Objective: to evaluate the performance of the 4 ‘A’s Test (4AT) in screening for delirium in older patients. The 4AT is a new test for rapid screening of delirium in routine clinical practice.Design: prospective study of consecutively admitted elderly patients with independent 4AT and reference standard assessments.Setting: an acute geriatrics ward and a department of rehabilitation.Participants: two hundred and thirty-six patients (aged ≥70 years) consecutively admitted over a period of 4 months.Measurements: in each centre, the 4AT was administered by a geriatrician to eligible patients within 24 h of admission. Reference standard delirium diagnosis (DSM-IV-TR criteria) was obtained within 30 min by a different geriatrician who was blind to the 4AT score. The presence of dementia was assessed using the Alzheimer's Questionnaire and the informant section of the Clinical Dementia Rating scale. The main outcome measure was the accuracy of the 4AT in diagnosing delirium.Results: patients were 83.9 ± 6.1 years old, and the majority were women (64%). Delirium was detected in 12.3% (n = 29), dementia in 31.2% (n = 74) and a combination of both in 7.2% (n = 17). The 4AT had a sensitivity of 89.7% and specificity 84.1% for delirium. The areas under the receiver operating characteristic curves for delirium diagnosis were 0.93 in the whole population, 0.92 in patients without dementia and 0.89 in patients with dementia.Conclusions: the 4AT is a sensitive and specific method of screening for delirium in hospitalised older people. Its brevity and simplicity support its use in routine clinical practice.

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The systemic injection of L-Acetylcarnitine (L-Ac) induces a reversible increase in recurrent inhibition. In addition, L-Ac potentiation of recurrent inhibition has been found to increase the synchronous activity of single motor units, as detected by traditional linear analysis in the time domain. This result has been recently confirmed using a nonlinear method based on the analysis of embedded determinism (%DET) extracted from the surface EMG. The present study aimed at testing the general applicability of RQA methodology, as a viable tool for assessing motor unit synchronization, by extending the analysis of surface EMG, as revealed by changes in %DET induced by L-Ac, to many upper and lower limb muscles and to muscles that are not easily studied by needle electrodes, such as the orbicularis oculi. Subjects performed brief periods of tonic contractions, alternated to periods of rests to avoid muscle fatigue. Pharmacological enhancement of recurrent inhibition was obtained by a short-lasting intravenous injection of L-Ac. Control experiments were performed replacing L-Ac injection with saline injection. The average %DET showed a significant increase during L-Ac injection in the deltoid, biceps brachii, extensor carpi radialis, while no effect was observed in the opponens pollicis and abductor digiti minimi for the upper limb muscles. Similarly, the average %DET showed a significant increase during L-Ac injection in the quadriceps, soleus, and tibialis anterior, while no effect was observed in the abductor hallucis for the lower limb muscles. RQA of orbicularis oculi muscle activity showed no increase in %DET during L-Ac injection in analogy to what found in the intrinsic muscles of the hand and foot, known to be devoid of recurrent inhibition. The presence or absence of drug-induced increase in motor unit synchronization agrees with the known distribution of recurrent inhibition in the various motor nuclei. The overall significance of these findings is the potential application of RQA methodology as a reliable and independent tool for generally assessing motor unit synchronization from surface EMG under strictly controlled experimental condition.

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This study showed that participation during physical therapy affects the extent of functional gain at discharge in a large population of older patients with multiple diseases receiving in-hospital rehabilitation.