Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Multicenter Study
. 2018 Feb 10;8(2):e015572.
doi: 10.1136/bmjopen-2016-015572.

Protocol for validation of the 4AT, a rapid screening tool for delirium: a multicentre prospective diagnostic test accuracy study

Susan D Shenkin  1 , Christopher Fox  2 , Mary Godfrey  3 , Najma Siddiqi  4 , Steve Goodacre  5 , John Young  6 , Atul Anand  7 , Alasdair Gray  8 , Joel Smith  9 , Tracy Ryan  10 , Janet Hanley  11 , Allan MacRaild  12 , Jill Steven  12 , Polly L Black  12 , Julia Boyd  13 , Christopher J Weir  13   14 , Alasdair Mj MacLullich  1
Affiliations
Multicenter Study

Protocol for validation of the 4AT, a rapid screening tool for delirium: a multicentre prospective diagnostic test accuracy study

Susan D Shenkin et al. BMJ Open. .

Abstract

Introduction: Delirium is a severe neuropsychiatric syndrome of rapid onset, commonly precipitated by acute illness. It is common in older people in the emergency department (ED) and acute hospital, but greatly under-recognised in these and other settings. Delirium and other forms of cognitive impairment, particularly dementia, commonly coexist. There is a need for a rapid delirium screening tool that can be administered by a range of professional-level healthcare staff to patients with sensory or functional impairments in a busy clinical environment, which also incorporates general cognitive assessment. We developed the 4 'A's Test (4AT) for this purpose. This study's primary objective is to validate the 4AT against a reference standard. Secondary objectives include (1) comparing the 4AT with another widely used test (the Confusion Assessment Method (CAM)); (2) determining if the 4AT is sensitive to general cognitive impairment; (3) assessing if 4AT scores predict outcomes, including (4) a health economic analysis.

Methods and analysis: 900 patients aged 70 or over in EDs or acute general medical wards will be recruited in three sites (Edinburgh, Bradford and Sheffield) over 18 months. Each patient will undergo a reference standard delirium assessment and will be randomised to assessment with either the 4AT or the CAM. At 12 weeks, outcomes (length of stay, institutionalisation and mortality) and resource utilisation will be collected by a questionnaire and via the electronic patient record.

Ethics and dissemination: Ethical approval was granted in Scotland and England. The study involves administering tests commonly used in clinical practice. The main ethical issues are the essential recruitment of people without capacity. Dissemination is planned via publication in high impact journals, presentation at conferences, social media and the website www.the4AT.com.

Trial registration number: ISRCTN53388093; Pre-results.

Keywords: confusion; delirium; diagnostic test accuracy; hospital.

PubMed Disclaimer

Conflict of interest statement

Competing interests: No competing interests.

Figures

Figure 1
Figure 1
Study overview flow chart. CAM, Confusion Assessment Method; ED, emergency department; MOE, Medicine of the Elderly; 4AT, 4A's Test.
See this image and copyright information in PMC

References

    1. American Psychiatric Association. Task Force on DSM‐IV Diagnostic and statistical manual of mental disorders: dsm‐iv‐tr. 4th ed Washington, DC: American Psychiatric Association, 2000.
    1. American Psychiatric Association, American Psychiatric Association. Diagnostic and statistical manual of mental disorders: dsm‐v. 5th ed Washington, DC: American Psychiatric Association, 2013.
    1. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 2006;35:350–64. 10.1093/ageing/afl005 - DOI - PubMed
    1. Goldberg SE, Whittamore KH, Harwood RH, et al. . The prevalence of mental health problems among older adults admitted as an emergency to a general hospital. Age Ageing 2012;41:80–6. 10.1093/ageing/afr106 - DOI - PMC - PubMed
    1. Collins N, Blanchard MR, Tookman A, et al. . Detection of delirium in the acute hospital. Age Ageing 2010;39:131–5. 10.1093/ageing/afp201 - DOI - PubMed

Publication types

Associated data