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Impact of Nurses' Knowledge, Self‐Efficacy and Clinical Reasoning Competency on Difficulties in Caring for Patients With Delirium in the Intensive Care Unit: A Cross‐Sectional Study
Abstract:
Aim: To examine the impact of critical care nurses' delirium knowledge, self‐efficacy and clinical reasoning competency on delirium care difficulties based on the information–motivation–behavioural (IMB) skills model from a behavioural perspective.
Design: Cross‐sectional study.
Methods: A total of 440 critical care nurses from five hospitals in China were selected using convenience sampling and invited to complete an online questionnaire for measurement. Data were collected in November 2024 and analysed using SPSS/AMOS with descriptive statistics, Pearson's correlation coefficient and multiple regression. Structural equation modelling was constructed to test the hypothesised relationships among the variables, with bootstrapping to assess mediation effects.
Results: The level of delirium care difficulties was moderated. Delirium care difficulties were negatively correlated with delirium knowledge, self‐efficacy and clinical reasoning competency. Clinical reasoning competency partly mediated delirium knowledge and self‐efficacy with regard to delirium care difficulties.
Conclusion: Delirium knowledge, self‐efficacy and clinical reasoning competency are essential for improving critical care nurses' delirium care competencies. The role of clinical reasoning competency in the relationship between the other two variables and delirium care difficulties was highlighted. Establishing multifaceted innovative delirium education programmes, emphasising individuals' sense of competence and enhancing clinical reasoning competency as behavioural skills were supported. Exploring these pathways using a nurse behaviour change‐based perspective is critical.
Implications for the Profession and/or Patient Care: Critical care managers should value nurses' delirium care competencies. Enhancing continuing professional development through system‐level support with high reliability and multiform professional education, including innovative theoretical and practical training; advancing policies that increase work motivation and self‐planning to stimulate self‐efficacy; and exercising critical and reflective thinking to improve clinical reasoning competency may enhance nurses' delirium recognition and care competencies, including prioritisation, potentially improving delirium care dilemmas and patient outcomes.
Reporting Method: The STROBE checklist was used as a guideline.
Patient or Public Contribution: Nurses completed questionnaires.
Trial Registration: Chinese Clinical Trial Registry (ChiCTR2400092177). https://www.chictr.org.cn/bin/project/edit?pid=249216
Source: Dong J. Journal of Clinical Nursing, Feb 2026; 35(2): 729-746
The role of AI-driven communication in delirium prevention, detection, and care for critically ill ICU patients: A systematic review with inductive thematic synthesis
Abstract: Delirium remains one of the most consequential complications among critically ill patients in ICUs, exerting profound effects on morbidity, mortality, and annual healthcare costs exceeding $81 billion. Communication barriers between sedated or mechanically ventilated patients, their families, and multidisciplinary teams frequently delay recognition and impair management of delirium. This systematic review examines how AI-driven communication technologies can address these barriers, enhance early detection, and promote more integrated, patient- and family-centered delirium care. A systematic review of literature published between 2015 and 2025 was conducted across five electronic databases: Scopus, PubMed, Web of Science, Embase, and IEEE Xplore. The search strategy employed keywords as "delirium," "intensive care," "artificial intelligence," "AI-driven communication technologies", "natural language processing", "computer vision", "multidisciplinary clinical collaboration", and "family engagement". Studies were eligible for inclusion if they focused on AI-enhanced communication in ICU delirium care. The included studies were analyzed using an inductive thematic synthesis approach. From 87 screened records, 16 studies demonstrated AI's significant benefits across three clinical domains: 1) Prevention using AI-driven tools; 2) Early Detection via multimodal AI systems; and 3) Patient Care through Natural Language Processing (NLP)-powered support. An inductive thematic synthesis of these findings further delineated six core thematic domains: (1) inherent communication barriers; (2) AI as a multidirectional interface; (3) passive AI listening for early detection; (4) AI-enhanced family engagement; (5) AI-structured handovers for teamwork; and (6) ethical-regulatory-practical challenges. AI-driven communication tools effectively bridge critical gaps in ICU delirium care, facilitating early detection, prevention, and patient-centered management. By enabling proactive interventions and fostering a collaborative care environment, these technologies demonstrate direct potential to reduce delirium duration, decrease antipsychotic use, improve long-term cognitive outcomes, and alleviate the substantial economic burden on healthcare systems. These findings validate AI's role in transforming delirium care through enhanced multidirectional communication. ICU nurses are pivotal in utilizing AI tools through interpreting NLP-generated alerts, calibrating computer vision outputs, and facilitating family engagement to translate AI insights into empathetic, tailored bedside interventions, thereby reinforcing human-AI collaboration.
Source: Pandian V. Intensive and Critical Care Nursing, Apr 2026; 93:104323
Source: Dong J. Journal of Clinical Nursing, Feb 2026; 35(2): 729-746
The role of AI-driven communication in delirium prevention, detection, and care for critically ill ICU patients: A systematic review with inductive thematic synthesis
Abstract: Delirium remains one of the most consequential complications among critically ill patients in ICUs, exerting profound effects on morbidity, mortality, and annual healthcare costs exceeding $81 billion. Communication barriers between sedated or mechanically ventilated patients, their families, and multidisciplinary teams frequently delay recognition and impair management of delirium. This systematic review examines how AI-driven communication technologies can address these barriers, enhance early detection, and promote more integrated, patient- and family-centered delirium care. A systematic review of literature published between 2015 and 2025 was conducted across five electronic databases: Scopus, PubMed, Web of Science, Embase, and IEEE Xplore. The search strategy employed keywords as "delirium," "intensive care," "artificial intelligence," "AI-driven communication technologies", "natural language processing", "computer vision", "multidisciplinary clinical collaboration", and "family engagement". Studies were eligible for inclusion if they focused on AI-enhanced communication in ICU delirium care. The included studies were analyzed using an inductive thematic synthesis approach. From 87 screened records, 16 studies demonstrated AI's significant benefits across three clinical domains: 1) Prevention using AI-driven tools; 2) Early Detection via multimodal AI systems; and 3) Patient Care through Natural Language Processing (NLP)-powered support. An inductive thematic synthesis of these findings further delineated six core thematic domains: (1) inherent communication barriers; (2) AI as a multidirectional interface; (3) passive AI listening for early detection; (4) AI-enhanced family engagement; (5) AI-structured handovers for teamwork; and (6) ethical-regulatory-practical challenges. AI-driven communication tools effectively bridge critical gaps in ICU delirium care, facilitating early detection, prevention, and patient-centered management. By enabling proactive interventions and fostering a collaborative care environment, these technologies demonstrate direct potential to reduce delirium duration, decrease antipsychotic use, improve long-term cognitive outcomes, and alleviate the substantial economic burden on healthcare systems. These findings validate AI's role in transforming delirium care through enhanced multidirectional communication. ICU nurses are pivotal in utilizing AI tools through interpreting NLP-generated alerts, calibrating computer vision outputs, and facilitating family engagement to translate AI insights into empathetic, tailored bedside interventions, thereby reinforcing human-AI collaboration.
Source: Pandian V. Intensive and Critical Care Nursing, Apr 2026; 93:104323
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Delirium in the Elderly
Abstract: Delirium is a common and serious neuropsychiatric syndrome in older adults, characterized by acute and fluctuating disturbances in attention, awareness, and cognition. It is associated with multiple adverse outcomes, including increased mortality, functional decline, long-term cognitive impairment, and institutionalization. This review synthesizes current knowledge on the pathophysiology, risk factors, clinical presentation, diagnosis, prevention, treatment, and prognosis of delirium in elderly patients. Delirium arises from complex interactions between predisposing vulnerabilities (such as dementia, frailty, and sensory deficits) and acute precipitants (including infections, medications, surgery, and environmental stressors), resulting in a transient but often severe breakdown of cerebral function. Diagnostic tools such as the Confusion Assessment Method (CAM) and 4AT improve detection, though challenges remain in hypoactive presentations and in patients with underlying dementia. Multicomponent non-pharmacological interventions - focused on orientation, sleep hygiene, mobilization, hydration, medication review, and sensory support - are the most effective preventive and therapeutic strategies. Pharmacological treatment, primarily with antipsychotics, is reserved for severe behavioral disturbances and does not alter the course of the syndrome. Delirium is a clinical red flag indicating systemic decompensation and should prompt both acute management and structured follow-up to mitigate long-term consequences. Greater integration of delirium screening and prevention into hospital protocols is essential to improve care outcomes in this vulnerable population.
Source: Briganti G. Psychiatria Danubina, Sep 2025; 37(suppl 1): 104-111
The Prevention and Treatment of Postoperative Delirium in the Elderly: A Narrative Systematic Review of Reviews
Abstract:
Delirium in the Elderly
Abstract: Delirium is a common and serious neuropsychiatric syndrome in older adults, characterized by acute and fluctuating disturbances in attention, awareness, and cognition. It is associated with multiple adverse outcomes, including increased mortality, functional decline, long-term cognitive impairment, and institutionalization. This review synthesizes current knowledge on the pathophysiology, risk factors, clinical presentation, diagnosis, prevention, treatment, and prognosis of delirium in elderly patients. Delirium arises from complex interactions between predisposing vulnerabilities (such as dementia, frailty, and sensory deficits) and acute precipitants (including infections, medications, surgery, and environmental stressors), resulting in a transient but often severe breakdown of cerebral function. Diagnostic tools such as the Confusion Assessment Method (CAM) and 4AT improve detection, though challenges remain in hypoactive presentations and in patients with underlying dementia. Multicomponent non-pharmacological interventions - focused on orientation, sleep hygiene, mobilization, hydration, medication review, and sensory support - are the most effective preventive and therapeutic strategies. Pharmacological treatment, primarily with antipsychotics, is reserved for severe behavioral disturbances and does not alter the course of the syndrome. Delirium is a clinical red flag indicating systemic decompensation and should prompt both acute management and structured follow-up to mitigate long-term consequences. Greater integration of delirium screening and prevention into hospital protocols is essential to improve care outcomes in this vulnerable population.
Source: Briganti G. Psychiatria Danubina, Sep 2025; 37(suppl 1): 104-111
The Prevention and Treatment of Postoperative Delirium in the Elderly: A Narrative Systematic Review of Reviews
Abstract:
Objectives: Postoperative delirium (POD) is a common complication after major surgeries, posing significant challenges to patient recovery and outcomes, particularly among the elderly. A narrative systematic review was conducted to assess the clinical effectiveness and safety of interventions aimed at preventing and treating POD.
Methods: A review of the literature from 2017 to September 29, 2023, was conducted using MEDLINE, EMBASE, and CINAHL. Systematic reviews, with or without meta-analyses, as well as practice guidelines, were included. Participants were adults, ≥60 years. The methodological quality of included reviews was appraised using AMSTAR 2.
Results: After the search strategy identified 2295 references, 36 review studies were selected. Multicomponent interventions, incorporating both pharmacological and nonpharmacological approaches, demonstrate promise, particularly in hip fracture patients. Notably, dexmedetomidine emerges as a potential preventive measure, showing a notable reduction in delirium incidence following cardiac surgery. While several pharmacological interventions show potential, evidence remains inconclusive, necessitating further investigation. Similarly, varying anesthesia type and monitoring methods has mixed outcomes on delirium prevention. Despite methodological variations and quality appraisal limitations, this review underscores the importance of multicomponent interventions and the potential efficacy of dexmedetomidine in mitigating POD. Integration of evidence-based protocols into clinical practice is advocated to improve patient outcomes. However, the complex interplay between intervention components calls for further research to optimize delirium management strategies.
Conclusions: The strength of evidence associated with multicomponent interventions and dexmedetomidine use should require a genuine commitment from health care institutions to support their integration into efficient strategies to prevent and treat POD. Ongoing research is vital to uncover their full potential and refine clinical protocols, ultimately enhancing patient care outcomes.
Source: Deblois S. Journal of Patient Safety, Apr 2025; 21(3): 174-192
Source: Deblois S. Journal of Patient Safety, Apr 2025; 21(3): 174-192
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Cost-effectiveness of adopting a postoperative delirium risk prediction tool with nonpharmacological delirium prevention interventions for surgical patients
Abstract:
Cost-effectiveness of adopting a postoperative delirium risk prediction tool with nonpharmacological delirium prevention interventions for surgical patients
Abstract:
Background Postoperative delirium (POD) arises among older surgical patients. Screening followed by prevention efforts are recommended. A risk prediction tool called PIPRA plus has been developed, yet its performance and whether adoption into health services is cost-effective are unknown.
Objective To estimate the expected change to 'total costs' and 'health benefits' measured by quality adjusted life years (QALYs) from a decision to adopt PIPRA plus for screening purpose to find at-risk individuals who are then offered nonpharmacological interventions to reduce risks of POD.
Design Cost-effectiveness modelling study that draws on a range of relevant data sources. Setting Swiss healthcare system. Subjects Surgical inpatients aged 60 or older, excluding cardiac and intracranial surgeries.
Methods A decision tree model was used to capture the events likely to impact on cost and health outcomes. Information was harvested from a prospective before–after study done in Switzerland and augmented with other data. Probabilistic sensitivity analysis was undertaken to reveal the probability that adoption was cost-effective against a stated maximum willingness to pay threshold for decision-making in Switzerland.
Results Patients in both phases of the study were similar. Costs were lower by 2898 CHF (SD 1050) per patient with the adoption of the risk screening tool and there was a modest gain to health benefits of 0.01 QALY (SD 0.026). There was a 99.7% probability that adoption would be cost-saving and 91% probability that adoption would be cost-effective.
Conclusions We provide early-stage evidence that a decision to adopt the risk screening tool and offer risk-reducing interventions could be cost-effective.
Source: Graves N. Age and Ageing, May 2025; 54(5): 1-8
Source: Graves N. Age and Ageing, May 2025; 54(5): 1-8
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Proportional Sedation for Persistent Agitated Delirium in Palliative Care: A Randomized Clinical Trial
Abstract:
Proportional Sedation for Persistent Agitated Delirium in Palliative Care: A Randomized Clinical Trial
Abstract:
IMPORTANCE: Neuroleptic and benzodiazepine medications are often considered for patients with persistent agitated delirium in the last days of life; however, the risk-to-benefit ratio of these medications is ill-defined and benzodiazepine medications have not been compared to placebo.
OBJECTIVE: To compare the effect of scheduled haloperidol, lorazepam, haloperidol plus lorazepam, and placebo on patients with advanced cancer and delirium and experiencing restlessness and/or agitation in the palliative care setting.
DESIGN, SETTINGS, AND PARTICIPANTS: This multicenter randomized clinical trial was conducted at 3 acute palliative care units in Taiwan and the US with patients with advanced cancer experiencing persistent restlessness and/or agitation despite nonpharmacologic therapies and standard-dose haloperidol. Among 245 eligible patients, 111 were enrolled, and 75 received blinded treatments. Participants were randomized in a 1:1:1:1 ratio (stratified by site and Richmond Agitation-Sedation Scale [RASS] score). The study period was from July 16, 2019, to June 8, 2023, with a 30-day follow-up after medication administration. Data analysis was performed from October 10, 2023, to April 11, 2025.
INTERVENTIONS: Scheduled intravenous haloperidol, lorazepam, haloperidol plus lorazepam, or placebo every 4 hours until discharge, death, or withdrawal from study. Medications in all 4 groups had identical volume and appearance.
MAIN OUTCOMES AND MEASURES: Change in RASS scores during the first 24 hours. Secondary outcomes included the use of rescue neuroleptics or benzodiazepines for breakthrough restlessness or agitation during the first 24 hours, delirium severity, perceived patient comfort, and adverse events.
RESULTS: The primary outcome was assessed in 72 patients (mean [SD] age, 64 [12] years, 42 male [58%]) with a median (IQR) MDAS score of 24 (18-29). The lorazepam group had significantly lower RASS scores than the haloperidol group (mean difference, -2.1; 95% CI, -3.4 to -0.9; P < .001) and the combination group had significantly lower RASS scores than the haloperidol group (-2.0; 95% CI, -3.2 to -0.8; P = .002); however, there was no difference observed between haloperidol and placebo groups (-0.5; 95% CI, -1.7 to 0.7; P = .42) nor between the combination and lorazepam groups (0.2; 95% CI, -1.1 to 1.4; P = .79). The combination and lorazepam groups required fewer rescue medications for breakthrough restlessness or agitation compared to the haloperidol and placebo groups (32%, 37%, 56%, 83%, respectively; P = .006). Adverse events or survival did not differ between groups.
CONCLUSIONS AND RELEVANCE: The results of this randomized clinical trial indicate that proactive use of scheduled sedatives, particularly lorazepam-based regimens, may reduce persistent restlessness and/or agitation in patients with advanced cancer and delirium in the palliative care setting.
TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03743649.
Source: Hui D. JAMA Oncology, Sep 2025; 11(9): 1031-1043
Source: Hui D. JAMA Oncology, Sep 2025; 11(9): 1031-1043
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4AT screening for delirium in dementia: meta-analysis of diagnostic performance
Abstract: Delirium is frequently underdiagnosed in older adults, especially those with dementia, due to overlapping clinical features. In this meta-analysis, we evaluate the diagnostic performance of the 4 'A's Test (4AT) in detecting delirium specifically among dementia patients. Five eligible diagnostic accuracy studies were identified in a systematic search in six databases, comprising 1,304 older adults, including 482 with dementia. Pooled sensitivity and specificity were 88 and 79%, respectively, with a diagnostic odds ratio of 32.0, indicating strong discriminatory power. The 4AT high sensitivity supports its use as an initial screening tool to rule out delirium in dementia patients, especially in acute or resource-limited settings. However, moderate specificity highlights the need for confirmatory assessments in positive cases. In this review, we underscore the clinical utility of the 4AT for rapid delirium detection in complex geriatric populations and recommend further research on its performance across dementia subtypes and healthcare environments.
Source: Keane A. Dementia and Neuropsychologia 20, Dec 2025; 20: e20250378–0378
Misdiagnosing Urinary Tract Infections as Delirium in Older Adults: A Systemic Review of Evidence from Ireland and the UK...72nd Annual Scientific Meeting (ASM) of Irish Gerontological Society (IGS), October 2-4, 2025, Killlarney, Ireland
Abstract:
4AT screening for delirium in dementia: meta-analysis of diagnostic performance
Abstract: Delirium is frequently underdiagnosed in older adults, especially those with dementia, due to overlapping clinical features. In this meta-analysis, we evaluate the diagnostic performance of the 4 'A's Test (4AT) in detecting delirium specifically among dementia patients. Five eligible diagnostic accuracy studies were identified in a systematic search in six databases, comprising 1,304 older adults, including 482 with dementia. Pooled sensitivity and specificity were 88 and 79%, respectively, with a diagnostic odds ratio of 32.0, indicating strong discriminatory power. The 4AT high sensitivity supports its use as an initial screening tool to rule out delirium in dementia patients, especially in acute or resource-limited settings. However, moderate specificity highlights the need for confirmatory assessments in positive cases. In this review, we underscore the clinical utility of the 4AT for rapid delirium detection in complex geriatric populations and recommend further research on its performance across dementia subtypes and healthcare environments.
Source: Keane A. Dementia and Neuropsychologia 20, Dec 2025; 20: e20250378–0378
Misdiagnosing Urinary Tract Infections as Delirium in Older Adults: A Systemic Review of Evidence from Ireland and the UK...72nd Annual Scientific Meeting (ASM) of Irish Gerontological Society (IGS), October 2-4, 2025, Killlarney, Ireland
Abstract:
Background: Delirium is a common, serious, and often under-recognized condition in older adults. Misdiagnosis as urinary tract infection (UTI) is widespread, particularly in institutional care settings, leading to inappropriate antibiotic use and poorer health outcomes.
Methods: A systematic review was conducted according to PRISMA guidelines. Literature searches were done using the PubMed, EMBASE, Cochrane, and HSE Library databases, focusing on studies published between 2015 and 2025. The inclusion criteria were studies that assessed the diagnosis of urinary tract infections (UTIs) in adults aged 65 and older with delirium, conducted in Ireland or the UK, and reported clinical outcomes. Data extraction concentrated on study design, sample size, care setting, diagnostic tools use, and misdiagnosis rates. The quality of the studies was evaluated using the NewcastleOttawa Scale (NOS). A meta-analysis was carried out using a random-effects model in RevMan 5.4.
Results: The misdiagnosis rate of UTIs in older adults with delirium was 36% (95% CI: 29–42%), with over one-third of delirium cases wrongly attributed to UTIs. Long-term care facilities had the highest misdiagnosis rate at 42%, followed by emergency departments at 35% and hospital wards at 28%. About 65% of misdiagnosed cases relied solely on positive dipstick results, causing frequent false positives. Only 40% of cases utilized standardized delirium screening tools. Empiric antibiotic therapy was prescribed in 37% of misdiagnosed cases without confirmatory urine cultures, raising concerns about antimicrobial overuse and associated risks such as adverse drug reactions and resistant infections.
Conclusion: UTI misdiagnosis remains a major barrier to accurate delirium management in older adults. Our findings target urgent policy action to standardize delirium screening, restrict inappropriate antibiotic use, and train healthcare staff. Embedding tools like 4AT in EMR, enhancing clinical governance through audits, and aligning with HSE/NICE antimicrobial guidelines could reduce diagnostic error and improve outcomes in geriatric population.
Source: Khan M B. Age and Ageing, 2025; 54: 7
A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU
Abstract:
Source: Khan M B. Age and Ageing, 2025; 54: 7
A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU
Abstract:
RATIONALE: Critically ill adults are at risk for a variety of distressing and consequential symptoms both during and after an ICU stay. Management of these symptoms can directly influence outcomes.
OBJECTIVES: The objective was to update and expand the Society of Critical Care Medicine's 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.
PANEL DESIGN: The interprofessional inclusive guidelines task force was composed of 24 individuals including nurses, physicians, pharmacists, physiotherapists, psychologists, and ICU survivors. The task force developed evidence-based recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including task force selection and voting.
METHODS: The task force focused on five main content areas as they pertain to adult ICU patients: anxiety (new topic), agitation/sedation, delirium, immobility, and sleep disruption. Using the GRADE approach, we conducted a rigorous systematic review for each population, intervention, control, and outcome question to identify the best available evidence, statistically summarized the evidence, assessed the quality of evidence, and then performed the evidence-to-decision framework to formulate recommendations.
RESULTS: The task force issued five statements related to the management of anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adults admitted to the ICU. In adult patients admitted to the ICU, the task force issued conditional recommendations to use dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation over usual mobilization/rehabilitation, and administer melatonin. The task force was unable to issue recommendations on the administration of benzodiazepines to treat anxiety, and the use of antipsychotics to treat delirium.
CONCLUSIONS: The guidelines task force provided recommendations for pharmacologic management of agitation/sedation and sleep, and nonpharmacologic management of immobility in critically ill adults. These recommendations are intended for consideration along with the patient's clinical status.
Source: Lewis K. Critical Care Medicine, Mar 2025; 53(3): e711-e727
Enhancing Delirium Prediction in ICU Older Patients Through the 5-Factor Modified Frailty Index
Source: Lewis K. Critical Care Medicine, Mar 2025; 53(3): e711-e727
Enhancing Delirium Prediction in ICU Older Patients Through the 5-Factor Modified Frailty Index
Abstract:
Background: Delirium and frailty are prevalent in the ICU, yet there is a paucity of research utilising frailty as determined by the 5‐factor modified frailty index (mFI‐5) to examine its correlation with delirium in intensive care unit (ICU) older patients.
Aim: The aim of this research was to explore the association between the mFI‐5 and the occurrence of delirium in older patients admitted to the ICU, while assessing the mFI‐5's predictive value for delirium. Study Design: This study employed data extracted from the Medical Information Mart for Intensive Care IV database. The participants were classified into three groups based on their mFI‐5 scores: non‐frail (mFI‐5 = 0), intermediate frailty (mFI‐5 = 1) and high frailty (mFI‐5 ≥ 2). The predictive value of mFI‐5 for delirium was evaluated using the area under the curve, the net reclassification improvement and the integrated discrimination improvement metrics. Results: Delirium was observed in 9919 of the 30 280 patients included in the study. Patients with intermediate frailty (adjusted odds ratios OR]: 1.38, 95% CI: 1.28–1.48, p < 0.001) and high frailty (adjusted OR: 1.83, 95% CI: 1.69–1.97, p < 0.001) exhibited a markedly elevated risk of delirium in comparison to non‐frail patients. Furthermore, the incorporation of the mFI‐5 into the multivariate model markedly enhanced its predictive accuracy for delirium. Conclusions: Frailty as assessed by the mFI‐5 is strongly correlated with an elevated risk of delirium in older ICU patients. The incorporation of the mFI‐5 into delirium prediction models may enhance the predictive accuracy of these models. Relevance to Clinical Practice: The mFI‐5 is a valuable tool for identifying older ICU patients at higher risk of delirium, aiding in early intervention and tailored care.
Source: Li X. Nursing in Critical Care, Jul 2025; 30(4): e70098
Validation of the 4AT for assessing recovery from delirium in older hospital patients
Abstract:
Source: Li X. Nursing in Critical Care, Jul 2025; 30(4): e70098
Validation of the 4AT for assessing recovery from delirium in older hospital patients
Abstract:
Background A crucial part of delirium care is assessing for recovery, yet there are no validated methods for this. The 4AT is a widely used delirium assessment tool, but its performance in assessing recovery remains unstudied. This study evaluated the 4AT's performance in assessing recovery from delirium.
Materials and methods In this prospective diagnostic accuracy study, older hospitalised patients (≥70 years) with reference standard delirium on enrolment were assessed 2–4 times over ≤9 days. Paired researchers independently conducted blinded assessments of (i) a reference standard (Diagnostic and Statistical Manual for Mental Disorders, 5th edition), including the Delirium Rating Scale-Revised-98 and neuropsychological tests and (ii) the 4AT (index test, score ≥ 4 positive) plus brief measures of distress and psychotic symptoms.
Results A total of 120 people with delirium participated median age 86.3, range 70–99, 67 (55.8%) female and 55 (45.8%) with dementia]. All of them completed the first two assessments, 103 (85.8%) completed three and 69 (57.5%) four. Reference standard delirium was present in 102/120 (85%), 72/103 (69.9%) and 53/69 (76.8%) cases at assessments two to four, respectively. In Receiver Operating Characteristic analyses, the 4AT's sensitivity for detecting delirium was 0.95 (confidence interval 0.91–0.99), 0.96 (0.91–1) and 0.94 (0.88–1), and specificity was 0.67 (0.13–1), 0.88 (0.71–1) and 1 (1–1) at assessments two to four. In total 18 (15%) participants recovered from delirium. Distress was common in delirium and decreased with recovery.
Conclusion The 4AT maintains diagnostic accuracy on repeated admissions and may effectively assess delirium recovery in acute hospital settings. Fewer patients than expected recovered within 9 days, suggesting more studies on the natural history of delirium in different settings would be informative.
Source: McCartney H. Age and Ageing, May 2025; 54(6): afaf166
Melatonin for prevention of delirium in patients receiving mechanical ventilation in the intensive care unit: a multiarm multistage adaptive randomized controlled clinical trial (DEMEL)
Abstract:
Source: McCartney H. Age and Ageing, May 2025; 54(6): afaf166
Melatonin for prevention of delirium in patients receiving mechanical ventilation in the intensive care unit: a multiarm multistage adaptive randomized controlled clinical trial (DEMEL)
Abstract:
PURPOSE: To determine the dose of melatonin with an optimal pharmacokinetic profile and to test whether this dose reduces the prevalence of delirium in mechanically ventilated ICU patients as compared to placebo.
METHODS: DEMEL, a multicenter adaptive phase 2b/3 randomized, placebo-controlled, double-blind trial included patients at 20 health centers in France from February 1st, 2019 through January 5th, 2021. Patients were randomized (1:1:1) to receive either placebo or low (0.3 mg) or high (3 mg) dose melatonin enterally at 9:00 p.m. for 14 consecutive nights or until death or ICU discharge, whichever came first. The interim primary endpoint (activity stage) was the percentage of patients who achieved an optimal melatonin pharmacokinetic profile 24 h after starting study treatment; the final primary endpoint (efficacy phase) was the percentage of patients who experienced delirium between randomization and day 14 (or until death or ICU discharge, whichever came first). Delirium was assessed twice daily using the Confusion Assessment Method for ICU.
RESULTS: We randomized 355 patients and included 334 in the primary analysis. At the preplanned analysis of the activity stage performed in 75 patients, the low-dose melatonin group had the highest rate of optimal pharmacokinetic profiles (12/24, 50%) when compared with the high-dose melatonin group (6/25, 24%) and the placebo group (0/26). Therefore, the Steering Committee recommended that the high-dose melatonin group be discontinued and that the low-dose melatonin group be selected to continue in the efficacy phase along with the placebo group. At the end of the efficacy stage, there was no difference in the final primary outcome of delirium incidence between the low-dose melatonin group and the placebo group: 80/147 (54.4%) vs 85/154 (55.2%), risk ratio, 0.986 [95% CI 0.803 to 1.211]; key secondary outcomes were also similar between groups. These included sleep quality, delirium-free, coma-free, and ventilator-free days at day 28; ICU and hospital length of stay; mortality at day 28, in the ICU, and in hospital; as well as long-term outcomes such as quality of life and postintensive care syndrome at day 90.
CONCLUSIONS: This randomized clinical trial found that the low-dose of melatonin (0.3 mg nightly) achieved a better pharmacokinetic profile than the high-dose (3 mg nightly), but did not change the incidence of delirium compared to placebo in mechanically ventilated critically-ill patients.
TRIAL REGISTRATION: ClinicalTrial.gov website (NCT03524937).
Source: Mekontso Dessap A. Intensive Care Medicine, Jul 2025; 51(7): 1292-1305
Social Disparities, Delirium Occurrence, and Related Outcomes Among Hospitalized Older Adults
Source: Mekontso Dessap A. Intensive Care Medicine, Jul 2025; 51(7): 1292-1305
Social Disparities, Delirium Occurrence, and Related Outcomes Among Hospitalized Older Adults
Abstract:
Background: Underlying socio‐economic and health burden may variably impact delirium presentation among older adults. We characterized differences in patient factors related to social marginalization and studied their effects on delirium occurrence and hospital outcomes. Methods: We conducted a 7‐year retrospective analysis of older adults (aged ≥ 70 years) who systematically underwent screening for delirium at an 8‐hospital healthcare system. Our primary exposure included patient characteristics related to demographics and social marginalization. Multivariable logistic regression models were built to identify factors associated with increased odds of delirium occurrence, either (1) present‐on‐admission (D‐POA) or (2) hospital‐acquired (HAD). Secondary outcomes included hospital length of stay, in‐hospital mortality, and discharge disposition.
Results: A total of 260,200 older adults were screened for delirium (median IQR] age in years: 78.0 74.0–84.0]; female: 143,402 55.1%]; non‐Hispanic Black: 40,737 15.8%]; Hispanic: 30,760 11.9%]; median IQR] Area Deprivation Index: 4.0 2.0–6.0]; median IQR] Charlson Comorbidity Index: 10.0 8.0–13.0]). Rates of D‐POA were 25.5% across all screened patients. Among patients delirium‐free at admission, 10.4% later acquired HAD. In addition to known risk associations with older age and comorbidity burden, increased odds of D‐POA were observed for non‐Hispanic Black patients (aOR, 95% CI: 1.49, 1.44–1.54), Hispanic patients (aOR, 95% CI: 1.31, 1.26–1.36), higher ADI‐defined socio‐economic marginalization (aOR, 95% CI: 1.01, 1.00–1.01), and prior dementia (aOR: 6.53, 6.37–6.68). HAD risks were also higher for males (aOR, 95% CI: 1.07, 1.04–1.11), non‐Hispanic Black patients (1.39, 1.32–1.46), Hispanic patients (aOR, 95% CI: 1.28, 1.21–1.35), residence in higher ADI neighborhoods (aOR, 95% CI: 1.02, 1.02–1.03), and prior dementia (aOR, 95% CI: 2.44, 2.34–2.53). Effects of delirium on poor hospital outcomes did not differ by socio‐demographic sub‐groups.
Conclusions: Delirium risks were higher among minoritized and socio‐economically marginalized older adults. These findings present an opportunity to consider social marginalization as an important factor in delirium risk stratification.
Source: Pan Alan P. Journal of the American Geriatrics Society, Dec 2025; 73(12): 3729-3737
Time to routinely perform 4AT at the 'front door'; evidence informing policy and practice
Abstract: The article focuses on the use of the 4′A′s Test (4AT) as a screening tool for identifying delirium and dementia in older patients during hospital admissions. It advocates for a 'front door' triple assessment, which includes the national early warning score, clinical frailty score, and 4AT, for all patients over 65 presenting to emergency departments. A study involving over 75,000 older adult admissions found that while the 4AT is effective in identifying existing dementia and delirium, there are still instances of false negatives, highlighting the need for comprehensive clinical assessments. The article emphasizes the importance of embedding 4AT screening into routine care to improve early diagnosis and management of these conditions, ultimately enhancing patient outcomes and care transitions.
Source: Partridge Judith S L. Age and Ageing, 2025; 54(8): afaf213
Using scores from the 4AT delirium detection tool as an indicator of possible dementia: a study of 75 221 older adult hospital admissions
Abstract: Introduction Overall dementia diagnosis rates are substantially below true rates. Hospital admissions of older people involve cognitive and functional assessments relevant to dementia diagnosis. These assessments could be harnessed to contribute to identifying patients for further assessment. Yet relationships of inpatient cognitive tests with known dementia are unclear. The 4AT (www.the4AT.com) assesses for delirium (Scores 4–12) and also cognitive impairment via embedded cognitive tests (Scores 1–3). We investigated relationships between 4AT scores and clinical dementia diagnoses. Methods We included participants aged ≥65 years admitted as a medical emergency to three hospitals from 4 January 2016 to 4 January 2020, who had the 4AT performed on admission. Clinical dementia diagnosis was ascertained from linked primary care, hospital discharge and community prescribing data. Results Of 75 221 admissions, 62 188 (82.7%; 33 625 unique patients; mean age 80.2 years; 55.8% female) had a 4AT on admission. Of these, 9948 (16.0%) had a recorded clinical dementia diagnosis at the time of admission, with a further 1197 (1.9%) receiving a new diagnosis at discharge. Of admissions with dementia, 9669/11 145 (86.8%) had a 4AT score ≥1 on admission, compared to 14 994/51 043 (29.4%) without dementia. 4AT ≥1 had a sensitivity of 0.87 (95% CI 0.86–0.87) and a specificity of 0.71 (0.70–0.71) in relation to clinical dementia diagnosis. 4AT ≥4 showed sensitivity of 0.50 (0.50–0.51) and a specificity of 0.88 (0.88–0.88). Conclusions 4AT scores were associated with clinically diagnosed dementia. These results suggest that routinely collected 4AT scores could be leveraged in conjunction with other clinical indicators to identify patients with possible undiagnosed dementia who could undergo further inpatient diagnostic assessment and/or post-discharge specialist follow-up.
Source: Penfold Rose S. Age and Ageing, 2025; 54(6): afaf144
Long-term clinical outcomes of delirium after hospital discharge: a systematic review and meta-analysis
Abstract:
Source: Pan Alan P. Journal of the American Geriatrics Society, Dec 2025; 73(12): 3729-3737
Time to routinely perform 4AT at the 'front door'; evidence informing policy and practice
Abstract: The article focuses on the use of the 4′A′s Test (4AT) as a screening tool for identifying delirium and dementia in older patients during hospital admissions. It advocates for a 'front door' triple assessment, which includes the national early warning score, clinical frailty score, and 4AT, for all patients over 65 presenting to emergency departments. A study involving over 75,000 older adult admissions found that while the 4AT is effective in identifying existing dementia and delirium, there are still instances of false negatives, highlighting the need for comprehensive clinical assessments. The article emphasizes the importance of embedding 4AT screening into routine care to improve early diagnosis and management of these conditions, ultimately enhancing patient outcomes and care transitions.
Source: Partridge Judith S L. Age and Ageing, 2025; 54(8): afaf213
Using scores from the 4AT delirium detection tool as an indicator of possible dementia: a study of 75 221 older adult hospital admissions
Abstract: Introduction Overall dementia diagnosis rates are substantially below true rates. Hospital admissions of older people involve cognitive and functional assessments relevant to dementia diagnosis. These assessments could be harnessed to contribute to identifying patients for further assessment. Yet relationships of inpatient cognitive tests with known dementia are unclear. The 4AT (www.the4AT.com) assesses for delirium (Scores 4–12) and also cognitive impairment via embedded cognitive tests (Scores 1–3). We investigated relationships between 4AT scores and clinical dementia diagnoses. Methods We included participants aged ≥65 years admitted as a medical emergency to three hospitals from 4 January 2016 to 4 January 2020, who had the 4AT performed on admission. Clinical dementia diagnosis was ascertained from linked primary care, hospital discharge and community prescribing data. Results Of 75 221 admissions, 62 188 (82.7%; 33 625 unique patients; mean age 80.2 years; 55.8% female) had a 4AT on admission. Of these, 9948 (16.0%) had a recorded clinical dementia diagnosis at the time of admission, with a further 1197 (1.9%) receiving a new diagnosis at discharge. Of admissions with dementia, 9669/11 145 (86.8%) had a 4AT score ≥1 on admission, compared to 14 994/51 043 (29.4%) without dementia. 4AT ≥1 had a sensitivity of 0.87 (95% CI 0.86–0.87) and a specificity of 0.71 (0.70–0.71) in relation to clinical dementia diagnosis. 4AT ≥4 showed sensitivity of 0.50 (0.50–0.51) and a specificity of 0.88 (0.88–0.88). Conclusions 4AT scores were associated with clinically diagnosed dementia. These results suggest that routinely collected 4AT scores could be leveraged in conjunction with other clinical indicators to identify patients with possible undiagnosed dementia who could undergo further inpatient diagnostic assessment and/or post-discharge specialist follow-up.
Source: Penfold Rose S. Age and Ageing, 2025; 54(6): afaf144
Long-term clinical outcomes of delirium after hospital discharge: a systematic review and meta-analysis
Abstract:
Background Delirium has been linked to adverse health outcomes. There has not been a comprehensive attempt to synthesise these outcomes.
Objective To synthesise evidence comparing post-discharge clinical outcomes in individuals who experienced delirium in hospital compared to those who did not.
Methods A systematic electronic search was conducted in Medline, Embase, CINAHL, PsycINFO and Cochrane databases. Random-effects models were used to assess effect size differences between those who experienced delirium and those who did not: odds ratios (OR) for categorical outcomes and Hedges' g for continuous outcomes. Analyses were conducted for each outcome relative to ≤6 months, >6–12 months, 12+ months and collapsed across time post-discharge.
Results Data were synthesised from 253 studies representing 29 814 participants who experienced delirium and 107 583 participants who did not experience delirium. The mean (SD) age of participants was 76.0 (9.3) years. Collapsed over follow-up period, results included, those who experienced delirium in hospital showed higher objective cognitive decline (OR = 1.58, P <.001), greater subjective cognitive impairment (OR = 2.11, P =. 041), greater functional decline (g = −0.43, P =. 001), lower quality of life (g = −0.44, P <.001), higher burden of poor mental health (OR = 1.69, P <.001), increased risk of dementia (OR = 5.37, P <.001), higher likelihood of institutionalisation (OR = 2.80, P <.001), greater rates of hospital readmission (OR = 1.70, P <.001) and increased mortality (OR = 2.55, P <.001) post-hospital discharge compared to those who did not experience delirium in hospital. Time-specific analyses did not reveal any consistent patterns of effects.
Conclusions Older adults who experience delirium in hospital demonstrate significantly worse long-term clinical outcomes compared to those who do not.
Source: Tesfaye Y. Age and Ageing, 2025; 54(7): afaf188
Nurses Must Improve Delirium Care: A Call to Action
Abstract: World Delirium Awareness Day is March 12, 2025. This important annual event is a reminder that delirium is a frequently overlooked yet treatable health issue. Globally, delirium significantly and negatively impacts the wellbeing of millions of people, particularly those who are older. The purpose of this event is to raise awareness about delirium and the wide-ranging effects it has on people experiencing delirium, their families, carers and significant others, as well as health systems and health professionals.
Source: Traynor V. Japan Journal of Clinical Nursing, 2025; 34(6): 1979-1981
Comparative effectiveness of delirium recognition with and without a clinical decision assessment system on outcomes of hospitalized older adults: Cluster randomized controlled trial
Abstract: Early recognition of delirium is essential for effective management, but it often goes unrecognized, resulting in adverse outcomes. Clinical decision support systems can enhance adherence to guidelines and improve patient outcomes. We developed a mobile-based clinical decision assessment tool (3D-DST) based on the 3-minute diagnostic interview for confusion assessment method-defined delirium (3D-CAM). Implementing the 3D-DST may enhance delirium recognition and adherence to interventions among healthcare professionals, potentially improving outcomes in older adults. To test whether improved recognition of delirium could lead to better clinical outcomes in older adults. A cluster randomized controlled trial with pair-matching. A tertiary geriatric hospital. Patients aged ≥ 65 years. Four general wards were paired and randomly assigned to the intervention group (two wards) or the control group (two wards). The intervention included routine delirium assessments by nurses using either the 3D-DST or the 3D-CAM, along with delirium prevention and intervention measures carried out by a multidisciplinary team. Outcomes measured included delirium incidence, duration, severity, length of stay, and adherence to the delirium assessment, prevention, and treatment protocol. A trained nursing researcher collected data on demographics, clinical characteristics, and primary and secondary outcomes. 211 eligible patients participated (106 in the intervention group and 105 in the control group), with 21 identified as delirium-positive using the 3D-DST. The median Charlson comorbidity index score among older adults in the intervention group was 1 (1–2), compared to 2 (1–3) in the control group (P = 0.032). Nurses' adherence to delirium assessment was significantly higher in the intervention group than in the control group (73 % vs. 31 %). The recognition rate of delirium among nurses was 89 % in the intervention group and 42 % in the control group. There were no statistically significant differences in delirium duration (6 3–9] vs. 7 2–14], P = 0.967), incidence (8.5 % vs. 11.4 %, P = 0.500), severity (2 1–3] vs. 2 1–4], P = 0.891) or length of hospital stay (15 14–18] vs. 18 13–22], P = 0.568) between the intervention and control groups. The 3D-DST enhanced adherence to routine delirium recognition by nurses. However, effective strategies are urgently needed to strengthen multidisciplinary collaboration and enhance adherence to delirium management among healthcare professionals. Chinese Clinical Trial Registry, Identifier: ChiCTR1900028402.
Source: Wang J. International Journal of Nursing Studies, Feb 2025; 162: 104979
Source: Tesfaye Y. Age and Ageing, 2025; 54(7): afaf188
Nurses Must Improve Delirium Care: A Call to Action
Abstract: World Delirium Awareness Day is March 12, 2025. This important annual event is a reminder that delirium is a frequently overlooked yet treatable health issue. Globally, delirium significantly and negatively impacts the wellbeing of millions of people, particularly those who are older. The purpose of this event is to raise awareness about delirium and the wide-ranging effects it has on people experiencing delirium, their families, carers and significant others, as well as health systems and health professionals.
Source: Traynor V. Japan Journal of Clinical Nursing, 2025; 34(6): 1979-1981
Comparative effectiveness of delirium recognition with and without a clinical decision assessment system on outcomes of hospitalized older adults: Cluster randomized controlled trial
Abstract: Early recognition of delirium is essential for effective management, but it often goes unrecognized, resulting in adverse outcomes. Clinical decision support systems can enhance adherence to guidelines and improve patient outcomes. We developed a mobile-based clinical decision assessment tool (3D-DST) based on the 3-minute diagnostic interview for confusion assessment method-defined delirium (3D-CAM). Implementing the 3D-DST may enhance delirium recognition and adherence to interventions among healthcare professionals, potentially improving outcomes in older adults. To test whether improved recognition of delirium could lead to better clinical outcomes in older adults. A cluster randomized controlled trial with pair-matching. A tertiary geriatric hospital. Patients aged ≥ 65 years. Four general wards were paired and randomly assigned to the intervention group (two wards) or the control group (two wards). The intervention included routine delirium assessments by nurses using either the 3D-DST or the 3D-CAM, along with delirium prevention and intervention measures carried out by a multidisciplinary team. Outcomes measured included delirium incidence, duration, severity, length of stay, and adherence to the delirium assessment, prevention, and treatment protocol. A trained nursing researcher collected data on demographics, clinical characteristics, and primary and secondary outcomes. 211 eligible patients participated (106 in the intervention group and 105 in the control group), with 21 identified as delirium-positive using the 3D-DST. The median Charlson comorbidity index score among older adults in the intervention group was 1 (1–2), compared to 2 (1–3) in the control group (P = 0.032). Nurses' adherence to delirium assessment was significantly higher in the intervention group than in the control group (73 % vs. 31 %). The recognition rate of delirium among nurses was 89 % in the intervention group and 42 % in the control group. There were no statistically significant differences in delirium duration (6 3–9] vs. 7 2–14], P = 0.967), incidence (8.5 % vs. 11.4 %, P = 0.500), severity (2 1–3] vs. 2 1–4], P = 0.891) or length of hospital stay (15 14–18] vs. 18 13–22], P = 0.568) between the intervention and control groups. The 3D-DST enhanced adherence to routine delirium recognition by nurses. However, effective strategies are urgently needed to strengthen multidisciplinary collaboration and enhance adherence to delirium management among healthcare professionals. Chinese Clinical Trial Registry, Identifier: ChiCTR1900028402.
Source: Wang J. International Journal of Nursing Studies, Feb 2025; 162: 104979
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Delirium in Critically Ill Geriatric Surgical Patients: A Systematic Review of Screening, Risk Factors, Diagnosis, and Management
Abstract:
Delirium in Critically Ill Geriatric Surgical Patients: A Systematic Review of Screening, Risk Factors, Diagnosis, and Management
Abstract:
OBJECTIVE: This systematic review aims to evaluate optimal early screening strategies, significant risk factors, and effective diagnostic and management approaches for delirium in critically ill geriatric surgical patients.
DATA SOURCES: A comprehensive search was conducted across five databases: PubMed, Google Scholar, ProQuest, Embase, and Cochrane.
STUDY SELECTION: Studies were included based on their relevance to early screening, risk factors, diagnostic accuracy, and management strategies for delirium in critically ill geriatric surgical patients. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
DATA EXTRACTION: A total of 31 studies met the inclusion criteria. Outcomes of interest included effective early screening/prevention strategies, significant risk factors, sensitive diagnosis tools, and effective management strategies.
DATA SYNTHESIS: Early screening strategies, including advanced neural networks and E-PROD-NS, demonstrated high sensitivity and specificity (area under the receiver operating characteristic curve >0.76). Key risk factors included advanced age, renal dysfunction, cognitive impairment, prolonged intensive care unit length of stay (ICU-LOS), and mechanical ventilation time. Diagnostic tools such as the 4A's test and serum biomarkers exhibited superior accuracy compared to the ICU Confusion Assessment Method and Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria. Management strategies effectively reduced delirium duration, including acetaminophen, environmental modifications, and family involvement.
CONCLUSIONS: E-PROD-NS and the 4A's test were associated with early delirium detection and intervention. Risk factors for delirium included advanced age, renal dysfunction, and existing cognitive dysfunction. Mitigating mechanical ventilation and ICU-LOS duration, treatment with acetaminophen, and environmental modifications reduced delirium duration in critically ill geriatric surgical patients. REGISTRATION: PROSPERO #CRD42025632279.
Source: Yates Z. Journal of Trauma Nursing, Jul 2025; 32(4): 169-179
Source: Yates Z. Journal of Trauma Nursing, Jul 2025; 32(4): 169-179
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The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study
Abstract:
The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study
Abstract:
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 fifth 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 years.
RESULTS: A total of 137 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. About 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 add to the literature evaluating methods of delirium detection in palliative care settings. TRIAL REGISTRY: ISCRTN 97417474.
Source: Arnold E. Palliative Medicine, May 2024; 38(5): 535-545
Diagnostic Accuracy of the Recognizing Acute Delirium as Part of Your Routine (RADAR) Scale for Delirium Assessment in Hospitalized Older Adults: A Cross-Sectional Study
Abstract: Delirium is highly prevalent among hospitalized older adults and is associated with unfavorable outcomes. However, delirium often remains undiagnosed in the hospital context. Having a valid, simple, and fast screening tool could help in limiting the additional workload for healthcare professionals, without leaving delirium undetected. The aim of this study was to estimate the sensitivity and specificity of the Recognizing Acute Delirium As part of your Routine (RADAR) scale in an Italian hospital. An observational cross-sectional study was conducted. A total of 150 patients aged ≥70 years were enrolled. Receiver operating characteristic (ROC) curves using the Confusion Assessment Method (CAM) criterion-defined delirium as the gold standard were plotted to evaluate the performance of the RADAR scale. The cut-off suggested by previous research was used to estimate the sensitivity, specificity, and positive and negative predictive values of the RADAR scale. The involved patients were mostly females (60%; n = 90), with a median age of 84 years (I-III quartiles: 80-88). According to the CAM and the RADAR scale, 37 (25%) and 58 (39%) patients were classified as experiencing delirium, respectively. The area under the ROC curve of the RADAR scale was 0.916. Furthermore, the RADAR scale showed robust sensitivity (95%), specificity (80%), and positive (60%) and negative predictive values (98%). The RADAR scale is thus suggested to be a valid tool for screening assessment of delirium in hospitalized older adults.
Source: Fabrizi D. Healthcare (Basel, Switzerland), Jun 2024; 12(13): 1294
The 4AT scale for rapid detection of delirium in emergency department triage
Abstract:
Source: Arnold E. Palliative Medicine, May 2024; 38(5): 535-545
Diagnostic Accuracy of the Recognizing Acute Delirium as Part of Your Routine (RADAR) Scale for Delirium Assessment in Hospitalized Older Adults: A Cross-Sectional Study
Abstract: Delirium is highly prevalent among hospitalized older adults and is associated with unfavorable outcomes. However, delirium often remains undiagnosed in the hospital context. Having a valid, simple, and fast screening tool could help in limiting the additional workload for healthcare professionals, without leaving delirium undetected. The aim of this study was to estimate the sensitivity and specificity of the Recognizing Acute Delirium As part of your Routine (RADAR) scale in an Italian hospital. An observational cross-sectional study was conducted. A total of 150 patients aged ≥70 years were enrolled. Receiver operating characteristic (ROC) curves using the Confusion Assessment Method (CAM) criterion-defined delirium as the gold standard were plotted to evaluate the performance of the RADAR scale. The cut-off suggested by previous research was used to estimate the sensitivity, specificity, and positive and negative predictive values of the RADAR scale. The involved patients were mostly females (60%; n = 90), with a median age of 84 years (I-III quartiles: 80-88). According to the CAM and the RADAR scale, 37 (25%) and 58 (39%) patients were classified as experiencing delirium, respectively. The area under the ROC curve of the RADAR scale was 0.916. Furthermore, the RADAR scale showed robust sensitivity (95%), specificity (80%), and positive (60%) and negative predictive values (98%). The RADAR scale is thus suggested to be a valid tool for screening assessment of delirium in hospitalized older adults.
Source: Fabrizi D. Healthcare (Basel, Switzerland), Jun 2024; 12(13): 1294
The 4AT scale for rapid detection of delirium in emergency department triage
Abstract:
AIMS: To assess the diagnostic accuracy and time impact of the 4AT scale in emergency department triage.
METHODS: A Prospective diagnostic accuracy study was carried out. People aged ≥65 years presenting to the emergency department from 1 November 2021 to 30 June 2022 were included. Nurses opportunistically screened eligible patients using the 4AT scale during triage according to the Manchester Triage System Francesc de Borja Hospital emergency department, Gandía (Spain). Accuracy was compared with medical diagnosis of delirium. Time (seconds) spent in triage with and without screening was assessed.
RESULTS: The study included 370 patients (55.1% men, mean age 81.8 years), of whom 58.4% (n = 216) were screened. A final diagnosis of delirium was made in 41.4% of those screened. The most frequently used presentational flow charts and discriminators were 'behaving strangely' (15%) and 'rapid onset' (33.3%). The highest accuracy was obtained for a score of 3 points or more (sensitivity 85.1%; specificity 66.9%; positive predictive value 52.8%; negative predictive value 71.7%). No significant differences were found in the time spent in triage according to the performance of screening.
CONCLUSION: A score of 3 points or more on the 4AT scale enables rapid detection of delirium in emergency department triage, without consuming more time than conventional triage.
Source: Soler-Sanchis A. Frontiers in Medicine, May 2024; 11: 1345983
Diagnostic accuracy of the 4AT for delirium: A systematic review and meta-analysis
Abstract:
Source: Soler-Sanchis A. Frontiers in Medicine, May 2024; 11: 1345983
Diagnostic accuracy of the 4AT for delirium: A systematic review and meta-analysis
Abstract:
INTRODUCTION: Despite common, serious, costly, and often fatal conditions affecting up to 50 % of older patients, delirium is often unrecognized and overlooked. We examine the accuracy of the 4AT for detecting older patients with delirium.
METHODS: We performed a systematic search of PubMed, Web of Science, PsycINFO, and EMBASE databases from inception to April 2020 and updated to January 2022. Four independently reviewers extracted study data and assessed the methodological quality using the revised quality assessment of diagnostic accuracy studies tool (QUADAS-2). Pooled estimates of sensitivity and specificity were generated using a bivariate random effects model. All statistical analyses were performed with STATA version 15.1 and Meta-DiSc version 1.4 software.
RESULTS: Eleven studies with 2789 participants were included. The pooled sensitivity and specificity were 0.87 (95 % CI: 0.81-0.91) and 0.87 (95 % CI: 0.79-0.92), respectively, and the positive and negative likelihood ratios were 6.66 (95 % CI: 4.12-10.74) and 0.15 (95 % CI: 0.10-0.23), respectively. Deeks' test indicated no significant publication bias (t = 0.83, P = 0.43). Univariable meta-regression showed that patient selection and flow and timing significantly influenced the pooled sensitivity (P < 0.05), settings significantly influenced the pooled specificity (P < 0.05).
CONCLUSION: Our meta-analysis demonstrates that 4AT is a sensitive and specific screening tool for delirium in older patients. Its brevity and simplicity support its use in routine clinical practice, particularly in time-poor settings. Clinicians should come to a conclusion based largely on the 4AT findings in conjunction with clinical judgment.
Source: Hou L. Asian Journal of Psychiatry, Feb 2023; 80: 103374
Source: Hou L. Asian Journal of Psychiatry, Feb 2023; 80: 103374
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Delirium screening in a stroke unit by nurses using 4AT: Results from a quality improvement project
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Delirium screening in a stroke unit by nurses using 4AT: Results from a quality improvement project
Abstract:
AIM: To assess the feasibility of delirium screening with the screening tool 4AT conducted by stroke unit nurses. DESIGN: Observational.
METHODS: Patients with confirmed acute stroke admitted to the stroke unit at Baerum Hospital, Norway, from March to October 2020, were consecutively recruited. Nurses performed delirium screening using the rapid screening tool 4AT within 24 h of admission, at discharge and when delirium was suspected, and filled out a questionnaire assessing their experiences with the delirium screening. A geriatrician validated the delirium diagnosis. RESULTS: In all, 62 patients were included, mean age 73.3 years. 4AT was performed according to protocol in 49 (79.0%) and 39 (62.9%) patients at admission and discharge respectively. Lack of time (40%) was reported as the most common reason for not performing delirium screening. The nurses reported that the felt competent to carry out the 4AT screening, and did not experience it as significant extra workload. Five patients (8%) were diagnosed with delirium. Delirium screening performed by stroke unit nurses seemed feasible and the nurses experienced that 4AT was a useful tool for this purpose.
Source: Ihle-Hansen, H. Nursing Open, Nov 2023; 10(11): 7431-7436
Delirium assessment tools among hospitalized older adults: A systematic review and metaanalysis of diagnostic accuracy
Abstract: Delirium is a common neuropsychiatric syndrome that is often overlooked in clinical settings. The most accurate instrument for screening delirium has not been established. This study aimed to compare the diagnostic accuracy of the 4 'A's Test (4AT), Nursing Delirium Screening Scale (Nu-DESC), and Confusion Assessment Method (CAM) in detecting delirium among older adults in clinical settings. These assessment tools feature concise item sets and straightforward administration procedures. Five electronic databases were systematically searched from their inception to September 7, 2022. Studies evaluating the sensitivity and specificity of the 4AT, Nu-DESC, and CAM against the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases as the reference standard were included. Bivariate random effects model was used to summarize the sensitivity and specificity results. A total of 38 studies involving 7378 patients were included. The 4AT, Nu-DESC, and CAM had comparable sensitivity in detecting delirium (0.76, 0.78, and 0.80, respectively). However, the specificity of the CAM was higher than that of the 4AT (0.98 vs 0.89, P = .01) and Nu-DESC 0.99 vs 0.90, P = .003). Diagnostic accuracy was moderated by the percentage of women, acute care setting, sample size, and assessors. The three tools exhibit comparable sensitivity, and the CAM has the highest specificity. Based on the feasibility of the tools, nurses and clinical staffs could employ the Nu-DESC and the 4AT on screening out positive delirium cases and integrate these tools into daily practice. Further investigations are warranted to verify our findings.
Source: Lin C. Sep 2023, Ageing Research Reviews; 90: 102025
Source: Ihle-Hansen, H. Nursing Open, Nov 2023; 10(11): 7431-7436
Delirium assessment tools among hospitalized older adults: A systematic review and metaanalysis of diagnostic accuracy
Abstract: Delirium is a common neuropsychiatric syndrome that is often overlooked in clinical settings. The most accurate instrument for screening delirium has not been established. This study aimed to compare the diagnostic accuracy of the 4 'A's Test (4AT), Nursing Delirium Screening Scale (Nu-DESC), and Confusion Assessment Method (CAM) in detecting delirium among older adults in clinical settings. These assessment tools feature concise item sets and straightforward administration procedures. Five electronic databases were systematically searched from their inception to September 7, 2022. Studies evaluating the sensitivity and specificity of the 4AT, Nu-DESC, and CAM against the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases as the reference standard were included. Bivariate random effects model was used to summarize the sensitivity and specificity results. A total of 38 studies involving 7378 patients were included. The 4AT, Nu-DESC, and CAM had comparable sensitivity in detecting delirium (0.76, 0.78, and 0.80, respectively). However, the specificity of the CAM was higher than that of the 4AT (0.98 vs 0.89, P = .01) and Nu-DESC 0.99 vs 0.90, P = .003). Diagnostic accuracy was moderated by the percentage of women, acute care setting, sample size, and assessors. The three tools exhibit comparable sensitivity, and the CAM has the highest specificity. Based on the feasibility of the tools, nurses and clinical staffs could employ the Nu-DESC and the 4AT on screening out positive delirium cases and integrate these tools into daily practice. Further investigations are warranted to verify our findings.
Source: Lin C. Sep 2023, Ageing Research Reviews; 90: 102025
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Barriers to completing the 4AT for delirium and its clinical implementation in two hospitals: a mixed-methods study
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Barriers to completing the 4AT for delirium and its clinical implementation in two hospitals: a mixed-methods study
Abstract:
PURPOSE: To assess the clinical implementation and barriers to completing the 4AT for delirium in general medical and geriatric patients over 75 years upon admission to Wellington and Kenepuru Hospitals during the first eight months of 2017, 2018 and 2019. METHODS: Retrospective data from electronic health records were analysed using an explanatory-sequential mixed-methods approach. The initial quantitative phase measured doctors' adherence to the 4AT and the rate of positive 4ATs (≥ 4). The subsequent qualitative phase identified doctors' main reasons for omitting the 4AT through conventional content analysis.
RESULTS: The quantitative population included 7799 acute admissions (mean age 84, 58.2% female). There was good clinical implementation of the 4AT, evidenced by an overall adherence rate of 83.2% and a rate of positive 4ATs of 14.8% that is in keeping with expected delirium rates in similar settings. The qualitative sample consisted of 875 acute admissions (mean age 84, 56.3% female) with documented reasons for omitting the 4AT. The main barriers to completing the 4AT were: reduced patient alertness, communication barriers (language, deafness, aphasia and dysarthria), prioritising patients' wellness and comfort (addressing critical illnesses, symptoms, end-of-life issues and promoting sleep), pre-existing cognitive disorders, and unstructured delirium assessments.
CONCLUSION: Adherence to the 4AT was high and sustainable in both hospitals. Most barriers to completing the 4AT were potentially avoidable. Education about the 4AT in relation to these barriers may improve its implementation.
Source: Alhaidari, Abdullah A O. European Geriatric Medicine, Feb 2022; 13(1): 163-172
A prospective study of remote delirium screening using the modified K-4AT for COVID-19 inpatients
Abstract:
Source: Alhaidari, Abdullah A O. European Geriatric Medicine, Feb 2022; 13(1): 163-172
A prospective study of remote delirium screening using the modified K-4AT for COVID-19 inpatients
Abstract:
BACKGROUND: Delirium is a neuropsychiatric condition strongly associated with poor clinical outcomes such as high mortality and long hospitalization. In the patients with Coronavirus disease 2019 (COVID-19), delirium is common and it is considered as one of the risk factors for mortality. For those admitted to negative-pressure isolation units, a reliable, validated and contact-free delirium screening tool is required.
MATERIALS AND METHODS: We prospectively recruited eligible patients from multiple medical centers in South Korea. Delirium was evaluated using the Confusion Assessment Method (CAM) and 4'A's Test (4AT). The attentional component of the 4AT was modified such that respondents are required to count days, rather than months, backward in Korean. Blinded medical staff evaluated all patients and determined whether their symptoms met the delirium criteria of the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). An independent population of COVID-19 patients was used to validate the 4AT as a remote delirium screening tool. We calculated the area under the receiver operating characteristic curve (AUC).
RESULTS: Out of 286 general inpatients, 28 (9.8%) inpatients had delirium. In this population, the patients with delirium were significantly older (p = 0.018) than the patients without delirium, and higher proportion of males were included in the delirium group (p < 0.001). The AUC of the 4AT was 0.992 [95% confidence interval (CI) 0.983-1.000] and the optimal cutoff was at 3. Of the independent COVID-19 patients, 13 of 108 (12.0%) had delirium. Demographically, the COVID-19 patients who had delirium only differed in employment status (p = 0.047) from the COVID-19 patients who did not have delirium. The AUC for remote screening using the 4AT was 0.996 (0.989-1.000). The optimal cutoff of this population was also at 3.
CONCLUSION: The modified K-4AT had acceptable reliability and validity when used to screen inpatients for delirium. More importantly, the 4AT efficiently screened for delirium during remote evaluations of COVID-19 patients, and the optimal cutoff was 3. The protocol presented herein can be used for remote screening of delirium using the 4AT.
Source: Hur, Hyun J. Frontiers in Psychiatry, Aug 2022; 13: 976228
Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis: a prospective cohort study
Abstract:
Source: Hur, Hyun J. Frontiers in Psychiatry, Aug 2022; 13: 976228
Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis: a prospective cohort study
Abstract:
PURPOSE: We aimed to study the use of The 4 'A's test (4AT), a rapid delirium screening tool, performed upon Emergency Department (ED) admission, and to characterize older patients admitted to the ED with and without sepsis in terms of delirium features.
METHODS: In this prospective cohort study, we included patients aged ≥ 65 years, admitted to the ED with suspected sepsis. ED nurses and doctors performed delirium screening with 4AT within two hours after ED admission, and registered the time spent on the screening in each case. Sepsis and delirium during the hospital stay were diagnosed retrospectively, according to recommended diagnosis criteria.
RESULTS: Out of the 196 patients included (mean age 81 years, 60% men), 100 patients fulfilled the sepsis diagnosis criteria. The mean 4AT screening time was 2.5 Minutes. In total, 114 patients (58%) had a 4AT score ≥ 1, indicating cognitive impairment, upon ED admission. Sepsis patients more often had a 4AT score ≥ 4, indicating delirium, than patients without sepsis (40% vs. 26%, p < 0.05). Out of the 100 patients with sepsis, 68 (68%) had delirium during the hospital stay, as compared to 34 out of 96 patients (35%) without sepsis (p < 0.05). CONCLUSION: Delirium screening upon ED admission, using 4AT, was feasible among patients aged ≥ 65 years admitted with suspected sepsis. Two out of three patients had at least one feature of delirium upon admission. The prevalence of delirium during the hospital stay was high, particularly in patients with sepsis. Delirium screening with 4AT in the Emergency Department.
Source: Myrstad M. European Geriatric Medicine, Feb 2022; 13(1): 155-162
Is the 4AT Score Accurate in Identifying Delirium in Older Adults?
Abstract: Take-Home Message
The 4 A’s Test (4AT) has good diagnostic accuracy for detecting delirium in patients aged 65 years or older across different hospital settings.
Methods
Data Sources
Two authors searched the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, Web of Science Core Collection, MEDLINE, Cumulative Index of Nursing and Allied Health Literature Plus, Database of Abstracts of Reviews of Effects, and ClinicalTrials.gov from 2011 at the release of the 4AT score to December 21, 2019. Authors used search terms to comprehensively capture 4AT scores, as well as organic causes of delirium. There were no language restrictions.
Study Selection
Authors included studies with the following criteria: study population comprised patients aged 65 years or older, evaluated the diagnostic accuracy of the 4AT score for delirium, referenced a standard delirium tool with diagnostic criteria or a validated tool, and used a cross-sectional, retrospective, or prospective cohort design. In studies assessing patients younger and older than the age threshold, the authors contacted the original study authors to obtain the data for only those older than the age threshold. They excluded patients with delirium tremens. Two authors independently assessed studies for relevance and resolved disagreements through discussion, arbitrated by a third author.
Data Extraction and Synthesis
Two pairs of investigators independently extracted data from included studies, with discrepancies resolved by a third author or discussion. The primary outcome was identification of delirium by the 4AT score. The authors stratified subgroup analyses by assessing sensitivity and specificity when including only studies at low risk of bias, excluding retrospective studies, and excluding stroke patients. Investigators estimated sensitivity and specificity with 95% confidence interval, using a bivariate random-effects model. Summary estimates of sensitivities and specificities were calculated with receiver operating characteristics plots. Risk of bias and applicability of each study were assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool.
Source: Bridwell Rachel E. Annals of Emergency Medicine, Jun 2021; 77(6): 628-630
The delirium screening tool 4AT in routine clinical practice: prediction of mortality, sensitivity and specificity
Abstract:
Source: Myrstad M. European Geriatric Medicine, Feb 2022; 13(1): 155-162
Is the 4AT Score Accurate in Identifying Delirium in Older Adults?
Abstract: Take-Home Message
The 4 A’s Test (4AT) has good diagnostic accuracy for detecting delirium in patients aged 65 years or older across different hospital settings.
Methods
Data Sources
Two authors searched the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, Web of Science Core Collection, MEDLINE, Cumulative Index of Nursing and Allied Health Literature Plus, Database of Abstracts of Reviews of Effects, and ClinicalTrials.gov from 2011 at the release of the 4AT score to December 21, 2019. Authors used search terms to comprehensively capture 4AT scores, as well as organic causes of delirium. There were no language restrictions.
Study Selection
Authors included studies with the following criteria: study population comprised patients aged 65 years or older, evaluated the diagnostic accuracy of the 4AT score for delirium, referenced a standard delirium tool with diagnostic criteria or a validated tool, and used a cross-sectional, retrospective, or prospective cohort design. In studies assessing patients younger and older than the age threshold, the authors contacted the original study authors to obtain the data for only those older than the age threshold. They excluded patients with delirium tremens. Two authors independently assessed studies for relevance and resolved disagreements through discussion, arbitrated by a third author.
Data Extraction and Synthesis
Two pairs of investigators independently extracted data from included studies, with discrepancies resolved by a third author or discussion. The primary outcome was identification of delirium by the 4AT score. The authors stratified subgroup analyses by assessing sensitivity and specificity when including only studies at low risk of bias, excluding retrospective studies, and excluding stroke patients. Investigators estimated sensitivity and specificity with 95% confidence interval, using a bivariate random-effects model. Summary estimates of sensitivities and specificities were calculated with receiver operating characteristics plots. Risk of bias and applicability of each study were assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool.
Source: Bridwell Rachel E. Annals of Emergency Medicine, Jun 2021; 77(6): 628-630
The delirium screening tool 4AT in routine clinical practice: prediction of mortality, sensitivity and specificity
Abstract:
PURPOSE: Delirium is common and associated with poor outcomes, partly due to underdetection. We investigated if the delirium screening tool 4 A's test (4AT) score predicts 1 year mortality and explored the sensitivity and specificity of the 4AT when applied as part of a clinical routine.
METHODS: Secondary analyses of a prospective study of 228 patients acutely admitted to a Medical Geriatric Ward. Physicians without formal training conducted the index test (the 4AT); a predefined cut-off ≥ 4 suggested delirium. Reference standard was delirium diagnosed by two geriatricians using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). We calculated hazard ratios (HR) using Cox regression based on the groups 4AT = 0, 1-3, 4-7 and ≥ 8, first unadjusted, then adjusted for the covariates age, comorbidity, and personal activities of daily living. We calculated sensitivity, specificity, and the area under the receiver operating curve (AUC).
RESULTS: Mean age of patients was 86.6 years, 139 (61.0%) were female, 78 (34.2%) had DSM-5 delirium; of these, 56 had 4AT-delirium. 1 year mortality was 27.6% (63 patients). Compared to 4AT score 0, the group 4AT ≥ 8 had increased 1 year mortality (HR 2.86, 95% confidence interval 1.28-6.37, p = 0.010). The effect was reduced in multiadjusted analyses (HR 1.69, 95% confidence interval 0.70-4.07, p = 0.24). Sensitivity, specificity, and AUC were 0.72, 0.84, and 0.88, respectively.
CONCLUSIONS: 4AT ≥ 8 indicates increased mortality, but the effect was reduced in multiadjusted analyses. 4AT had acceptable sensitivity and specificity when applied as a clinical routine.
Source: Evensen S. European Geriatric Medicine, Aug 2021; 12(4): 793-800
Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis
Abstract:
Source: Evensen S. European Geriatric Medicine, Aug 2021; 12(4): 793-800
Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis
Abstract:
OBJECTIVE: Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 'A's Test (4AT) is a short (<2 minutes) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection.
METHODS: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model.
RESULTS: Seventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8-32.1%; range 10.5-61.9%). The pooled sensitivity was 0.88 (95% CI 0.80-0.93) and the pooled specificity was 0.88 (95% CI 0.82-0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77-0.92) and the pooled specificity was 0.89 (95% CI 0.83-0.93). The methodological quality of studies varied but was moderate to good overall.
CONCLUSIONS: The 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection. PROSPERO REGISTRATION NUMBER: CRD42019133702.
Source: Tieges Z. Age and Ageing, May 2021; 50(3): 733-743
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.
Source: Jeong E. International Journal of Environmental Research and Public Health, Oct 2020; 17(20): 7515
RADAR: A Measure of the Sixth Vital Sign?
Abstract: The objective of this study was to investigate the potential of RADAR (Recognizing Active Delirium As part of your Routine) as a measure of the sixth vital sign. This study was a secondary analysis of a study (N = 193) that took place in one acute care hospital and one long-term care facility. The primary outcome was a positive sixth vital sign, defined as the presence of both an altered level of consciousness and inattention. These indicators were assessed using the Confusion Assessment Method. RADAR identified 30 of the 43 participants as having a positive sixth vital sign and 58 of the 70 cases as not, yielding a sensitivity and specificity of 70% and 83%, respectively. Positive predictive value was 71%. RADAR's characteristics, including its brevity and acceptability by nursing staff, make this tool a good candidate as a measure of the sixth vital sign. Future studies should address the generalizability of RADAR among various populations and clinical settings.
Source: Voyer P. Clinical Nursing Research, Feb 2016; 25(1): 9-29
Source: Tieges Z. Age and Ageing, May 2021; 50(3): 733-743
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.
Source: Jeong E. International Journal of Environmental Research and Public Health, Oct 2020; 17(20): 7515
RADAR: A Measure of the Sixth Vital Sign?
Abstract: The objective of this study was to investigate the potential of RADAR (Recognizing Active Delirium As part of your Routine) as a measure of the sixth vital sign. This study was a secondary analysis of a study (N = 193) that took place in one acute care hospital and one long-term care facility. The primary outcome was a positive sixth vital sign, defined as the presence of both an altered level of consciousness and inattention. These indicators were assessed using the Confusion Assessment Method. RADAR identified 30 of the 43 participants as having a positive sixth vital sign and 58 of the 70 cases as not, yielding a sensitivity and specificity of 70% and 83%, respectively. Positive predictive value was 71%. RADAR's characteristics, including its brevity and acceptability by nursing staff, make this tool a good candidate as a measure of the sixth vital sign. Future studies should address the generalizability of RADAR among various populations and clinical settings.
Source: Voyer P. Clinical Nursing Research, Feb 2016; 25(1): 9-29
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Recognizing acute delirium as part of your routine [RADAR]: a validation study
Abstract:
Recognizing acute delirium as part of your routine [RADAR]: a validation study
Abstract:
BACKGROUND: Although detection of delirium using the current tools is excellent in research settings, in routine clinical practice, this is not the case. Together with nursing staff, we developed a screening tool (RADAR) to address certain limitations of existing tools, notably administration time, ease-of-use and generalizability. The purpose of this study was not only to evaluate the validity and reliability of RADAR but also to gauge its acceptability among the nursing staff in two different clinical settings.
METHODS: This was a validation study conducted on three units of an acute care hospital (medical, cardiology and coronary care) and five units of a long-term care facility. A total of 142 patients and 51 residents aged 65 and over, with or without dementia, participated in the study and 139 nurses were recruited and trained to use the RADAR tool. Data on each patient/resident was collected over a 12-hour period. The nursing staff and researchers administered RADAR during the scheduled distribution of medication. Researchers used the Confusion Assessment Method to determine the presence of delirium symptoms. Delirium itself was defined as meeting the criteria for DMS-IV-TR delirium. Inter-rater reliability, convergent, and concurrent validity of RADAR were assessed. At study end, 103 (74%) members of the nursing staff completed the RADAR feasibility and acceptability questionnaire. RESULTS: Percentages of agreement between RADAR items that bedside nurses administered and those research assistants administered varied from 82% to 98%. When compared with DSM-IV-TR criterion-defined delirium, RADAR had a sensitivity of 73% and a specificity of 67%. Participating nursing staff took about seven seconds on average, to complete the tool and it was very well received (≥98%) overall.
CONCLUSIONS: The RADAR tool proved to be efficient, reliable, sensitive and very well accepted by nursing staff. Consequently, it becomes an appropriate new option for delirium screening among older adults, with or without cognitive impairment, in both hospitals and nursing homes. Further projects are currently underway to validate the RADAR among middle-aged adults, as well as in newer clinical settings; home care, emergency department, medical intensive care unit, and palliative care.
Source: Voyer P. BMC Nursing, Apr 2015; 14: 19
Source: Voyer P. BMC Nursing, Apr 2015; 14: 19
