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

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

*Corresponding author for this work

Research output: Contribution to journalArticle

Abstract

© 2019 The Author(s). 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.
Original languageEnglish
Article number138
JournalBMC Medicine
Volume17
Issue number1
DOIs
Publication statusPublished - 24 Jul 2019

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Confusion
Delirium
Routine Diagnostic Tests
Inpatients
Coma
ROC Curve
Diagnostic and Statistical Manual of Mental Disorders
Hospital Emergency Service
Randomized Controlled Trials

Cite this

Shenkin, Susan ; Fox, Christopher ; Godfrey, Mary ; Siddiqi, Najma ; Goodacre, Steve ; Young, John ; Anand, Atul ; Gray, Alasdair ; Hanley, Janet ; MacRaild, Allan ; Steven, Jill ; Black, Polly ; Tieges, Zoe ; Boyd, Julia ; Stephen, Jacqueline ; Weir, Christopher J. ; MacLullich, Alasdair. / Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. In: BMC Medicine. 2019 ; Vol. 17, No. 1.
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title = "Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method",
abstract = "{\circledC} 2019 The Author(s). 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.",
author = "Susan Shenkin and Christopher Fox and Mary Godfrey and Najma Siddiqi and Steve Goodacre and John Young and Atul Anand and Alasdair Gray and Janet Hanley and Allan MacRaild and Jill Steven and Polly Black and Zoe Tieges and Julia Boyd and Jacqueline Stephen and Weir, {Christopher J.} and Alasdair MacLullich",
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Shenkin, S, Fox, C, Godfrey, M, Siddiqi, N, Goodacre, S, Young, J, Anand, A, Gray, A, Hanley, J, MacRaild, A, Steven, J, Black, P, Tieges, Z, Boyd, J, Stephen, J, Weir, CJ & MacLullich, A 2019, 'Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method', BMC Medicine, vol. 17, no. 1, 138. https://doi.org/10.1186/s12916-019-1367-9

Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. / Shenkin, Susan; Fox, Christopher; Godfrey, Mary; Siddiqi, Najma; Goodacre, Steve; Young, John; Anand, Atul; Gray, Alasdair; Hanley, Janet; MacRaild, Allan; Steven, Jill; Black, Polly; Tieges, Zoe; Boyd, Julia; Stephen, Jacqueline; Weir, Christopher J.; MacLullich, Alasdair.

In: BMC Medicine, Vol. 17, No. 1, 138, 24.07.2019.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method

AU - Shenkin, Susan

AU - Fox, Christopher

AU - Godfrey, Mary

AU - Siddiqi, Najma

AU - Goodacre, Steve

AU - Young, John

AU - Anand, Atul

AU - Gray, Alasdair

AU - Hanley, Janet

AU - MacRaild, Allan

AU - Steven, Jill

AU - Black, Polly

AU - Tieges, Zoe

AU - Boyd, Julia

AU - Stephen, Jacqueline

AU - Weir, Christopher J.

AU - MacLullich, Alasdair

N1 - Acceptance from webpage OA article Author not at GCU at time of pub. Applied Gold exception as published in OA journal (immediate OA). ET 29/10/19

PY - 2019/7/24

Y1 - 2019/7/24

N2 - © 2019 The Author(s). 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.

AB - © 2019 The Author(s). 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.

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DO - 10.1186/s12916-019-1367-9

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JO - BMC Medicine

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