Calc Function

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    Patent Pending

    4 A’s Test for Delirium Screening

    Diagnoses delirium in older patients.
    Favorite
    When to Use
    Pearls/Pitfalls
    Why Use

    Patients admitted to geriatric wards, to screen for delirium.

    • 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.
    • 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.

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    If delirium is diagnosed, identify and treat underlying cause.

    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.

    Facts & Figures

    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)

    Dr. Giuseppe Bellelli

    About the Creator

    Giuseppe Bellelli, MD, is a geriatric physician at the Azienda Ospedaliera San Gerardo in Monza, Italy. He is also an associate professor in the department of medicine and surgery at the Università degli Studi di Milano-Bicocca. Dr. Bellelli’s research interests include aging, delirium, and behavioral and psychotic symptoms of dementia (BPSD).

    To view Dr. Giuseppe Bellelli's publications, visit PubMed