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![4AT
Assessment t est
for delirium &
cognitive impairment
(label)
Patient name:
Date of birth:
Patient number:
_________________________________________________________
Date: Time:
Tester:
CIRCLE
[1] ALERTNESS
This includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy
during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with
speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating.
Normal (fully alert, but not agitated, throughout assessment) 0
Mild sleepiness for <10 seconds after waking, then normal 0
Clearly abnormal 4
[2] AMT4
Age, date of birth, place (name of the hospital or building), current year.
No mistakes 0
1 mistake 1
2 or more mistakes/untestable 2
[3] ATTENTION
Ask the patient: “Please tell me the months of the year in backwards order, starting at December.”
To assist initial understanding one prompt of “what is the month before December?” is permitted.
Months of the year backwards Achieves 7 months or more correctly 0
Starts but scores <7 months / refuses to start 1
Untestable (cannot start because unwell, drowsy, inattentive) 2
[4] ACUTE CHANGE OR FLUCTUATING COURSE
Evidence of significant change or fluctuation in: alertness, cognition, other mental function
(eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs
No 0
Yes 4
4 or above: possible delirium +/- cognitive impairment
1-3: possible cognitive impairment
0: delirium or severe cognitive impairment unlikely (but
delirium still possible if [4] information incomplete)
4AT SCORE
GUIDANCE NOTES Version 1.2. Information and download: www.the4AT.com
The 4AT is a screening instrument designed for rapid initial assessment of delirium and cognitive impairment. A score of 4 or more
suggests delirium but is not diagnostic: more detailed assessment of mental status may be required to reach a diagnosis. A score of 1-3](https://image.slidesharecdn.com/jojames-demetiavsdelerium-171025100601/75/Jo-james-demetia-vs-delerium-17-2048.jpg)
Uploaded byGeriatric Emergency Medicine Bootcamp
Jo james demetia vs delerium
This document defines dementia and delirium, differentiates between the two, and provides assessment and management tips for delirium. It notes that delirium is acute with sudden onset while dementia has slow onset and decline. Key points are that delirium is underrecognized, has poor outcomes if left untreated, and can be prevented and managed by addressing potential triggers and maintaining hydration, mobility, and nutrition. Assessment tools like CAM and 4AT can help identify delirium which requires prompt treatment of the underlying cause.
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Jo james demetia vs delerium
- 1. Dementia & Delirium JoJames Lead Nurse Dementia Imperial College Healthcare NHS Trust
- 2. Objectives • Define thedifferences between dementia & delirium • Top tips to identify delirium • Explore Assessment and Management
- 3. How does dementiadiffer from delirium? • Dementia is a long term condition with slow onset and decline • Delirium is an acute, short term response to a physical insult – comes on suddenly and can resolve in days to months. • Delirium is always acute onset and is characterised by level of arousal (awakeness)
- 4. Differentiating the threeDs Depression Delirium Dementia Onset Generally insidious, Precipitant? Coincides with life changes, often abrupt Acute Chronic Course Typically worse in the morning; situational fluctuations but less than delirium Short, often worse at night, in the dark and on waking Long. Symptoms progressive but stable over time Duration At least two weeks, can be months to years Hours to less than one month, rarely (but sometimes) longer Months to years
- 5. Differentiating the threeDs (2) Depression Delirium Dementia Awareness Clear Reduced Clear Arousal /Alertness Normal Fluctuates; lethargic or hyper-vigilant Generally normal Attention Minimal impairment but distractible Impaired, fluctuates Generally normal Thinking/ Perception Intact; delusions and hallucinations absent except in severe cases Disorganised, fragmented Distorted, delusions hallucinations, difficulty distinguishing reality and misperceptions. Difficulty with abstraction, poor judgement, difficulty finding words Misperceptions often absent
- 6. Prevalence (66% of casesgo unrecognised in hospital) • Prevalent (on admission) 14-24% • Incident (in hospital) 6-56% • Postoperative: 15-53% • Intensive care unit: 70-87% • Nursing home/post-acute care: 20-60% • Palliative care (up to) 80% ( Inouye SK, NEJM 2006;354:1157-65)
- 7. Outcomes • Increased lengthof stay. • Increased mortality (Hospital mortality rates of patients with delirium are twice as high) Hospital mortality: 22-76% One-year mortality: 35-40% • Increased risk of institutional placement. • Patients with delirium are also three times more likely to develop dementia.
- 8. Delirium phenotypes • Hyperactive(20%) “Confused” – Agitated, hyper-alert, restless, sympathetic overdrive • Hypoactive (30%) “Not themselves” – Drowsy, inattentive, poor oral intake • Mixed (50%) Hypoactive delirium carries higher mortality and is more often unrecognised (Kiely et al. J of Geront Series A: 2007; 62: 174- 179)
- 9.
- 10. Is it somethingelse? •Dysphasia •Deaf •Drunk •Drugged •Depressed •Downright difficult •Dementia
- 11. Is it acute? Geta collateral history •When did it start? •What were they like yesterday, a week ago? •Has it happened before? •What else have you noticed?
- 12.
- 13. Who is atrisk? • Older people • Poly pharmacy. • Dementia. • Dehydrated. • Infection. • Severely ill people. • People who are nearing the end of their life. • Older people with constipation or urinary retention
- 14. What can triggerdelirium? • Immobility • Use of physical restraint • Use of bladder catheter • Pain • Hypoxia • Malnutrition • Multiple medications • Intercurrent illness (infection/cardiac event etc) • Dehydration or Constipation • Sensory Impairment • Sleep Disturbance
- 15. Early Signs ofDelirium
- 16. 1 Acute onset& Fluctuating Course Does abnormal behaviour come & go? Fluctuate during day? Increase/decrease in severity? 2 Inattention Does Pt Has difficulty focussing attention? Become easily distracted? Have difficulty keeping track of what’s being said? 3 Disorganized thinking Is pt’s thinking disorganised? Incoherent? i.e. rambling/incoherent Unpredictable switching of subjects? Unclear/illogical flow of ideas? 4 Altered LOC Alert or vigilant? Lethargic or stuporous Comatose ? Delirium requires presence of (1 & 2 )+(either 3 or 4) Confusion Assessment Method (CAM)
- 17. 4AT Assessment t est fordelirium & cognitive impairment (label) Patient name: Date of birth: Patient number: _________________________________________________________ Date: Time: Tester: CIRCLE [1] ALERTNESS This includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating. Normal (fully alert, but not agitated, throughout assessment) 0 Mild sleepiness for <10 seconds after waking, then normal 0 Clearly abnormal 4 [2] AMT4 Age, date of birth, place (name of the hospital or building), current year. No mistakes 0 1 mistake 1 2 or more mistakes/untestable 2 [3] ATTENTION Ask the patient: “Please tell me the months of the year in backwards order, starting at December.” To assist initial understanding one prompt of “what is the month before December?” is permitted. Months of the year backwards Achieves 7 months or more correctly 0 Starts but scores <7 months / refuses to start 1 Untestable (cannot start because unwell, drowsy, inattentive) 2 [4] ACUTE CHANGE OR FLUCTUATING COURSE Evidence of significant change or fluctuation in: alertness, cognition, other mental function (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs No 0 Yes 4 4 or above: possible delirium +/- cognitive impairment 1-3: possible cognitive impairment 0: delirium or severe cognitive impairment unlikely (but delirium still possible if [4] information incomplete) 4AT SCORE GUIDANCE NOTES Version 1.2. Information and download: www.the4AT.com The 4AT is a screening instrument designed for rapid initial assessment of delirium and cognitive impairment. A score of 4 or more suggests delirium but is not diagnostic: more detailed assessment of mental status may be required to reach a diagnosis. A score of 1-3
- 18. What about Sedation? •Should be a last resort • Follow NICE Guidance • Low doses are usually effective in Delirium • Should be a short term solution
- 19. Management • Try andidentify the cause • Out of ED as soon as possible – prioritise with bed managers • Safety – might abscond - positioning in clinical area • Inform family ASAP • Do not catheterise unless absolutely necessary • Orientate • Maintain optimal hydration, mobility & nutrition- prevent/treat constipation/pain
- 20. Key Points • Deliriumis an emergency (ED staff are good at spotting emergencies….) • We can improve outcomes if it is identified and flagged up early • Untreated, it can have disastrous effects on the patient – including death • It often goes unrecognised in hospitals – (remember a false positive/suspicion is better than missing it completely)