Screened Least where Risk is Highest: A Two Cycle Audit of 4AT Delirium Screening on an Acute Medical Unit

Introduction: Delirium affects 20–30% of older inpatients and independently increases mortality, length of stay and long-term cognitive decline. However, it is frequently missed when diagnostic attention is shifted entirely to a primary acute illness or when confounded by baseline cognitive impairment. NICE guidelines recommend routine 4AT screening of older patients on acute admission (audit standard ≥90%). We audited 4AT completion in patients aged ≥65 on an acute medical unit (AMU) and examined which presentations were least likely to be screened.

Method: A two-cycle audit was performed reviewing whether a 4AT was completed during the admission of AMU patients aged ≥65 during one week in September 2025 (cycle 1) and July 2026 (cycle 2). The intervention was a departmental teaching session presenting the baseline results and highlighting the importance of compliance.

Results: There was an improvement in 4AT documentation from 4/30 (13%) to 15/52 (29%). However, this remained far below the ≥90% target. Completion was lowest in patients with infection/sepsis (3/15 or 20%) and known dementia (4/11 or 36%), compared with those presenting with falls (7/12 or 58%). Only 3/9 (33%) of patients presenting with confusion or altered mental state had a 4AT completed. During cycle 2, 6/15 (40%) with 4AT completed scored ≥4 (probable delirium).

Conclusion: Delirium was recognised least in those who were acutely unwell or who had cognitive impairment. To drive further improvement in 4AT screening, targeted feedback and trigger-based alerts on electronic health record systems for patients aged ≥65 may offer an effective next step.