The 4AT, a rapid delirium detection tool, in hospice inpatient units: Findings from a validation study

Background: Delirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 ‘A’s test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking.

Aim: To determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients.

Design: A diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment.

Setting/participants: Two hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ≥18.

Results: 137/148 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD 10.6) years. 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79-98%) and a specificity of 94% (95% CI 90-99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94-1).

Conclusion: The results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and adds to the literature evaluating methods of delirium detection in palliative care settings.

Trial registry: ISCRTN 97417474