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Published in: BMC Medicine 1/2019

Open Access 01-12-2019 | Confusion | Research article

Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method

Authors: Susan D. Shenkin, Christopher Fox, Mary Godfrey, Najma Siddiqi, Steve Goodacre, John Young, Atul Anand, Alasdair Gray, Janet Hanley, Allan MacRaild, Jill Steven, Polly L. Black, Zoë Tieges, Julia Boyd, Jacqueline Stephen, Christopher J. Weir, Alasdair M. J. MacLullich

Published in: BMC Medicine | Issue 1/2019

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Abstract

Background

Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 ‘A’s Test (4AT, www.​the4AT.​com) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM).

Methods

This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0–12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment.

Results

Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84–0.96). The 4AT had a sensitivity of 76% (95% CI 61–87%) and a specificity of 94% (95% CI 92–97%). The CAM had a sensitivity of 40% (95% CI 26–57%) and a specificity of 100% (95% CI 98–100%).

Conclusions

The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care.

Trial registration

International standard randomised controlled trial number (ISRCTN) 53388093. Date applied 30/05/2014; date assigned 02/06/2014.
Appendix
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Metadata
Title
Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method
Authors
Susan D. Shenkin
Christopher Fox
Mary Godfrey
Najma Siddiqi
Steve Goodacre
John Young
Atul Anand
Alasdair Gray
Janet Hanley
Allan MacRaild
Jill Steven
Polly L. Black
Zoë Tieges
Julia Boyd
Jacqueline Stephen
Christopher J. Weir
Alasdair M. J. MacLullich
Publication date
01-12-2019
Publisher
BioMed Central
Keyword
Confusion
Published in
BMC Medicine / Issue 1/2019
Electronic ISSN: 1741-7015
DOI
https://doi.org/10.1186/s12916-019-1367-9

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