Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people

Bellelli, Giuseppe; Morandi, Alessandro; Davis, Daniel; Mazzola, Paolo; Turco, Renato; Gentile, Simona; Ryan, Tracy; Cash, Helen; Guerini, Fabio; Torpilliesi, Tiziana; Santo, Francesco Del; Trabucchi, Marco; Annoni, Giorgio; MacLullich, Alasdair M.J.

doi:10.1093/ageing/afu021

Cited by 570 publications

(519 citation statements)

References 24 publications

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“…9 The detection of cognitive impairment should always be accompanied by an assessment for delirium, for example using the 4-AT. 10 Delirium has acute onset, typically over days and weeks. Failed detection is associated with a sevenfold hazard for increased mortality, 11,12 and is an independent predictor of hospital length of stay.…”

Section: Delirium and Dementiamentioning

confidence: 99%

Acute geriatrics at the front door

Conroy

Parker

2017

Clinical Medicine

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Older people with frailty and urgent care needs are major uses of health and social care services. Comprehensive geriatric assessment (CGA) is an evidence-based approach to improving their outcomes, as well as improving service outcomes. Geriatricians form a small proportion of the overall workforce and cannot address the population need alone, so all clinicians (doctors, nurses, therapists and so on) need to engage in delivering CGA as a process of care, underpinned by specifi c competencies -which can be developed. Delivery of this care pathway needs to be measured and improved as rigorously as campaigns like those for improving sepsis or eradicating methicillin-resistant Staphylococcus aureus . IntroductionFor many older people -in the UK at least -the emergency department (ED) is the main portal of entry to urgent care. In many cases, the older person's urgent care needs can be quickly assessed and managed within a short period of time (the 4-hour standard); in the UK, about one-third of people over the age of 85 years accessing EDs are able to return home directly. But for many others, a more detailed assessment and management plan is required, delivered in either observation wards in the ED (typically for people with an anticipated stay of less than 24 hours; variously termed clinical decision units, emergency decision units and other such acronyms) or an acute medical unit (for post-ED management of medical patients, initially for up to 72 hours) -staffed by acute physicians trained in acute assessment of a wide range of conditions. 1 While older people (65 or 75+ years) form a significant proportion of patients at all of these axes of care, and around two-thirds of all those receiving ongoing care in acute hospitals, there is a discrete subset of people aged 75+ who account for the bulk of bed days. Emerging data from the Nuffield Trust indicate about 20% of all those aged 75+ account for 85% of bed days and 85% of readmission or deaths within 90 days of an urgent care episode. It appears that this 20% resemble older people with frailty.Frailty is a distinctive late-life health state in which apparently minor stressor events are associated with adverse health outcomes. The two established international models are the ABSTRACT Acute geriatrics at the front door frailty phenotype 2 and the cumulative deficit model, 3 both of which have been validated in large population cohort studies. The models identify people at increased risk of a range of adverse outcomes, including dependency, institutionalisation and premature death. Frailty can be measured; the cumulative deficit model of frailty expresses frailty as a ratio of deficits present to a total list of deficits that have been pre-defined using a standard procedure. 4 This model maps well onto the Clinical Frailty Scale, 5 which is quick (<1 minute), simple and easy to use in urgent care settings. 6Frailty identification is important at several levels. Older people with frailty will often present with so-called nonspecific presentations, multiple comorbid...

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Section: Delirium and Dementiamentioning

confidence: 99%

Acute geriatrics at the front door

Conroy

Parker

2017

Clinical Medicine

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“…1 However, their recommendation of these assessments are not specific to HF and a recent systematic review concluded that the accuracy of normative values for these tests in HF need to be established, 24 work that is currently underway by the4AT.com) as a quick screening tool for cognitive impairment and delirium. 25 This is a validated tool routinely used in clinical practice internationally to detect delirium with good sensitivity and specificity.…”

Section: Cognitive Impairmentmentioning

confidence: 99%

Chronic Heart Failure Care Planning: Considerations in Older Patients

Hill

Taylor

2017

Cardiac Failure Review

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In developed countries, it is estimated that 1-2 % of the adult population has heart failure (HF), with the prevalence increasing to more than 10 % in those aged >70 years.1 Despite advances in therapies for heart failure with reduced ejection fraction (HFrEF), it remains a condition associated with significant morbidity and mortality, punctuated by episodes of unplanned hospitalisation. 2HF is one of the commonest causes of unscheduled hospital admissions 3 and data consistently show a lower uptake of evidencebased investigations and therapies in adults >75 years as well as higher HF-related mortality.4 Mortality and rehospitalisation rates are higher amongst patients discharged to skilled nursing facilities than those going home. 5 Older patients more frequently experience comorbidities, frailty, polypharmacy and cognitive impairment and these factors have a significant impact on outcomes. These aspects require proper evaluation to best assess and plan patients' long-termcare needs.In this review, we examine HF-care planning in relation to older patients. While current guidance has its limitations, we offer here a pragmatic approach to care planning in this patient population. Care Planning in Skilled Nursing FacilitiesWhile the majority of older people live at home alone, or with carers, in the UK 16 % of people aged >85 years live in care homes. 6 The spectrum of care ranges from sheltered housing to a variety of assisted living facilities, residential and nursing homes. The reported prevalence of HF in nursing homes ranges from 20.0 to 37.4 %. 7The Heart Failure in Care Homes (HFinCH) study 8 found a higher prevalence of HF in UK care-facility residents aged 65-100 years than in community populations. Most cases were previously undiagnosed and three-quarters of previously recorded cases were unconfirmed using the latest European Society of Cardiology (ESC) guidelines, echocardiogram and brain natriuretic peptide measurements. AbstractIn developed countries, it is estimated that more than 10 % of adults aged over 70 years have heart failure (HF). Despite therapeutic advances, it remains a condition associated with significant morbidity and mortality. It is one of the commonest causes of unscheduled hospital admissions in older adults and data consistently show a lower uptake of evidence-based investigations and therapies as well as higher rates of HF hospitalisations and mortality than in younger adults. These rates are highest amongst patients discharged to 'skilled nursing facilities', where comorbidities, frailty and cognitive impairment are common and have a significant impact on outcomes. In this review, we examine current guidance and its limitations and offer a pragmatic approach to management of HF in this elderly population.

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“…[33] Common examples include the CAM, 4AT, Nursing Delirium Screening Scale (Nu-DESC), and NEECHAM Confusion Scale. [4,[36][37][38] These instruments are mostly designed to be completed by nurses and incorporate information obtained from patient observation, caregivers, or the medical record. The CAM tool is standardized and widely accepted owing to its brevity and reliability (see Figure 1).…”

Section: Recognition Toolsmentioning

confidence: 99%

Delirium: The 21st century health care challenge for bedside clinicians

Richards

Azad

Adeola

et al. 2016

JNEP

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Delirium is a leading cause of preventable injury in hospitalized patients. Early recognition and intervention for delirium are critical to prevent morbidity and mortality, especially in the older population. Older patients are at increased risk for delirium owing to a combination of age-related changes and environmental factors. Health care providers, including nurses and physicians, often miss delirium symptoms and diagnosis in patients. Without early recognition and treatment, delirium can have significant life-changing consequences in our most vulnerable patients. This acute change in cognition can continue throughout the hospital course and may require additional rehabilitation or placement, delaying transition to home. As the baby boomers age, the older population is expected to increase, with significant implications for health care. With this in mind, the health care team, including frontline caregivers, need to be well informed about delirium. This article will expand readers' knowledge and familiarity with delirium with the purpose of improving their practice and care of the older patient. It will also address the impact of delirium and discuss tools that can help to improve recognition. The most recent advances and current treatment methods to integrate into daily patient care are also discussed. This article places heavy emphasis on identification and prevention of delirium as these are the most important aspect of understanding delirium. Thus, treatment and management are both discussed after prevention since the primary focus of delirium is understanding and preventing this devastating syndrome in our hospitalized patients.

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Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people

Cited by 570 publications

References 24 publications

Acute geriatrics at the front door

Acute geriatrics at the front door

Chronic Heart Failure Care Planning: Considerations in Older Patients

Delirium: The 21st century health care challenge for bedside clinicians

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