri N, Belzile E. Does delirium increase hospital stay?. J Am Geriatr Soc 2003; 51(11): 1539-46
- Chen C, Li HS, Liang JT, et al. Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery. JAMA Surgery 2017; DOI: 10.1001/jamasurg.2017.1083