Diagnostic Test Accuracy of the 4AT for Delirium Detection: A Systematic Review and Meta-Analysis

Abstract

Under-recognition of delirium is an international problem. For the early detection of delirium, a feasible and valid screening tool for healthcare professionals is needed. This study aimed to present a scientific reason for using the 4 'A's Test (4AT) through a systematic review and meta-analysis of studies on the diagnostic test accuracy. We systematically searched articles in the EMBASE, MEDLINE, CINAHL, and PsycINFO databases and selected relevant articles on the basis of the predefined inclusion criteria. The quality of the included articles was evaluated using the Quality Assessment of the Diagnostic Accuracy Studies-2 tool. We estimated the pooled values of diagnostic test accuracy by employing the bivariate model and the hierarchical summary receiver operating characteristic (HSROC) model in data synthesis. A total of 3729 patients of 13 studies were included in the analysis. The pooled estimates of sensitivity and specificity of the 4AT were 81.5% (95% confidence interval: 70.7%, 89.0%) and 87.5% (79.5%, 92.7%), respectively. Given the 4AT's evidence of accuracy and practicality, we suggest healthcare professionals to utilize this tool for routine screening of delirium. However, for detecting delirium in the dementia population, further work is required to evaluate the 4AT with other cut-off points or scoring methods in order for it to be more sensitive and specific.

Keywords: 4AT; delirium; meta-analysis; sensitivity; specificity; systematic review.

Figure 1

The flow chart of the search for eligible studies.

Figure 2

Coupled forest plot of the 4AT. CI, confidence interval; 4AT, 4 ‘A’s Test.

Figure 3

Hierarchical summary receiver operating characteristics curve of the 4AT. HSROC, Hierarchical summary receiver operating characteristics curve; 4AT, 4 ‘A’s Test.

Figure 4

Predictive value of the 4AT. NPV, negative predictive value; PPV, positive predictive value; 4AT, 4 ‘A’s Test.