Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method.
Acute Disease
Aged
Aged, 80 and over
Algorithms
Checklist
/ methods
Confusion
/ diagnosis
Delirium
/ diagnosis
Diagnostic Tests, Routine
/ methods
Diagnostic and Statistical Manual of Mental Disorders
Emergency Service, Hospital
Female
Geriatric Assessment
/ methods
Humans
Inpatients
Male
Neuropsychological Tests
/ standards
Predictive Value of Tests
Reproducibility of Results
Sensitivity and Specificity
4AT
Confusion assessment method (CAM)
Delirium
Diagnostic test accuracy
Hospital
Sensitivity
Specificity
Journal
BMC medicine
ISSN: 1741-7015
Titre abrégé: BMC Med
Pays: England
ID NLM: 101190723
Informations de publication
Date de publication:
24 07 2019
24 07 2019
Historique:
received:
21
02
2019
accepted:
13
06
2019
entrez:
25
7
2019
pubmed:
25
7
2019
medline:
15
1
2020
Statut:
epublish
Résumé
Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM). This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment. Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%). The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care. International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.
Sections du résumé
BACKGROUND
Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM).
METHODS
This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment.
RESULTS
Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%).
CONCLUSIONS
The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care.
TRIAL REGISTRATION
International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.
Identifiants
pubmed: 31337404
doi: 10.1186/s12916-019-1367-9
pii: 10.1186/s12916-019-1367-9
pmc: PMC6651960
doi:
Banques de données
ISRCTN
['ISRCTN53388093']
Types de publication
Comparative Study
Journal Article
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
138Subventions
Organisme : Department of Health
ID : PB-PG-0610-22068
Pays : United Kingdom
Références
BMC Geriatr. 2012 Sep 14;12:55
pubmed: 22974329
Int Rev Psychiatry. 2009 Feb;21(1):30-42
pubmed: 19219711
Psychosomatics. 2004 Sep-Oct;45(5):426-31
pubmed: 15345788
Int J Geriatr Psychiatry. 2017 Dec;32(12):1322-1329
pubmed: 27766672
BMC Geriatr. 2018 Sep 17;18(1):217
pubmed: 30223771
Ann Intern Med. 1990 Dec 15;113(12):941-8
pubmed: 2240918
Eur J Intern Med. 2015 Nov;26(9):696-704
pubmed: 26333532
Br J Anaesth. 2008 Sep;101(3):338-43
pubmed: 18603528
Neuropsychiatr Dis Treat. 2013;9:1359-70
pubmed: 24092976
Int J Geriatr Psychiatry. 2013 Aug;28(8):804-12
pubmed: 23112139
Age Ageing. 2018 Jan 1;47(1):61-68
pubmed: 28985260
Age Ageing. 2012 Jan;41(1):80-6
pubmed: 21890483
Am J Geriatr Psychiatry. 2014 Dec;22(12):1513-21
pubmed: 24745562
Australas J Ageing. 2016 Mar;35(1):54-7
pubmed: 26365131
Int Psychogeriatr. 2015 May;27(5):777-84
pubmed: 25275655
JAMA. 2010 Aug 18;304(7):779-86
pubmed: 20716741
Aging Ment Health. 2018 Jul;22(7):903-911
pubmed: 29103316
Acad Emerg Med. 2015 Jul;22(7):878-82
pubmed: 26113020
JAMA. 2010 Jul 28;304(4):443-51
pubmed: 20664045
N Engl J Med. 2017 Oct 12;377(15):1456-1466
pubmed: 29020579
Gen Hosp Psychiatry. 2008 Mar-Apr;30(2):171-6
pubmed: 18291299
Int Psychogeriatr. 1999 Dec;11(4):431-8
pubmed: 10631588
Palliat Med. 2010 Sep;24(6):561-5
pubmed: 20837733
Acad Emerg Med. 2009 Mar;16(3):193-200
pubmed: 19154565
Ann Emerg Med. 2013 Nov;62(5):457-465
pubmed: 23916018
Crit Care Med. 2015 Jan;43(1):e23-4
pubmed: 25514728
Age Ageing. 2015 Jan;44(1):166-70
pubmed: 25324329
J Hosp Med. 2012 May-Jun;7(5):450-3
pubmed: 22173963
JAMA. 2017 Sep 26;318(12):1161-1174
pubmed: 28973626
J Med Assoc Thai. 2014 Jan;97(1):113-7
pubmed: 24701738
World J Surg. 2010 Mar;34(3):487-94
pubmed: 20066416
J Med Ethics. 2005 Mar;31(3):137-43
pubmed: 15738432
J Am Geriatr Soc. 2008 May;56(5):823-30
pubmed: 18384586
Am J Geriatr Psychiatry. 2013 Dec;21(12):1244-53
pubmed: 24080383
Arch Intern Med. 1995 Feb 13;155(3):301-7
pubmed: 7832602
Neuropsychiatr Dis Treat. 2016 Feb 24;12:437-43
pubmed: 26966365
J Crit Care. 2018 Dec;48:104-111
pubmed: 30176525
BMJ Open. 2018 Feb 10;8(2):e015572
pubmed: 29440152
BMC Med. 2017 Jul 27;15(1):140
pubmed: 28747225
Int Psychogeriatr. 2017 Oct;29(10):1585-1593
pubmed: 28560945
Age Ageing. 2010 Jan;39(1):131-5
pubmed: 19917632
Emerg Med Clin North Am. 2010 Aug;28(3):611-31
pubmed: 20709246
Psychopathology. 2009;42(4):270-6
pubmed: 19521144
Arq Neuropsiquiatr. 2001 Jun;59(2-A):175-9
pubmed: 11400020
BMJ Open. 2015 Nov 16;5(11):e007808
pubmed: 26576806
Int J Geriatr Psychiatry. 2002 Dec;17(12):1112-9
pubmed: 12461759
J Am Med Dir Assoc. 2016 Sep 1;17(9):828-33
pubmed: 27346621
Int J Geriatr Psychiatry. 2018 Nov;33(11):1501-1511
pubmed: 28393426
Age Ageing. 2009 Sep;38(5):559-63
pubmed: 19592539
Gerontologist. 2019 Mar 14;59(2):327-337
pubmed: 30870568
Am J Crit Care. 2015 Nov;24(6):480-7
pubmed: 26523005
Arch Intern Med. 2001 Nov 12;161(20):2467-73
pubmed: 11700159
BMC Fam Pract. 2011 Jul 01;12:65
pubmed: 21722373
Int Psychogeriatr. 2015 Aug;27(8):1251-62
pubmed: 25742756
BMC Med. 2014 Oct 08;12:141
pubmed: 25300023
Aging Ment Health. 2020 May;24(5):820-827
pubmed: 30595038
JAMA Psychiatry. 2017 Mar 01;74(3):244-251
pubmed: 28114436
Palliat Med. 2009 Jan;23(1):40-5
pubmed: 19010967
J Am Med Dir Assoc. 2006 Sep;7(7):412-5
pubmed: 16979083
Stroke. 2013 Nov;44(11):3078-83
pubmed: 23988641
BMC Med. 2018 Dec 11;16(1):231
pubmed: 30526577
J Am Geriatr Soc. 2012 Aug;60(8):1471-7
pubmed: 22881707
Neurol Sci. 2017 Jun;38(6):1101-1104
pubmed: 28150101
Age Ageing. 2016 Nov;45(6):832-837
pubmed: 27503794
Ann Intern Med. 2014 Oct 21;161(8):554-61
pubmed: 25329203
PLoS One. 2016 Nov 30;11(11):e0166754
pubmed: 27902744
J Am Med Dir Assoc. 2016 Mar 1;17(3):214-9
pubmed: 26585091
Am J Emerg Med. 2017 Sep;35(9):1324-1326
pubmed: 28559128
J Am Geriatr Soc. 1994 Mar;42(3):252-6
pubmed: 8120308
Age Ageing. 2014 Jul;43(4):496-502
pubmed: 24590568
BMJ Open. 2016 Nov 14;6(11):e012799
pubmed: 28137831
Arch Intern Med. 1995 Dec 11-25;155(22):2459-64
pubmed: 7503605
Psychosomatics. 1996 Nov-Dec;37(6):533-46
pubmed: 8942204
J Pain Symptom Manage. 2005 Apr;29(4):368-75
pubmed: 15857740
Am J Respir Crit Care Med. 2002 Nov 15;166(10):1338-44
pubmed: 12421743
BMC Geriatr. 2017 Dec 08;17(1):283
pubmed: 29216846
Int J Geriatr Psychiatry. 2016 Sep;31(9):974-89
pubmed: 26898375
Int J Geriatr Psychiatry. 2014 Dec;29(12):1185-97
pubmed: 24760756
Ann Emerg Med. 2010 Sep;56(3):244-252.e1
pubmed: 20363527
Gerontologist. 2015 Dec;55(6):1079-99
pubmed: 26543179
Australas J Ageing. 2015 Dec;34(4):259-64
pubmed: 26059554
Age Ageing. 2009 Mar;38(2):235-7
pubmed: 19110484
Anaesthesia. 2019 Oct;74(10):1260-1266
pubmed: 31038212
J Neuropsychiatry Clin Neurosci. 2001 Spring;13(2):229-42
pubmed: 11449030